Endodontic Practice US Spring 2018 Vol 11 No 1

clinical articles • management advice • practice profiles • technology reviews Spring 2018 – Vol 11 No 1

PROMOTING

EXCELLENCE

IN

THE ULTIMATE MASTERY COURSE

ENDODONTICS

The foundation of minimally invasive endodontics: research, technology, and technique Dr. Stephen R. Ottosen

Furcation perforation: current approaches and future perspectives Drs. Manal Farea, Adam Husein, and Cornelis H. Pameijer

Effectively treating the complex anatomies of root canal systems Sonendo®

Endodontic treatment of a tooth with pulp necrosis and severe inflammatory external apical root resorption Dr. Ricardo Machado, et al.

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DR. ACE GOERIG

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* Images courtesy Khang T. Le, DDS 1 Sigurdsson A et al. (2016) J Endod. 42:1040-48 2 Molina B et al. (2015) J Endod. 41:1701-5 3 Vandrangi P et al. (2015) Oral Health 72-86

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Spring 2018 - Volume 11 Number 1 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 2018. All rights reserved.

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

S

ince the beginning of the 2008 recession, the business of endodontics has become more competitive and stressful. The recession caused practice decline in over 78% of all endodontic practices. If your practice is not growing, it’s declining. These challenges and stresses are broken down to external (things we can’t control) and internal (things we can control).

External stresses • More corporate offices • Insurance companies controlling our fees • More general dentists doing endodontics • Implants instead of retreatments • More endodontists to compete with Dr. Albert (Ace) Goerig • Fewer endodontists retiring • Increased consumer spending Internal stress • Low production/low doctor income • Fewer patients and open schedule • Challenging cases • No-shows and last-minute cancellations • Office stress and drama • Leading your team • Student debt • Business management challenges • Your vacations (wondering who’s taking your patients) We have no control over the external forces. We must focus our time and resources on solving the internal issues within the practice. If this is done well, the external forces become irrelevant. The internal problems have little to do with clinical expertise but more about a highly trained and incredible team, strong office systems, and a culture that provides superior customer service while creating strong relationships with patients and referring offices. We need to learn how to create an emotional connection with every person we meet. Also, doctors need to understand and master the business side of their practice.

This process all begins with creating a vision and culture for your practice that’s fun and safe while providing the highest quality of care. As the owner, your practice is your canvas; you have the brush and can create your practice in any way you envision. Once you have shared your vision with your team, then develop a structured program to train them on how to deliver the WOW experience with patients and referring offices. Replace all team members who cause drama in your practice. Start having fun again! Develop a schedule that flows smoothly, so you focus on one patient at a time. A smooth schedule will do much to eliminate the stress in the office and allow time for you to focus on marketing the practice.

When marketing is done well, you’ll fill your book daily, increase profitability, and get easier, straightforward cases from your referring doctors. Successful marketing is all about creating strong relationships and differentiating yourself in the dental community. Remember, until you have the right team and systems in place, you should not market. The number one marketing idea is to be able to see emergency patients the day the referring office calls and complete the case that day. With marketing, it is always the best relationship that wins, not always the best doctor.

If change is to occur, you must take action! Don’t be like the chess piece that is moved around the board by others. Learn to be the chess player and control your own destiny while creating the practice of your dreams.

Dr. Albert (Ace) Goerig Albert (Ace) Goerig, DDS, MS, is a nationally known speaker who has lectured extensively in his field of endodontics and dental practice management to dentists throughout the United States, Canada, and abroad. He has authored over 60 articles and is a contributing author to the following textbooks: Pathways of the Pulp, Ingle’s Endodontics, and Practical Endodontics. Dr. Goerig is a Diplomate of the American Board of Endodontics and a Fellow of both the American and International College of Dentists. He has been involved in teaching both endodontics and general dentistry residents for many years. He is in private dental practice in Olympia, Washington, specializing in endodontics. In 1996, he co-founded Endodontic Practice Mastery to teach endodontists the business of dentistry while helping them to love their practice.

Since then he has personally coached over 22% of all endodontists and their teams in the U.S. and Canada. He is also the co-author of Time and Money: Your Guide to Financial Freedom. He and his wife, Nancy, were married in 1969 and have five children. He has many hobbies, including fishing, scuba diving, skiing, and travel.

ISSN number 2372-6245

Volume 11 Number 1

Endodontic practice 1

INTRODUCTION

Transforming practice fears into action and profitability

TABLE OF CONTENTS

Clinical research

Clinical The foundation of minimally invasive endodontics: research, technology, and technique

6

Dr. Stephen R. Ottosen discusses new directions that allow endodontists to experience greater success and long-term value for patients

Accuracy comparison of three different electronic apex locators in single-rooted teeth — an in vitro study Drs. Amil Sharma, Gregori M. Kurtzman, Sandeep Gupta, Shivanshu Bhardwaj, and Poorvasha Dhanare discuss accurate determination of the location of the working length...........18

Endodontic insight The value of the CBCT in the endodontic practice

Clinical 12 Influence of calcium hydroxide and the type of endodontic sealer in the adehsion of fiberglass posts on the bovine root dentin Drs. Tiago André Fontoura de Melo and Daniel Galafassi, along with Bruna Machado dos Passos, Sheila Machado dos Passos Zini, Priscila Souza de Souza, and Cláudia Wagner, analyze the effects of calcium hydroxide as intracanal medication and the type of cement used on the adhesion of fiberglass posts with RelyX™ U200

Dr. Albert (Ace) Goerig discusses the benefits of 3D imaging to the diagnostic process..........................22

Industry news................24

ON THE COVER X-ray image courtesy of Brian T. Wells, DMD. See article on page 38.

2 Endodontic practice

Volume 11 Number 1

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TABLE OF CONTENTS

Continuing education Furcation perforation: current approaches and future perspectives Drs. Manal Farea, Adam Husein, and Cornelis H. Pameijer discuss current approaches and a new perspective for repair and regeneration in endodontology.............................. 25

Product profile Freedom without compromise Ultradent’s Endo-Eze™ Genius® reciprocation and rotary endodontic system...........................................37

Technique Effectively treating the complex anatomies of root canal systems

Continuing education

33

Endodontic treatment of a tooth with pulp necrosis and severe inflammatory external apical root resorption in a single session: Is it possible? A case report

Drs. Ricardo Machado, Emanuely da Silva Chrun, Luiz Fernando Tomazinho, and Lucas da Fonseca Roberti Garcia consider the possibility of endodontic treatment of a tooth with pulp necrosis and severe inflammatory external apical root resorption in a single session

Sonendo® discusses eliminating infections from intricate root canal systems and preventing reinfection ...................................................... 38

Product profile The evolution of the taper ......................................................40

New updates to CS 8100 3D help endodontists practice at the highest level....................... 41

Practice development Endodontic engagement: the GP and endodontist can achieve more as a team Dr. Brett E. Gilbert discusses the important interaction between generalists and specialists..............42

Product profile What does neuroscience have to do with dentistry? A lot!

Sandra Marlowe discusses a method of achieving a profound mental state of peak performance........................... 44

Star® ETorque™ Electric System Power, performance, and flexibility ....................................................... 46

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com MANAGING EDITOR | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email: mark@medmarkmedia.com NATIONAL ACCOUNT MANAGER | Celeste Scarfi-Tellez Email: celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com

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Dr. Joel C. Small offers a technique for creative problem solving.................. 48

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4 Endodontic practice

Volume 11 Number 1

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CLINICAL

The foundation of minimally invasive endodontics: research, technology, and technique Dr. Stephen R. Ottosen discusses new directions that allow endodontists to experience greater success and long-term value for patients Introduction The triad of bacterial-related disease in dentistry consists of coronal decay, periodontal infection, and endodontic infection.

These have common traits, similarities, and differences. All have at their origin biofilm.

With coronal decay, the primary traits of the bacteria involved are the production of extracellular polysaccharides from sucrose to allow adhesion to the tooth surface and each other. They also digest sugars and produce lactic acid. The combination of plaque and acid leads to tooth decay.

In advanced periodontal disease, the bacteria involved primarily produce an extracellular matrix to allow adhesion to the root surface and toxins that promote inflammation of the surrounding tissue.

Endodontic infections are the result of pulpal necrosis and the accompanying bacterial colonization of the pulp space. The dominant bacteria in the canal space inhabit biofilm (Figure 1) formed by the production of extracellular polymeric substances (EPS).

The bacteria within the pulpal space produce various toxins. These include endotoxin (lipopolysaccharide [LPS]), exotoxin, and short chain fatty acids.

The major difference among these biofilms found in the mouth is the ability of the coronal biofilms to produce acid and physically break down the tooth structure. This results in the need for removal of destroyed enamel and dentin during treatment (restoration) of the coronal hard tissue (Figure 3).

Stephen R. Ottosen, DDS, MSD, graduated from the University of Washington School of Dentistry in 1994 and the University of Washington Endodontic Specialty Training in 1996. His research was in NiTi rotary instruments. He opened his practice in 1996 in Wenatchee, Washington. Dr. Ottosen has taught for the University of Washington continuing education department. He provides endodontic continuing education to several Washington state study clubs and dental societies. Dr. Ottosen is a member of the American Dental Association, the American Association of Endodontists, and the North Central District of the American Dental Association.

Disclosure: Dr. Ottosen is the founder and president of MicroEndo.

He can be reached at (509)664-6669, steve@ottoendo.com or by visiting www.microendosolutions.com.

6 Endodontic practice

Figure 2: Dentin after PIPS-activated irrigation

Figure 1: Endodontic biofilm

With periodontal disease, the root surface is contaminated but generally not carious. The goal is to remove the biofilm to allow the inflammation to decrease. Further treatment of the root surface is needed to allow reattachment of the connective tissue.

In endodontic infections, the dentin and accompanying isthmuses and accessory canals are contaminated by the bacteria.

These are areas that are inaccessible to endodontic files during canal instrumentation and preparation. Caries or significant demineralization or structural degradation of the dentin is not found (Figure 3). Ideal treatment would be to remove the bacteria and their associated EPS and toxins and to leave the dentin intact.

Irrigation As 35%1 or more of the canal walls are not touched by instrumentation during endodontic treatment, we are very reliant upon irrigation to clean the pulpal space.

The following irrigation techniques generally use sodium hypochlorite 5% and EDTA 17%. Sodium hypochlorite (NaOCl) proved to be the most effective endodontic irrigant because of its excellent antimicrobial efficiency, biofilm disruption, organic tissue dissolution, and debris removal properties.2,3,4,5 EDTA, a chelator, is used during root canal therapy to remove the inorganic component of the smear layer produced by instrumentation.6 Its biofilm-dispersing

Figure 3: Coronal biofilm byproduct: decay. Canal space biofilm byproduct: apical periodontitis.

property7,8 means that EDTA can also be used to “loosen” or clean endodontic biofilms. The recommended protocol for irrigation includes the use of sodium hypochlorite (NaOCl) during mechanical preparation to dissolve the organic matter and kill microorganisms followed by a chelating agent such as EDTA to remove the smear layer and to leave an adequate substrate for optimal efficacy of the final irrigant.9,10 Small gauge side-vented irrigation needle and negative pressure irrigation systems are effective in cleaning the main canal space coronal to the depth of needle placement.13 These techniques provide good columnar irrigant flow with decrease incidence of apical extrusion of irrigants into the periapical tissue.

Volume 11 Number 1

CLINICAL

Figure 4: File cross section comparison.

Turbulent flow of irrigant is needed to reach anatomy that extends away from the main canal.14 Additionally, frequent exchange of irrigant assists in removing debris from the canal system adjacent to the main canals.

Sonic and ultrasonic metal and non-metal points are effective at creating turbulence, but their effectiveness is greatly diminished when they contact the canal wall.15 Upon contact with the canal wall, their energy is dampened and does not transmit efficiently through the irrigation solution. Metal ultrasonics are prone to breakage. Ultrasonics can gouge the canal wall.16 Erbium Yag (Er:YAG) lasers17 and sound wave18 irrigation activation systems are very effective (Figure 2). Both of these systems are effective due to their ability to impart energy and thus movement of the irritants within the canal system. The Fotona Erbium Yag laser performing the PIPS (Photon Induced Photo Acoustic Streaming) technique results in irrigant flow 20 to 100 times faster than ultrasonic techniques.19 PIPS is based on the activation of liquid irrigants by mediuminfrared laser (2,940 Nm). The tip is placed inside the pulp chamber only. The technique uses a radial firing and stripped tip, allowing lateral emission of laser energy in the liquids. The use of subablative energy (20 mJ) delivered in a very short time (pulse duration of 50 microseconds) produces a high peak power of 400 W, causing an explosion-implosion phenomenon within the irrigant solution. The result is a strong photoacoustic shock wave that induces irrigant streaming three-dimensionally throughout the entire root canal system while avoiding any direct laser irradiation on the dentin and consequent unwanted thermal effects.11,12 The irrigant activation reaches over 20 mm away from the tip compared to only 2 mm for ultrasonics.19 Blade or “wing” type rotary irrigation instruments have shown good results in research studies.20 Easy Clean (Easy Equipamentos Odontologicos; Belo Horizonte, Brazil) has a blade design that is used in large Volume 11 Number 1

Endodontic practice 7

CLINICAL angle reciprocation or complete rotation. The MicroIrrigator (MicroEndo LLC, Wenatchee, Washington) has a wing design (Figure 5) with a twist down the long axis. It is used in a reciprocating hand piece. This design provides turbulence as well as rapid slight positive and negative pressure.

Instrumentation As instrumentation alone is ineffective at cleaning the canal system, its main function is debridement of the canal and creating, when necessary, a pathway for irrigation.

The more a canal is tapered, flared, or enlarged at the coronal portion, the weaker the root becomes.21 Rotary instruments with a taper greater than 4% (.04) have consistently shown to create small dentin defects or cracks in research studies.22,23 These cracks are suspected to lead to root fractures. The higher the torque used in rotary instrumentation, the higher the incidence of dentin cracks.24 Reciprocating techniques used with tapered files create dentin cracks at a higher incidence than a traditional rotary technique.25 This may be partially due to the large changes in file dimensions between files used in these techniques and the resulting high torques created.

The amount of dentin removed during instrumentation is directly correlated with the cross section of the rotary instruments used. The area of the circle scribed by the cross section of the instrument is found by the formula π r2. Thus, the radius of the instrument dramatically effects the amount of dentin removed during instrumentation. Most endodontic file systems have a very tapered design. This usually results in a maximum flute diameter of 1.0 mm-1.2 mm. Path Glider™ (Komet; Rock Hill, South Carolina) and MicroFiles (MicroEndo; Wenatchee, Washington) (Figure 5) have a low taper (2%-3%) design with a maximum flute diameter of 0.6 mm.

When instrumenting a calcified canal, a standard rotary file may remove 200%-300% more dentin in the coronal portion of the canal (Figure 4). These small diameter files require much less torque to operate.

A recent long-term recall study of an endodontic specialty practice demonstrated less incidence of vertical root fracture in endodontically treated teeth with less tapered canal preparations.30 Finite element analysis has demonstrated that dentin preservation at the cervical area of the tooth is most important in retaining tooth strength under occlusal forces.31

Obturation Ideally, obturation is achieved with 3D adaptation of gutta percha to the canal 8 Endodontic practice

Figure 6: Irrisonic tip and Easy Equipmentos Odontologicos Easy Clean irrigator

Figure 7: MicroObturator being coated in warm gutta percha Figure 5: (left to right) Komet PathGlider 20, MicroEndo MicroFile 20, Pro Taper Next X1, MicroEndo MicroIrrigator 27

anatomy and a thin layer of sealer between the gutta percha (GP) and dentin.26 The only way to adapt GP to complex anatomy is through heat and pressure.27 GP only conducts heat ~4 mm ahead of a heated instrument tip.

This has led to various heating techniques.

Most techniques involve placing a heated metal instrument into the GP and then down packing the warmed GP with a smaller cool metal instrument. Unfortunately, the root canal has to be enlarged to accommodate the metal heating and packing instruments.

These instruments rarely reach the apical area in curved or small canals to provide a closely adapted GP/sealer/dentin interface.27 Carrier-based systems have been widely used. They often do not provide a guttapercha apical seal.28 The carrier provides a variety of challenges, and apical stripping of the warmed GP from the carrier is a common occurrence during insertion, resulting in carrier contact with the apical canal wall with no intervening GP. Mechanical (rotary) heating and compaction of gutta percha has been shown to be very effective.29 MicroObturators (MicroEndo) use a reverse wound rotary obturator (Figure 6) to place warm gutta percha into the canal and then compact the GP to form an ideal seal regardless of canal shape. The MicroObturators are able to obturate very small canals. If Erbium Yag (PIPS/Fotona) or multisonic (SonendoÂŽ, Laguna Hills, California) systems are used, instrumentation is sometimes unnecessary with rotary or hand files.

The MicroObturator technique uses an Obtura (Kerr, Orange, California) type backfill device to cover the obturator with warm low

Figure 8: Applying sealer to warm gutta percha

Figure 9: MicroObturator placed to working length (1 mm short of apical foramen)

viscosity gutta percha (Figure 7). The obturator and GP are then coated at its apical half in sealer (Figure 8) and placed into the canal 1 mm from the apical foramen (Figure 9). The obturator is then rotated at 20,000 rpm and withdrawn from the canal. This results in the GP on the rotary instrument being adapted to the canal of the root, and an ideal seal results.

Cases Case 1 (Figures 10-12) Tooth No. 30 was diagnosed with pulpal necrosis and chronic apical periodontitis. The canal anatomy was uncomplex with one broad distal canal and two mesial canals that joined. Very little root dentin was removed to debride the canals. A size 20 .03 PathGlider (Komet) was used as the final instrument.

The canal system was cleaned with Er-Yag Volume 11 Number 1

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CLINICAL

Figure 10: Case 1 — pre-op radiograph

Figure 11: Case 1 — post-op radiograph

Figure 12: Case1 — 1-year recall radiograph

laser-activated irrigation (Fotona). Obturation was completed with a size 16 MicroObtuator (MicroEndo), NanoFlow (Healthdent Technology Intl., Inc.; Palmdale, California) gutta percha and Kerr Pulp Canal Sealer EWT. Ideal healing was seen at 1-year follow-up.

Case 2 (Figures 13-14) Tooth No. 4 was diagnosed with pulpal necrosis and acute apical periodontitis.

After access, No. 4 was irrigated with PIPS, dried with paper points, and obturated with a MicroObturator size 16. NanoFlow gutta percha and Kerr EWT sealer were used. No instrumentation was needed due to the size of the existing canal space.

Figure 13: Case 2 — pre-op radiograph

Figure 14: Case 2 — post-op radiograph

Case 3 (Figures 15-16) Tooth No. 3 was diagnosed with pulpal necrosis and acute apical periodontitis. The palatal canal was instrumented to a size 35 .02 MicroFile (MicroEndo); the mesial and distal buccal canals to a size 30.02 MicroFile. Irrigation was completed with Er-Yag laser-activated irrigation. Obturation was completed with a MicroObturator size 16.

NanoFlow gutta percha and Kerr EWT sealer were used.

Summary

Figure 15: Case 3 — pre-op radiograph 10 Endodontic practice

Figure 16: Case 3 — post-op radiograph

For the past 30-plus years, the techniques associated with endodontic treatment have been focused on creating tapered canals to allow adequate cleansing and obturation. With new irrigation and obturation techniques, creating these tapers and the associated tooth weakening is no longer necessary (Figure 17). Preservation of cervical tooth structure maintains the strength of the area of the tooth, which under Volume 11 Number 1

CLINICAL

Figure 17: Cracked mesial root No. 18

occlusal loading has the highest stress. Thus, conservative instrumentation in the cervical area of the canals does not weaken the tooth as may happen with more aggressive instrumentation (Figure 18).

We are at an amazing time when new techniques, technology, and understanding allow us to step away from previously held beliefs and perceptions. We can move in new directions that will allow us to experience greater success and long-term value for our patients and ourselves. Most importantly, the time is now! EP

REFERENCES 1. Peters OA, Schonenberger K, LaiB A. Effects of four NiTi preparation techniques on root canal geometry assessed by micro computed tomography. Int Endod J. 2001;34(3):221-230.

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

3. Zehnder M. Root canal irrigants. J Endod. 2006;32(5): 389-398.

4. Del Carpio-Perochena AE, Bramante CM, Duarte MA, et al. Biofilm dissolution and cleaning ability of different irrigant solutions on intraorally infected dentin. J Endod.

2011;37(8):1134-1138.

5. Arias-Moliz MT, Ordinola-Zapata R, Baca P, et al. Antimicrobial activity of chlorhexidine, peracetic acid and sodium hypochlorite/etidronate irrigant solutions against Enterococcus faecalis biofilms. Int Endod J. 2015;48(12):1188-1193.

6. Teixeira CS, Felippe MCS, Felippe WT. The effect of application time of EDTA and NaOCl on intracanal smear layer removal: an SEM analysis. Int Endod J. 2005;38(5):285-290.

Volume 11 Number 1

Figure 18: No. 31 endodontically treated with minimally invasive techniques

7. Banin E, Brady KM, Greenberg EP. Chelator-induced dispersal and killing of Pseudomonas aeruginosa cells in a biofilm. Appl Environ Microbiol. 2006;72(3):2064-2069.

8. Cavaliere R, Ball JL, Turnbull, L, Whitchurch CB. The biofilm matrix destabilizers, EDTA and DNaseI, enhance the susceptibility of nontypeable Hemophilus influenzae biofilms to treatment with ampicillin and ciprofloxacin. Microbiologyopen. 2014;3(4):557-567.

9. Zehnder M. Root canal irrigants. J Endod. 2006;32(5): 389-398.

10. Baca P, Junco P, Arias-Moliz MT, González-Rodríguez MP, Ferrer-Luque CM. Residual and antimicrobial activity of final irrigation protocols on Enterococcus faecalis biofilm in dentin. J Endod. 2011;37(6):363-366.

using Particle Image Velocimetry (PIV). Clin Oral Investig.

2016;20(2):381-386.

20. Kato AS, Cunha RS, da Silveira Bueno CE, et al. Investigation of the efficacy of passive ultrasonic irrigation versus irrigation with reciprocating activation: an environmental scanning electron microscopic study. J Endod.

2016;42(4):659-663.

21. Rundquist B, Versluis A. How does taper effect root stresses? Int. Endod J. 2006;39(3):226-237.

22. Bier C, Shemesh H, Tanomaru-Filho M, Wesselink P, Wu M. The ability of different nickel-titanium rotary instruments to induce dentinal damage during canal preparation. J Endod.

2009;35(2):236-238.

11. Lin S, Liu Q, Peng Q. et al. The ablation threshold of Er:YAG laser and Er,Cr:YSGG laser in dental dentin. Sci Res Essays.

2010;5(16):2128-2135.

23. Li SH, Lu Y, Song D, et al. Occurrence of dentinal microcracks in severely curved root canals with ProTaper Universal, WaveOne, and ProTaper Next file systems. J Endod. 2015;41(11):1875-1879.

12. Majaron B, Lukac M, Sustercic D, Funduk N, Skaleric U. Threshold and efficiency analysis in Er:YAG laser ablation of hard dental tissue. Proc SPIE. 1996;2922:233-242.

24. Dane A, Capar I, Arslan H, AkçayM, Uysal B. Effect of different torque settings on crack formation in root dentin.

J Endod. 2016;41(2):304-306.

13. Siu C, Baumgartner JC. Comparison of the debridement efficiency of the EndoVac irrigation system and conventional needle root canal irrigation in vivo. J Endod. 2010;36(11): 1782-1785.

25. Burklein, Tsotsis P, Schäfer E. Incidence of dentinal defects after root canal preparation: reciprocating versus rotary instrumentation. J Endod. 2013;39(4):501-504.

14. Neelakantan P, Devaraj S, Jagannathan N. Histologic assessment of debridement of the root canal isthmus of mandibular molars by irrigation activation techniques ex vivo. J Endod. 2016;42(8):1268-1272.

15. Amato M, Vanoni-Heineken I, Hecker H, Weiger R. Curved versus straight root canals: the benefit of activated irrigation techniques on dentin debris removal. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(4):529-534.

26. Wu M, Wesselink P, Boersma J. A 1-year follow-up study on leakage of four root canal sealers at different thicknesses.

Int Endod J. 1995;28(4):185-189.

27. Smith RS, Waller RN, Loushine RJ, Kimbrough WF. Effect of varying the depth of heat application on the adaptability of gutta percha during warm vertical compaction. J Endod.

2000;26(11):668-672.

28. Juhlin JJ, Walton RE, Dovgan JS. Adaptation of Thermafil components to canal walls. J Endod. 1993;19(3):130-135.

16. Retsas A, Koursoumis A, Tzimpoulas N, Boutsioukis C, Uncontrolled removal of dentin during in vitro ultrasonic irrigant activation in curved root canals. J Endod.

2016;42(10):1545-1549.

29. O’Neill K, Pitts D, Harrington G. Evaluation of the apical seal produced by the McSpadden compactor and by lateral condensation with chloroform softened primary core. J Endod. 1983;9:190-197.

17. Lloyd A, Uhles J, Clement D, Garcia-Goday F. Elimination of intracanal tissue and debris through a novel laser-activated system assessed using high-resolution micro-computed tomography: a pilot study. J Endod. 2013;40(4):584-587.

30. Grover, RE. Observation from follow-ups of intermediate to long term endodontically treated teeth. Presented at: AAE Annual Meeting. New Orleans, Louisiana; 2017.

18. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement of human molars using the GentleWave system. J Endod. 2015;41(10):1701-1705.

19. Kooh J, Jaramillo D, DiVito E, Peters O. Irrrigant flow during photon-induced photoacoustic streaming (PIPS)

31. Grande NM, Plotino G, Sinibaldi R, Mangani F, Cerutti A, Gambarini G. UC-based finite element analysis study on the stress distribution in root canal treated teeth with different cavity access and root canal preparation geometry.

Presented at: AAE Annual Meeting. Seattle, Washington; 2015.

Endodontic practice 11

CLINICAL

Influence of calcium hydroxide and the type of endodontic sealer in the adehsion of fiberglass posts on the bovine root dentin Drs. Tiago André Fontoura de Melo and Daniel Galafassi, along with Bruna Machado dos Passos, Sheila Machado dos Passos Zini, Priscila Souza de Souza, and Cláudia Wagner, analyze the effects of calcium hydroxide as intracanal medication and the type of cement used on the adhesion of fiberglass posts with RelyX™ U200 Abstract

Introduction

This article analyzes if calcium hydroxide as intracanal medication and the type of cement used in endodontic treatment influence adhesion of fiberglass posts with RelyX™ U200. Forty bovine teeth were endodontically prepared and then randomly divided into four groups: G1: Intracanal medication and endodontic filling with AH Plus® G2: Endodontic filling with AH Plus® and without intracanal medication G3: Intracanal medication and endodontic filling with Endofill® G4: Endodontic filling with Endofill® and without intracanal medication.

The fillings were then removed to receive the fiberglass post, cemented with RelyX U200, and stored for 48 hours in an oven. The samples were sectioned at 1 mm according to the thirds of the roots and subjected to the push-out test. The data obtained was treated by two-way ANOVA. The significance level was 5%. There were no statistical differences between the four groups tested.

Endodontically treated teeth often have insufficient amount of tooth structure to promote a good retention of restorative material. The use of prefabricated intrarradicular posts such as fiberglass posts presents physical chemical properties very similar to the dental structure (Monticelli, et al., 2006), which provides a homogeneous restoration self-contained among the intrarradicular portion and the coronary portion (Souza-Júnior, et al., 2010).

Despite the good bonding response between the fiberglass posts and the tooth structure with the use of resin cements, gaps in the adhesive layer are still reported (Ferrari and Mannocci, 2000). In the literature, one of the variables that can influence this adhesion is the type of the intracanal medication (ICM) employed in endodontic treatment (Paul and Schärer, 1997) as well as the endodontic sealer (Cohen, et al., 2002).

Calcium hydroxide intracanal medications are one of the most widely used by professionals in endodontics. The possible permanence of calcium hydroxide on dentin walls may interfere negatively in the adhesion of the cement (Cohen, et al., 2002).

The use of endodontic sealers is based on the belief that zinc oxide and eugenol can impair the adhesive cementation (Watanabe, et al., 1997). This may be related to the fact that endodontic sealer residues

Conclusions The use of medication intracanal calcium hydroxide-based as well as the type of endodontic sealer tested (AH Plus or Endofill) did not interfere with the strength of adhesion of fiberglass posts cemented in the root canal with RelyX U200.

Tiago André Fontoura de Melo holds a PhD in endodontics and is a teacher in the Department of Conservative Dentistry in the Dental School, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.

Daniel Galafassi holds a PhD in dentistry and is a teacher in the Clinical Department at the Dental School, College of Serra Gaúcha (FSG), Caxias do Sul/RS, Brazil.

Cláudia Wagner holds a MSc in endodontics and is a teacher in the Clinical Department of the Dental School, College of Serra Gaúcha (FSG), Caxias do Sul/RS, Brazil.

Bruna Machado dos Passos, Sheila Machado dos Passos Zini, and Priscila Souza de Souza are graduate students in the Clinical Department of the Dental School College of Serra Gaúcha (FSG), Caxias do Sul/RS, Brazil.

12 Endodontic practice

remain on the surface or even to its own constitution. The presence of eugenol is believed to inhibit the polymerization of composite materials, affecting its mechanical properties and adhesive-bonding ability (Fonseca, et al., 2005).

Thus, the characteristics between the materials and the protocols used in the endodontic treatment and the cementation of prefabricated posts are important aspects to be considered to obtain the success on the tooth rehabilitation. The present study proposes to analyze with the mechanical push-out test if calcium hydroxide as an intracanal medication and the type of the endodontic sealer used in root canal treatments influences the adhesion of fiberglass posts.

Methods Selection and preparation of samples Forty inferior bovine incisors were selected according to the standardization of the initial apical diameter of the root canal, equivalent to an endodontic instrument type-K No. 40 (Dentsply/Maillefer Instruments S.A., Ballaigues, Switzerland).

After being cleaned, the crowns of the teeth were sectioned at the cementoenamel junction (CEJ) with the aid of a carburundum disc in low rotation. The actual length of root remainder was standardized at 17 mm, and the working length (WL) was 1 mm short of this measurement (WL = 16 mm).

Division of experimental groups Samples were randomly divided into four experimental groups (Table 1), using the simple random sample technique using the Excel program (Microsoft Excel, Microsoft, USA).

Endodontic preparation of the samples All samples were prepared manually with first- and second-series K-type stainless steel endodontic instruments (Dentsply Volume 11 Number 1

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CLINICAL Maillefer Instruments S.A., Ballaigues, Switzerland; Tulsa, Oklahoma, USA).

The mechanical chemical preparation was performed using the instrument type K No. 30, continuing until No. 60 (all calibrated in WL). Afterward, the programmed progressive retreat was performed with two more instruments (Nos. 70 and 80), with a 1 mm and 2 mm retreat of the WL, respectively.

During the step of staging the preparation, care was taken to recapitulate the WL with instrument No. 60.

At each instrument change, the canals were irrigated with a plastic syringe (BD Solumed, São Paulo, São Paulo, Brazil) and NaviTip 25 mm 30ga needles (Ultradent, Indaiatuba, São Paulo, Brazil; South Jordan, Utah, USA), with 5% sodium hypochlorite (Iodontec Indústria e Comércio de Produtos Odontológicos Ltda., Porto Alegre, Rio Grande do Sul, Brazil) in a standard quantity of 2 mL. After the preparation, the final disinfection was made with 17% EDTA (Biodinamica, Ibiporã, Paraná, Brazil) for 3 minutes and under agitation of instrument No. 60. The canals were then dried with sterile absorbent paper tips No. 60 (Dentsply/Maillefer Instruments S.A., Ballaigues, Switzerland).

Intracanal medication protocol In the samples of groups G1 and G3, the intracanal medication protocol described here, before the endodontic obturation stage, was performed.

Calcium hydroxide PA (SS White, Rio de Janeiro, Rio de Janeiro, Brazil; Lakewood, New Jersey, USA) associated with saline solution (Cremer S.A., Blumenau, Santa Catarina, Brazil) was used as intracanal medication. The two substances were manipulated under a glass plate and with the aid of a cement spatula No. 24 until obtaining a homogeneous and consistent paste. The pulp was taken from (into) the root canal with the aid of a Lentulo spiral filler No. 45 (KG Sorensen Indústria e Comércio Ltda., Barueri, São Paulo, Brazil), calibrated 2 mm short of WL (14 mm).

After placement of the intracanal medication, the samples were temporarily restored with 2 mm of Cavitec™ (Kerr Dental, Orange, California, USA) and stored in a bottle containing distilled water in an oven at 37°C for 7 days.

No intracanal medication was administered in the G2 and G4 groups. The canals were immediately filled after completion of the mechanical chemical preparation.

Endodontic obturation protocol Before endodontic obturation for the samples of groups G1 and G3, the 14 Endodontic practice

Table 1: Four experimental groups Group

n

Intracanal medication used

Endodontic sealer used

G1

10

Yes

AH Plus®

G2

10

No

AH Plus®

G3

10

Yes

Endofill®

G4

10

No

Endofill®

Figure 1: Images of the execution of the push-out test — A (1 mm test body), B (test body positioned on the universal test machine), and C (test specimen with the extruded post after the mechanical test)

restorations were removed with the aid of a diamond bur No. 1012 (KG Sorensen Indústria e Comércio Ltda., Barueri, São Paulo, Brazil), and ICM was removed with the use of instrument No. 60 and 2.5% sodium hypochlorite irrigation. After the removal of the intracanal medication and final disinfecting procedure, 17% EDTA was performed again, followed by drying the canals with absorbent paper tips prior to filling.

The protocol of endodontic obturation executed in all of the samples followed the one recommended by the Tagger Hybrid Technique. As endodontic sealer, zinc oxide and eugenol — Endofill® (Dentsply Maillefer Instruments SA, Ballaigues, Switzerland; Tulsa, Oklahoma, USA) or epoxy resin-based material — AH Plus® (Dentsply/ Maillefer Instruments SA, Ballaigues, Switzerland; Tulsa, Oklahoma, USA), according to each experimental group, were provided and spatulated according to the manufacturer’s recommendations, and then the main gutta-percha points No. 60 (Dentsply Maillefer Instruments S.A., Ballaigues, Switzerland; Tulsa, Oklahoma, USA) were wrapped in sealer and introduced into the WL. After insertion of the fifth accessory point (Dentsply Maillefer Instruments SA, Ballaigues, Switzerland; Tulsa, Oklahoma, USA) with the aid of the bidigital spacer B (Dentsply/Maillefer Instruments SA, Ballaigues, Switzerland; Tulsa, Oklahoma, USA) during lateral condensation to obturate the middle and cervical thirds of the canals, gutta percha were plasticized by

McSpadden® compactor No. 60 (Dentsply/ Maillefer Instruments S.A., Ballaigues, Switzerland; Tulsa, Oklahoma, USA) calibrated at 4 mm below the WL. The compactor, driven clockwise in the lowrotating piece, was introduced and withdrawn from the moving canal. After the gutta-percha plastification and removal of the activated McSpadden® from the canal, the vertical condensation of the gutta percha was carried out using the Paiva instrument No. 2 (SS White, Rio de Janeiro, Rio de Janeiro, Brazil; Lakewood, New Jersey, USA).

After an obturation of all samples, they were temporarily restored with Cavitec and immersed in a bottle containing distilled water in an oven at 37°C and relative humidity to 100% for 2 days to complete setting of the endodontic sealer.

Protocol for removal of gutta percha from the canal and cementing the fiberglass post After removal of the restoration, the removal of gutta percha from the canals was done with the aid of a 12 mm drill DC2 (Whitepost, FGM, Joinville, Santa Catarina, Brazil) at low rotation, remaining 4 mm of the obturator material in the apical third.

Prior to the cementation of the fiberglass posts, the canals were irrigated with 2.5% sodium hypochlorite solution and dried with absorbent paper points, as recommended by the adhesive cement manufacturer.

On the dried canals, silane (FGM Produtos Odontológicos, Joinville, Santa Catarina, Brazil) was applied. Drying at room Volume 11 Number 1

Shear extrusion test (push-out) The samples were sectioned perpendicular to the long axis of the root, with a diamond disk (American Burrs, Porto Alegre, Rio Grande do Sul, Brazil) at a low rotation under refrigeration. A first cervical portion approximately 1 mm thick was discarded, as inherent imperfections in the adhesive zone may have influenced the results due mainly to the presence of oxygen. Then three slices of approximately 1 mm thickness each were obtained — one from the cervical third, one from the middle third, and the other from the apical third. After cutting each slice, markings were made with an overhead pen on the cervical surface of the sample to highlight this face for later positioning of the piece on the time of the test. Then during the pushout test, each sample was placed on a metal device with a central opening larger than the canal diameter. The slices always remained with the cervical side down, facilitating the extrusion of the canal post/cement, which already presents a conical shape, thus leaving the larger part of the diameter down. For the push-out test, an adapted metal cylinder (Ø = 1 mm) induced the load on the central portion of the post/cement without the load being applied to the dentin (Figure 1).

The test was performed in a universal test machine (EMIC, São José dos Pinhais, Paraná, Brazil) with a velocity of 0.5 mm/ min and a load of 50 N (newton). The results were recorded in newton and later converted to MPa (MegaPascal). The adhesion area (A) was calculated by the formula (2TTr) multiplied by the height (L). The force (F) that occurred resulting in the fault was recorded in N and converted to MPa. The adhesive resistance to push-out was measured by dividing the force (F) by the adhesion area (A).

Statistical analysis The obtained data was submitted to two-way ANOVA tests for multiple Volume 11 Number 1

Table 2: Mean and standard deviation of the experimental groups in relation to the root thirds Third root canal

Experimental group

Cervical Mean

SD

Medium Mean

SD

Apical Mean

P

SD

G1 - AH Plus® with MIC

6.11Aa ± (4.10)

6.11Aa ± (4.10)

4.35Aa ± (2.71)

P = 0.515

G2 - AH Plus® without MIC

5.56Aa ± (3.22)

5.82Aa ± (1.85)

5.21Aa ± (4.00)

P = 0.907

G3 - Endofill® with MIC

6.07Aa ± (3.38)

4.81Aa ± (2.24)

3.75Aa ± (3.33)

P = 0.247

G4 - Endofill® without MIC

4.97Aa ± (3.55)

3.90Aa ± (2.05)

2.86Aa ± (2.79)

P = 0.272

P

P = 0.881

P = 0.265

P = 0.559

comparisons. The level of significance was 5% (P ≤ 0.05). Statistical analysis was performed using SPSS 13.0 software (SPSS Inc., Chicago, Illinois, USA).

Results The mean values of the adhesion forces (map) of the different experimental groups in the different regions of the canals are shown in Table 2.

Means followed by distinct uppercase letters in the line and means followed by different lowercase letters in the line differ significantly by means of the analysis of variance at the significance level of 5%.

The ANOVA two-way statistical test did not show any statistical difference between the experimental groups, whether or not calcium hydroxide-based intracanal medication and endodontic sealer were used,

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CLINICAL

temperature followed by application of air jets at a distance of 15 cm for 1 minute. The resinous cement RelyX U200 (3M/ESPE, Saint Paul, Minnesota, USA) was applied to the root canal using a centrix syringe (DFL, Rio de Janeiro, Rio de Janeiro, Brazil) with a metal tip.

The post was introduced into the root canal and filled with cement to the coronal portion to seal the entrance and photoactivated with the EC450 (ECEL, Ribeirão Preto, São Paulo, Brazil) for 40 seconds. The fiberglass posts used in the experiment were No. 2 (Angelus, Londrina, Paraná, Brazil). They were cleaned prior to use with 70% alcohol (Icarai, São Paulo, São Paulo, Brazil).

CLINICAL regardless of the thirds of the roots on the evaluated canal.

Discussion The use of prefabricated intraradicular esthetic posts such as fiberglass represents a treatment option that offers optimal esthetics and function, which can be fixed by adhesion to root dentin. However, innumerable factors related to the endodontic approach may influence the clinical success of this rehabilitation technique throughout the time of preservation.

The mechanical push-out test method used is one of the research resources used to measure adhesive strength of materials (Armstrong, et al., 2010). According to Soares, et al. (2008), this method provides a more homogeneous distribution of tensions and less variability in the calibration process, thus preservation recommended and widely used to determine the bond strength of fiberglass posts to intrarradicular dentin.

The results obtained, regarding the adhesion strength of intrarradicular cemented fiberglass posts, did not show an influence in relation to the type of endodontic sealer tested, as verified in the studies of Manicardi, et al. (2011) and Aggarwal, et al. (2012).

Similar results were found by Shokouhinejad, et al. (2013) that compared the AH-Plus® and EndoSequence BC® sealers, which is a bioceramic sealer. On the other hand, Zhu, et al. (2006) found that endodontic sealer containing eugenol (Endofill®) may compromise the bond strength of intraradicular fiberglass posts when compared to resinous composites such as AHPlus. In the study by Mosharraf and Zare (2014), with the use of eugenol-based sealer (Endofill), there was a significant reduction in union strength by the push-out test between intraradicular fiberglass posts when compared to AH26®, which is a resinous sealer.

Rosa, et al. (2013) also performed a study to evaluate the influence of the endodontic sealer type (Endofill, AH Plus, and MTA Fillapex) on the adhesion of fiberglass posts to the bovine dentin root through the push-out test. The authors evaluated the cementation process of the posts in two experimental times, immediate cementation, that is, after the endodontic obturation and cementation after 15 days of obturation.

They could observe that when the fiberglass posts were cemented immediately, the adhesive strength was similar regardless of the type of endodontic sealer tested. However, after 15 days, teeth sealed with resin-based epoxy resin (AH Plus) presented the highest values ​​of adhesive strength, which may help 16 Endodontic practice

explain in a way the results obtained in the present study, since it is probable that the reduced time (48 hours) between completion of endodontic treatment and cementation of the fiberglass post may not have been able to influence the adhesion difference between the experimental groups.

The presence of eugenol (2-methoxy4-allylphenol) and phenolic components in the composition of the endodontic sealer can deactivate the polymer chain molecules and compromise the cementation process of the intraradicular post, decreasing the bond strength (Dias, et al., 2009; Demiryurek, et al., 2010; Aleisa, et al., 2012). This factor doesn’t seem to have influenced the adhesive strength of the studied groups.

The authors believe that the reduced time between canal obturation and disembedding may have been the most relevant factor in the good result obtained in this study.

For Davis and O’Connell (2007), a correct root canal cleansing protocol prior to adhesive cementation of the intraradicular post is essential to reduce interference and increase the bond strength.

Regarding the influence in the adhesion process from the use of intracanal medication in the previous endodontic treatment, no statistical differences were obtained between the groups, corroborating with the study of Erdermir, et al. (2004), who used chlorhexidine digluconate and calcium hydroxide as a medication.

Lambrianidis, et al. (2006) and Balvedi, et al. (2010), who evaluated different forms of calcium hydroxide-based intracanal medication, found that traces of calcium hydroxide in the walls of the root canal may impair the cementation and adhesion process of intraradicular posts. Calcium hydroxide reduces dentin permeability by physical blockage of the dentin tubules (Ngoh, et al., 2001) and by the chemical interaction between the RelyX self-adhesive cement and the calcium hydroxyapatite of the dentin wall as observed by Pashley, et al. (1986); Balvedi, et al. (2010), and Gerth, et al. (2006), who obtained lower results in the adhesion force when calcium hydroxide-based intracanal medication was previously used.

Conclusions According to the results, it can be concluded that the use of calcium hydroxidebased intracanal medication as well as the type of endodontic sealer tested (AH Plus or Endofill) did not interfere in the adhesion strength of fiberglass posts cemented intraradicular with RelyX U200. EP

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20. Rosa RA, Barreto MS, Moraes Rdo A, et al. Influence of endodontic sealer composition and time of fiber post cementation on sealer adhesiveness to bovine root dentin.

Braz Dent J. 2013;24(3):241-246.

21. Shokouhinejad N, Gorjestani H, Nasseh AA, Hoseini A, Mohammadi M, Shamshiri AR. Push-out bond strength of gutta-percha with a new bioceramic sealer in the presence or absence of smear layer. Aust Endod J. 2013;39(3):102-106.

22. Soares PV, Santos-Filho PC, Martins LR, Soares CJ. Influence of restorative technique on the biomechanical behavior of endodontically treated maxillary premolars.

Part I: Fracture resistance and fracture mode. J Prosthet Dent. 2008;99(1):30-37.

23. Souza-Júnior EJ, Bueno VC, Dias CT, Paulillo LA. Effect of endodontic sealer and resin luting strategies on pull-out bond strength of glass fiber posts to dentin. Acta Odontol Latinoam. 2010;23(3):216-221.

24. Watanabe EK, Yamashita A, Imai M, Yatani H, Suzuki K. Temporary cement remnants as an adhesion inhibiting factor in the interface between resin cements and bovine dentin. Int J Prosthodont. 1997;10(5):440-452.

25. Zhu S, Liu C, Zheng Z, Yang L, Gao X. Analysis of different endodontic sealers and strategies of root canal irrigation on the bond strength of fiber posts. Hua Xi Kou Qiang Yi Xue Za Zhi. 2015;33(3):311-314.

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CLINICAL RESEARCH

Accuracy comparison of three different electronic apex locators in single-rooted teeth — an in vitro study Drs. Amil Sharma, Gregori M. Kurtzman, Sandeep Gupta, Shivanshu Bhardwaj, and Poorvasha Dhanare discuss accurate determination of the location of the working length Abstract With many new inventions entering the dental field each day, endodontics has risen to a new level. Previously, root canal treatment was directed by “biomechanical preparation” and has shifted toward a “chemo-biomechanical preparation” methodology. Root canal treatment should be dependent on not only proper cleaning and shaping procedures but also access of the endodontic irrigants to the working length during treatment. The determination of correct working length is a very important factor leading to clinical success in root canal treatment. Numerous studies have demonstrated that when instrumentation and obturation reach the apical foramen, endodontic treatment provides predictable clinical results. Yet radiographic determination of working length with an endodontic file in the canal is an inaccurate method of deciding where the instrumentation and obturation needs to terminate. Therefore, accurate determination of the location of the working length is a very important factor in successful root canal treatment.

by electrical resistance would be possible.1 Working length (WL) determination is a very important factor in the success of root canal treatment. Failures in determination of WL such as measuring short or beyond the apex may cause failure of the root canal treatment due to placement of obturation material beyond the confines of the anatomic root.

Therefore, clinicians need to obtain accurate measurements during WL determination to yield predictable clinical results.2 Numerous studies have demonstrated different histological results after root canal treatment and have shown superior results when instrumentation is performed as well as obturation to the apical constriction (apical foramen). Thus, determination of the accurate WL by locating the minor apical diameter is very important for successful root canal treatment.2 Yet radiographic determination of working length with an endodontic file in the canal is an inaccurate method of determining where the instrumentation and obturation needs to terminate. The aim of this study is to evaluate the accuracy of three different electronic apex locators in single-rooted teeth.

Introduction

Materials and methods

Electrical resistance between the mucous membrane and periodontium can be considered to have a constant relationship, so a method for measurement can be developed.

Therefore, measuring the length of the canal Amil Sharma, BDS, MDS, has a BDS from Jiwaji University, Gwalior M.P. India, and a MDS from Madhya Medical Science University in Jabalpur, Madhya Pradesh, India (MPMSU).

Gregori M. Kurtzman, DDS, MAGD, is in private practice in Silver Spring, Maryland.

Sandeep Gupta, BDS, MDS received a BDS RGHUS in Karnataka and MDS from Dr. Bhimrao Ambedkar University, Agra, Uttar Pradesh, India.

Shivanshu Bhardwaj, BDS, MDS, received a BDS from Barkatullah University Bhopal M.P. India and a MDS from Madhya Medical Science University in Jabalpur, Madhya Pradesh, India (MPMSU).

Poorvasaha Dhanare, BDS, MDS, received a BDS from Barkatullah University Bhopal M.P. India and an MDS from Dr. Bhimrao Ambedkar University, Agra, Uttar Pradesh, India.

18 Endodontic practice

Sixty extracted human single-rooted permanent teeth with completely formed apices were used as study samples. The teeth were extracted for periodontal, prosthetic, or orthodontic reasons. After extraction, the teeth were placed in 5% sodium hypochlorite to remove the periodontal ligament. Stains and calculus were removed with the help of hand scalers and curettes.

Selected teeth were stored in a container containing 2% thymol crystals in distilled water until needed for the study. Endodontic access was prepared with burs using a highspeed handpiece. The study samples were analyzed for actual working length with the aid of a stereo microscope under 40x magnification by multiple observers, with a mean value of three observers set as the actual working length. A size 15 K-file was inserted into each study sample to access the root canal working length. Care was taken that each sample

Figure 1: Microscopic working length reading with file at the apex

was placed properly on the tray of the stereo microscope so that complete working length was analyzed. The apical exit of the inserted endodontic file was noticed (Figure 1), and the file was removed from the canal without changing the placement of the rubber stopper.

The working length was measured with an endo gauge; the procedure was repeated for each study sample 3 times by each observer, and the mean value as actual working length was set. The 60 extracted teeth were then divided into three groups.

Each tooth was placed in a container poured with alginate that was mixed with a saline liquid to replicate the conduction of electricity to simulate an oral environment.

The lip clip was placed into the alginate, and the wire from the apex locator was connected to the file.

Group I Containing 20 extracted human anterior single-rooted teeth whose working length was taken by using RAYPEX® 6 electronic apex locator (VDW®, Munich, Germany) (Figure 2, left).

Group 2 Containing 20 extracted human anterior single-rooted teeth whose working length was taken by using ROOT ZX II electronic apex locator (J. Morita Corp., Osaka and Tokyo, Japan; J. Morita USA, Inc., Irvine, California). (Figure 2, center).

Group 3 Containing 20 extracted human single-rooted teeth whose working length was taken by using Propex II™ electronic apex locator (Dentsply Sirona, York, Pennsylvania) (Figure 2, right).

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CLINICAL RESEARCH The observers then recorded three readings for each sample by reinserting the No.15 K-file, and measurements were obtained with the three Electronic Apex Locators: Root-ZX II (J. Morita), Propex II (Dentsply Sirona) and Raypex 6 (VDW). (Figure 3) These values were then compared with the actual working lengths previously obtained.

Statistical analysis All the statistical analysis was performed using SPSS version 18 and MedCalc® Version 14. A p-value of < 0.05 was considered statistically significant.

Statistical analysis was performed using paired t-test and Kruskal Wallis ANOVA with post-hoc Conover test. Statistical readings were considered significant when p < 0.001.

Figure 2: Electronic Apex Locators (EAL) used in the study

Results The mean value of working length for group 1 was 23.11 mm, and the standard deviation was 1.86 as measured with the microscope. The mean value of this group’s working length with the apex locator was 22.7 mm, and the standard deviation was 1.8.

The mean value of working length of group 2 was 20.98 mm, and the standard deviation was 1.76 as measured with the microscope. The mean value of working length for group 2 was 20.19 mm, and the standard deviation was 1.47 with the apex locator reading.

The mean value of working length of group 3 was 21.33 mm, and the standard deviation was 2.45 as measured with the microscope.

The mean value of working length of group 3 was 20.52 mm, and the standard deviation was 2.22 in apex locator reading.

The absolute agreement among the readings of the three apex locators was checked by intra-class correlation coefficient (0.93).

The absolute agreement among the three microscope readings was checked by intraclass correlation coefficient (0.92).

Discussion Correct working length determination is the main factor leading to success in endodontic treatment. Studies have shown the histological results after endodontic treatment to be superior when instrumentation and obturation are limited to the apical foramen and not beyond this anatomical landmark. Therefore, accurate determination of the location of the apical constriction is a key factor in successful endodontic therapy.3 In 1918, Custer was the first to report the use of an electric current to determine working length. In 1962, Sunada reported that there is a constant value (6.5k ohms) of electrical resistance between the mucous 20 Endodontic practice

Figure 3: Apex locators recording working length on specimen samples Table 1: Intra-group comparison of apex locator and microscope working length Apex Locator

Disinfection Protocol

p-value

Mean

SD

Mean

SD

Group 1

22.73

1.88

23.11

1.86

< 0.001; Sig

Group 2

20.19

1.47

20.98

1.76

< 0.001; Sig

Group 3

20.52

2.22

21.33

2.45

< 0.001; Sig

Table 2: Inter-group comparison of the mean difference of the microscope and apex locator working length Difference of microscope — apex locator working length Mean

SD

Group 1

0.37

0.22

Group 2

0.78

0.51

Group 3

0.82

0.77

membrane and the periodontium and stated that it is possible to use this value of resistance in the estimation of root length.

Additionally, he demonstrated that if an endodontic instrument is connected to an ohm meter — introduced into the canal and advanced until the ohm meter shows the value of 40 ohms — the tip of the instrument has reached the periodontal ligament at the apical foramen. The device utilized by Sunada in his research became the basis for electronic apex locators.3

p-value

Post hoc test

0.015

Group 2, 3 >1

In the study presented here, three different electronic apex locators were utilized (Root ZX II, Propex II, and Raypex 6) whose electronic working length was compared to the actual root length using a stereo microscope to determine the actual working length. The results demonstrated that the accuracy of the Raypex 6 EAL was more accurate than the Root ZX II EAL, which is similar to a study conducted by Samadi, et al.4 Additionally, the Propex II was not as accurate as the Raypex II as reported by Demiriz, et Volume 11 Number 1

perceived disadvantage of electronic apex locators has been the concern in use with patients who have implanted pacemakers or defibrillators. Yet multiple published studies have found the EAL has no negative effect on these implanted devices, and they are safe to use in these patients.15-17 EP

8. D’Assunção FL, de Albuquerque DS, de Queiroz Ferreira LC. The ability of two apex locators to locate the apical foramen: an in vitro study. J Endod. 32(6): 2006;32(6): 560-562.

9. Sadeghi S, Abolghasemi M. A comparison between the Raypex5 apex locator and conventional radiography for determining working length of straight and curved canals.

Iran Endod J. 2008;2(3):101-104.

10. Ebrahim AK, Wadachi R, Suda H. In vitro evaluation of the accuracy of five different electronic apex locators for determining the working length of endodontically retreated teeth.

Aust Endod J. 2007;33(1):7-12.

11. Bernardes R, Duarte AH, Vasconcelos BC, et al. Evaluation of precision of length determination with 3 electronic apex locators: Root ZX, Elements Diagnostic Unit and Apex Locator, and RomiAPEX D-30. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104 (4):91-94.

REFERENCES 1. Sunada I. New method for measuring the length of the root canal. J Dent Res. 1962;41(2):375-387.

2. Saglam BC, Çiek E, Kocak S, Kocak MM. Comparison of low versus full battery/charge conditions of electronic apex locators. J Dent Fac Atatürk Uni. 2015;181-184.

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

3. Ebrahim AK, Wadachi R, Suda H. Electronic apex locators — a review. J Med Dent Sci. 2007;54:125-136.

13. Thomas M, Acharya S. A comparative evaluation of the accuracy of third generation electronic apex locator (root zx) and conventional radiography to determine working length — an in vivo study. Endodontology. 2008;14-21.

4. Samadi Y, Harandi A, Soleymani A, Khafri S, Tavanafar S. Evaluation of the accuracy of two apex locators in endodontic treatment and retreatments: an ex vivo study: Caspian J Dent Res. 2016;5(1):21-28.

14. Vatkar N, Sathe S, Hedge V. In vitro evaluation of the efficacy of five apex locators. Endodontology. 2008;36-42.

5. Demiriz L, Kocak MM, Saglam BC, Kocak S. In vitro evaluation of the accuracy of ProPex II, Raypex 6, and Ipex II electronic apex locators in primary molar teeth. J Health Res Rev. 2016;3(2);37-40.

15. Garofalo RR, Ede EN, Dorn SO, Kuttler S. Effect of electronic apex locators on cardiac pacemaker function. J Endod.

2002;28(12):831-833.

6. Lucena-Martín C, Robles-Gijón V, Ferrer-Luque CM, de Mondelo JM. In vitro evaluation of the accuracy of three electronic apex locators. J Endod. 2004;30(4):231-233.

16. Idzahi K, de Cock CC, Shemesh H, Brand HS. Interference of electronic apex locators with implantable cardioverter defibrillators. J Endod. 2014;40(2):277-280.

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

17. Sriman N, Prabhakar V, Bhuvaneswaran JS, Subha N. Interference of apex locator, pulp tester and diathermy on pacemaker function. J Conserv Dent. 2015;18(1):15-19.

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Conclusions The study was performed to compare the accuracy of three different electronic apex locators in single-rooted teeth in vitro, in which the following key points were concluded: 1. The use of an electronic apex locator is a reliable and accurate method in determining working length.

2. There is a minor difference between actual working length taken by a stereo microscope and working length taken by electronic apex locator.12 3. The Raypex 6 electronic apex locator is most reliable in the determination of working length, followed by the Propex II electronic apex locator and the Root ZX II electronic apex locator.

The use of an electronic apex locator is an excellent adjunct to the practice of endodontics, provided accurate working length and clinical results can be obtained consistently with time savings during treatment. A Volume 11 Number 1

es remov ore g n i h t is m No l debr rally a u d i res ite ghly, l t of u o r o h t ou ing it pump al! † n the ca

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Endodontic practice 21

CLINICAL RESEARCH

al.5 The data collected in the study presented here found a statistically significant difference between the Raypex 6 EAL and the other two units evaluated by up to 1 mm between the samples studied. Comparison of accuracy between the RootZX II and Propex II demonstrated near equal accuracy between these two EALs. Lucena-Martin, et al., conducted a study to evaluate several apex locators and found that the Root ZX II was more reliable among the apex locators he evaluated.6 Haffner, et al., also conducted a study comparing apex locators with a microscope and confirmed that apex locators are very reliable in determining working length.7 D’Assunção, et al., evaluated two apex locators and found that apex locators are reliable in locating the apical foramen, thus confirming prior reported studies.8 Sadeghi and Abolghasemi compared apex locators with the conventional radiographic method in straight and curved root canals and found apex locators are reliable in determining working length, regardless of the curvature or lack of curvature of the root.9 Studies also have stated that the use of an electronic apex locator for working length determination is a much easier procedure and more accurate than taking the working length measurements with a radiograph and a file within the canal. An added benefit is minimization of radiation exposure to the patient. Thus, we can conclude that electronic apex locators are more accurate then alternative methods to clinically determine working length, saving chair time, and decreasing patient radiation exposure.

ENDODONTIC INSIGHT

The value of the CBCT in the endodontic practice Dr. Albert (Ace) Goerig discusses the benefits of 3D imaging to the diagnostic process

A

s a practicing endodontist for over 40 years, I’m always looking for new innovations to keep me excited about endodontics and expand my technical and diagnostic skills. In 2008, I purchased my first cone beam computed tomography (CBCT) unit and used it occasionally. Once I attended Dr. Marty Levin’s 2-day course on how to use the CBCT in endodontics, I then fully understood its capabilities and began using it many times during the day. I would say this technology is one of the top four most important endodontic developments in the past 30 years — with the others being motorized engine files, microscopes, and digital radiography. Many of our referring dentists are looking for a reason to refer their patients to our office, and this is the big one. Here is a list of some advantages of this technology that I share with my referring doctors.

The CBCT helps us determine tooth morphology, including location and number of canals, pulp chamber size and degree of calcification, root structure, direction and curvature, root tip extruding outside the cortical plate, fractures, iatrogenic defects, and the extent of dental caries. CBCT also identifies locations of anatomical landmarks such as the mandibular canal and sinus in relationship to the tooth. When assessing dental trauma, it is incredible in detecting horizontal root fractures and cortical bone fractures. CBCT is essential in determining the degree and extent of internal and external resorption and determining if an extraction would be the best treatment option.

With a difficult diagnostic case where the periapical lesion does not show up on a normal radiograph, it usually becomes evident with CBCT. Here is an example of a

Figure 1

patient with severe pain, no swelling, and all teeth nonresponsive to hot, cold, or percussion. Once the scan was taken, the diagnosis was obvious — the tooth required treatment of tooth No. 30. It is amazing how many other asymptomatic teeth with radiolucencies are found on the scan adjacent to teeth being treated.

Finding the size and locations of periapical lesions and proximity to anatomic landmarks such as the mandibular canal is imperative, especially if periapical surgery is being considered. This is especially helpful in routine root canal treatment of lower second molars, making sure not to overfill into the mandibular canal.

How often in the past have we retreated poorly filled root canals and determined later the infection was due to a vertical root fracture? Here is a case I treated over 20 years ago, and the patient complained of tenderness while chewing. Even though it’s not readily visible on the standard radiograph, the CBCT showed extensive bone loss all the way down the mesial lingual root, indicating a vertical root fracture and confirmed upon extraction.

Anytime I believe there is complex dental anatomy, I take a scan. There is a standing order among my team members to take a scan on all upper molars before I enter the

Albert (Ace) Goerig, DDS, MS, is a nationally known speaker who has lectured extensively in his field of endodontics and dental practice management to dentists throughout the United States, Canada, and abroad.

He has authored over 60 articles and is a contributing author to the following textbooks: Pathways of the Pulp, Ingle’s Endodontics, and Practical Endodontics. Dr. Goerig is a Diplomate of the American Board of Endodontics and a Fellow of both the American and International College of Dentists. He has been involved in teaching both endodontics and general dentistry residents for many years. He is in private dental practice in Olympia, Washington, specializing in endodontics. In 1996, he co-founded Endodontic Practice Mastery to teach endodontists the business of dentistry while helping them to love their practice. Since then he has personally coached over 22% of all endodontists and their teams in the U.S. and Canada. He is also the co-author of Time and Money: Your Guide to Financial Freedom. Dr. Goerig and his wife, Nancy, were married in 1969 and have five children. He has many hobbies, including fishing, scuba diving, skiing, and travel.

22 Endodontic practice

Figure 2

Figure 3

room. This helps me determine the exact location and presence of the second mesial buccal canal. This not only saves unnecessary removal of root structure, but also reduces reduces patient chair time. About 5% of the time, the palatal and distal buccal roots of maxillary molars connect all the way to the apex. Many of these can fail unless you find the extra canals in the root. Most retreatments of the maxillary molars are due to the missed MB2 canal.

CBCT scanning has elevated the standard of care of endodontics. This will become one of the main reasons why doctors refer to us. CBCT improves our diagnostic accuracy; increases speed of treatment; and improves productivity, patient satisfaction, and patient outcomes. It’s fun to have such a powerful tool that brings so much value to the diagnostic aspect of the practice! EP Volume 11 Number 1

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INDUSTRY NEWS New AAE.org website transforms members’ and patients’ online experience

The 5th Annual Sonendo® 5K Fun Run & Walk at AAE18

The American Association of Endodontists has developed and launched a new website that offers more content and easier navigation for members, dental professionals, and patients. The enhanced site’s homepage provides immediate access to a wealth of resources and exclusive benefits, such as a members-only website area, subscription to the Journal of Endodontics and to AAE Connection — the AAE’s members-only online discussion and networking platform. The AAE also is showcasing its member e-newsletter — Communiqué — in a fresh new way on the new site. Crisp, clean designs liven up each page and make it easy for all visitors to find information quickly. Prominent buttons ensure efficient navigation through materials and resources to support all needs.

The new site features a simplified, topic-based menu, with content reorganized for quick, intuitive searching. The new site also allows dental professionals to access numerous clinical tools, such as guidelines and position statements, including the recently released Endodontic Competency White Paper. Members have access to exclusive members-only content in the new Member Center, which offers a broad collection of practice management resources.

For more information, visit aae.org.

Sonendo® is five for five! For the 5th consecutive year, Sonendo is sponsoring its annual charitable 5K Fun Run & Walk at AAE18.

The 5th Annual Sonendo 5K Fun Run & Walk takes place on Thursday, April 26, starting at 6:00 a.m. in the Hyatt Regency’s Centennial Ballroom E with a 10-minute warm-up

by Morgan! A member of the Science Cheerleaders, Morgan is both an aerospace engineer and a Denver Broncos Cheerleader who enjoys spending her free time empowering women and encouraging those interested to pursue careers in science, technology, engineering and math (STEM) fields.

Online or on-site registrants for AAE and the 5K Fun Run will be prompted to make a donation to the Veteran’s Passport to Hope (VP2H), an organization dedicated to raising awareness and resources for U.S. military veterans in Colorado and beyond.

VP2H also strives to raise the level of collaboration among veterans organizations, cross-offering resources and services to best serve our troops.

Register for AAE and the 5th Annual Sonendo 5K Fun Run & Walk at http://bit.ly/2FtoAD1, where you can also support our host city by donating to the VP2H.

Visit Endo Mastery at AAE Booth #1308

Ultradent Products, Inc., celebrates 40th anniversary This year, Ultradent Products, Inc., a family-owned, international dental supply and manufacturing company, is celebrating 40 years in the dental industry. Ultradent has become a worldwide leader in its field — known for its innovative dental products, rock-solid core values, and family-friendly, people-centered business culture. Ultradent is also a proud USA-manufacturer. The company researches, designs, manufactures, packages, and ships 95% of what it sells in its South Jordan, Utah, facility. It also exports 70% of its products beyond U.S. borders to over 100 countries throughout the world.

Ultradent’s hallmark products include its expanded line of tissue management products, which still includes Astringedent® hemostatic and its world-renowned, industry-leading line of tooth whitening products, Opalescence® Whitening Systems. Ultradent’s product family also includes the multiple-award winning VALO® and VALO® Grand curing lights, Ultra-Etch® etchant, and its recently introduced dual-wave soft tissue diode Gemini® laser.

For more information, visit ultradent.com, or call 800-552-5512.

24 Endodontic practice

Our program is customized for each practice and provides a unique experience for each doctor. This program is for the endodontist that is ready for change. If you’re ready to rediscover your dreams, have a fulfilling life and a successful growing practice, we are the consultants for you.

• Financial freedom • Energize your practice Dr. Ace Goerig • New marketing strategies • Implement systems • Profitable schedule • Stronger leader • Set up a new practice • Eliminate stress For more information, visit endomastery.com, email info@endomastery.com, or call 800-482-7563.

Volume 11 Number 1

Drs. Manal Farea, Adam Husein, and Cornelis H. Pameijer discuss current approaches and a new perspective for repair and regeneration in endodontology

D

uring root canal treatment, many procedural accidents may occur of which perforation of the root canal system plays a significant role. Perforation is defined by the American Association of Endodontics (AAE) Glossary of Endodontic Terms (2003) as a mechanical or pathological communication between the root canal system and the external tooth surface, which is caused by caries, resorption, or iatrogenic factors. It has been identified as the second greatest cause of endodontic failure that accounts for 9.6% of all unsuccessful cases (Pitt Ford, et al., 1995).

As a result of furcation perforation, destruction of the periodontal tissues may occur, which ultimately lead to loss of the tooth (Arens, Torabinejad, 1996; Tsesis, Fuss, 2006). The prognosis of the tooth depends upon several factors: 1. The severity of initial damage to the periodontal tissue 2. The location and size of perforations 3. The bacterial contamination 4. The sealing ability or cytotoxicity of the repair materials (Tsesis, Fuss, 2006; Sinai, 1977; Balla, et al., 1991).

Even if a biocompatible material is used to treat a perforation, extensive injury may cause irreversible damage to the attachment apparatus at the furcation area (Sinai, et al., 1989.)

In large perforations, the complete sealing of the defect with a repair material is problematic and allows irritants to continuously penetrate into the furcation area (Balla,

Educational aims and objectives

This clinical article aims to discuss current approaches in the literature to furcation perforation and repair and regeneration in endodontology.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify surgical and non-surgical approaches that have been utilized for periodontal tissue re-establishment at the perforation site.

•

Realize specific criteria for selecting repair material.

•

Identify some essential prerequisites for the success of a perforation repair.

•

Identify possible materials used for furcation perforation repair.

•

Realize the essential role of cementum regeneration in the furcation perforation repair process.

et al., 1991). Perforations close to the gingival sulcus produce persistent inflammation and a down-growth of sulcular epithelium into the defect (Tsesis, Fuss, 2006). Sinai (1977) stated that coronally located perforations, including furcal perforations, were more serious than those in the middle and apical third of a canal. It is the objective of this review to collect and review the data that is available in the scientific literature and to reach a conclusion as to the best treatment options.

Methods Retrieval of literature An English-limited Medline search was performed of articles published from 2002 to 2015. The searched keywords included

Manal Farea, BDS, PhD, MSc, obtained her degree from Sana’a University, Sana’a, Yemen in 2003. She received her MSc degree in endodontics from Universiti Sains Malaysia (USM), Malaysia, in 2010. In 2015, she completed her PhD degree at the USM in regenerative endodontics. Dr. Manal was granted a scholarship from Sana’a University, Yemen, in 2007 and a fellowship from USM in 2011.

Professor Dr. Adam Husein, BDS, is a senior lecturer in the restorative unit (prosthodontics) and the dean of School of Dental Sciences, Universiti Sains Malaysia. He obtained his BDS from University of Adelaide, Australia, in 1996. In 2004, he obtained his graduate diploma in clinical dentistry, doctor in clinical dentistry, and fellowship of the Royal Australasian College of Dental Surgeons (FRACDS) from the University of Adelaide.

Cornelis H Pameijer, DMD, MScD, DSc, PhD, graduated from the University of Utrecht with a DDS in The Netherlands in 1967 and went on to further his studies at Boston University in Massachusetts. He is currently professor emeritus at the University of Connecticut in Farmington, Connecticut. He has lectured extensively worldwide and has published more than 300 publications in mostly peer-reviewed journals.

Volume 11 Number 1

perforations and endodontics, furcation perforation, root canal and perforation, and perforation and mineral trioxide aggregate (MTA). Then a hand search was done of the references of collected articles to determine if more papers relevant to the topic should be included.

Results A total of 820 articles were found, which, in order of their related keywords, accounted for the following: perforations and endodontics: 285; furcation perforation: 92; root canal and perforation: 299; and perforation and mineral trioxide aggregate (MTA): 144.

Perforation repair techniques and their prognosis Surgical and non-surgical approaches have been utilized for periodontal tissue re-establishment at the perforation site. In both surgical and non-surgical approaches, two factors should be considered: 1. An appropriate material selection 2. The use of a matrix (Clauder, Shin, 2009).

The repair material should be selected based on the following criteria: • Perforation site accessibility • Biocompatibility (be nontoxic and noncarcinogenic) Endodontic practice 25

CONTINUING EDUCATION

Furcation perforation: current approaches and future perspectives

CONTINUING EDUCATION • Ability to induce osteogenesis and cementogenesis • Moisture control • Easy handling • Esthetic considerations (Clauder, Shin, 2009; Bryan, Woollard, Mitchell, 1999; Yildirim, et al., 2005; Samiee, et al., 2010).

Matrix use Controlling hemostasis and placement of the repair material in the perforation site without extrusion into surrounding periodontal structures are essential prerequisites for the success of a perforation repair.

In order to achieve a fluid-tight seal, hemostasis has to be controlled (Clauder, Shin, 2009). Delayed perforation repair can lead to extrusion of repair materials as a result of breakdown of the surrounding periodontium that is replaced by granulation tissue. Thus, in an attempt to avoid extrusion of the repair material, internal matrices such as calcium sulfate, hydroxyapatite, collagen, demineralized freeze-dried bone, and GELFOAM® (Pfizer) have been used (Clauder, Shin, 2009; Roda, 2001; Bargholz, 2005).

The internal matrix concept was introduced by Lemon (1992) in order to adequately seal the furcation perforation and avoid extrusion of the material. He also recommended the use of hydroxyapatite as a matrix under amalgam.

Calcium sulfate and calcium hydroxide prevented extrusion of composite resin when used as a furcal repair material (Imura, et al., 1998). In 1999, Jantarat and colleagues demonstrated that amalgam placed with plaster of Paris as a matrix for furcal perforation repair improved its sealing ability.

HAPSET (65% non-resorbable hydroxyapatite and 35% plaster of Paris) and hydroxyapatite showed similar healing responses when used as internal matrices under amalgam (Rafter, et al., 2002). Rafter, et al. (2002), further reported that there was marked extrusion of amalgam into the underlying bone

Figure 1: MTA Caps (Acteon) 26 Endodontic practice

with an associated severe inflammatory response when used alone without a matrix.

Although it has been reported that without using an internal matrix the optimal strength and excellent sealability of MTA was achieved in the presence of moisture (Arens, Torabinejad, 1996; Holland, et al., 2001; Torabinejad, et al., 1994), conflicting results have been reported by some authors regarding the use of an internal matrix under MTA. In 2004, Kratchman suggested that the perforation site should be soaked with sodium hypochlorite after hemostasis had been achieved and that a physical barrier such as collagen or calcium sulfate must be used at the perforation site to prevent MTA from being packed into the bone.

According to Bargholz (2005), excellent clinical results were achieved when collagen matrix was used under MTA. A study by Al-Daafas and Al-Nazhan (2007) showed that calcium sulfate prevented extrusion of the repair material. However, an unfavorable inflammatory reaction — epithelial tissue migration into the defected perforation and the inability to induce bone regeneration — were detected.

Thus, the authors concluded that using calcium sulfate as an internal matrix for MTA is not recommended. When used as an internal matrix for furcal perforation repair, calcium sulfate, and Collaplug (Calcitek, Carlsbad, California) did not improve the sealing ability nor reduce the incidence of MTA overextension. Therefore, the authors concluded that these two materials are not recommended as an internal matrix for MTA (Zou, et al., 2008). Furthermore, calcium sulfate and hydroxyapatite did not improve the sealing ability of MTA when used as internal matrices for furcation perforation repair (Taneja, Kumari 2011).

Materials used for furcation perforation repair In an attempt to repair a furcation perforation, several materials such as amalgam, tricalcium phosphate (TCP), hydroxyapatite,

gutta percha, calcium hydroxide, zinc oxideeugenol-based cement (IRM and SuperEBA), glass ionomer cement, composite resins, resin-glass ionomer hybrids, demineralized freeze-dried bone, and MTA have been used over the years (Arens, Torabinejad, 1996; Balla, et al., 1995; Bryan, Woollard, Mitchell, 1999, Yildirim, et al., 2005; Salman, et al., 1999). However, none fulfill all requisite qualifications for an ideal biomaterial.

Balla, et al. (1991), reported that no hard tissue was formed at the furcation perforation defect site when treated with either tri-calcium phosphate, hydroxyapatite, amalgam, or calcium hydroxide (Life™); instead, the defect site was occupied by epithelium and acute inflammatory cells (Balla, et al., 1991). MTA is water-based cement that is derived from Portland cement (Type I). It was introduced as a root-end filling material in the early 1990s (Torabinejad, Watson, Pitt Ford, 1993; Torabinejad, Chivian, 1999). It was subsequently determined that it was a suitable material for various clinical applications such as pulp capping, and repair of furcal perforations, as well as root-end closure (Sinai, et al., 1989; Torabinejad, et al., 1995). MTA promotes periradicular tissue regeneration (Pitt Ford, et al., 1995; Yildirim, et al., 2005; Holland, et al., 2001; Zhu, Xia, Xia, 2003; Noetzel et al., 2006), and it differs from other materials by its ability to promote cementum regeneration, thus facilitating the regeneration of the periodontal apparatus (Pitt Ford, et al., 1995; Arens, Torabinejad, 1996). Its biocompatibility nature is suggested by its ability to form hydroxyapatite when exposed to simulated body tissue fluid (Sarkar, et al., 2005).

Two commercial forms of MTA are available: ProRoot® MTA (Dentsply Tulsa Dental), which is available in both gray or white form, of which the latter contains a lower amount of iron, and MTA-Angelus (Angelus) (Asgary, et al., 2005). MTA-Angelus was introduced to address the long setting time from 2 hours for ProRoot MTA to 10 minutes for MTA-Angelus. MTA-Angelus contains

Figure 2: ProRoot® MTA (Dentsply Tulsa Dental) Volume 11 Number 1

Figure 3: Harvard MTA OptiCaps Volume 11 Number 1

Perforation has been identified as the second greatest cause of endodontic failure that accounts for 9.6% of all unsuccessful cases.

2010). It also leaked significantly less than amalgam (Mehrvarzfar, et al., 2010). In the aforementioned study, the authors reported that the sealing ability of MTA and Geristore was reduced when bioglass was used as a matrix underneath.

Sluyk, Moon and Hartwell (1998) assessed the effect of time and moisture on setting, retention, and adaptability of MTA when used for furcal perforation repair.

Findings showed that MTA adaptation to perforation walls increased in the presence of moisture. They further suggested that a moistened matrix can be used under MTA to prevent under- or overfilling of the material.

Furthermore, Main, et al. (2004), indicated that MTA provided an effective seal for root perforations.

Yildirim, et al. (2005), investigated the histologic response to MTA and Super EBA (Bosworth Company) when used in furcation perforation repair in dogs. In their study, less inflammation and new cementum formation was observed with MTA compared to Super EBA, which demonstrated connective tissue repair without inflammation. Similar abilities to seal furcal perforations were observed for both Portland cement and MTA (De-Deus, et al., 2006; Noetzel et al, 2006) evaluated histologically the inflammatory reactions and tissue responses to experimental tricalcium phosphate (TCP) and MTA when used as repair materials in furcation perforations in dogs. Results showed no significant differences between MTA and TCP in terms of bone reorganization or deposition of fibrous connective tissue.

Thus, MTA is considered the gold standard and material of choice for perforation repair and has demonstrated good potential for clinical success. However, it has some disadvantages, including the inability to degrade to allow for replacement with natural tissues, low resistance to compression over the long-term, extended setting time, poor handling, and difficult insertion into cavities because of its granular consistency, while additional moisture is required to activate

the cement setting, and lastly, the high cost, despite its widespread use (Torabinejad, et al., 1995; Chng, et al., 2005; Kogan, et al., 2006; Coomaraswamy, Lumley, Hofmann, 2007; Parirokh, Torabinejad, 2010).

Many dental materials have been demonstrated in the literature to exhibit cytotoxic effects during setting. Low cell numbers were demonstrated in vivo with freshly mixed MTA (pH=10.2) compared to preset MTA (pH=12.5) (Tronstad, Wennberg, 1980).

However, histologically, no difference in bone and cementum regeneration was observed after periradicular surgery in dogs between fresh and preset ProRoot MTA (Apaydin, Shabahang, Torabinejad, 2004).

In 2006, Asgary and colleagues introduced a new endodontic cement, a calciumenriched mixture (CEM) cement. Major components of CEM cement powder are 51.75 wt.% calcium oxide, 9.53 wt.% sulfur trioxide, 8.49 wt.% phosphorous pentoxide, and 6.32 wt.% silicon dioxide; whereas the minor essential constituents are aluminium oxide > sodium oxide > magnesium oxide > chlorine. CEM cement has a similar pH but an increased flow compared to MTA. However, working time, film thickness, and price are considerably less (Asgary, et al., 2008a).

Unlike MTA, mixed CEM cement releases calcium and phosphate ions and forms hydroxyapatite not only in simulated body tissue fluid but also in normal saline solution (Asgary, et al., 2009; Amini, et al., 2009).

Although the chemical composition of CEM cement and MTA are different, they have similar clinical applications (Asgary, et al., 2008; Asgary, et al., 2008; Asgary, et al., 2009; Asgary, Ehsani, 2009). Similar to MTA, CEM cement had low cytotoxic effects on different cell lines (Asgary, et al., 2009).

However, it showed a better antibacterial effect comparable to calcium hydroxide (Asgary, et al., 2008). Similar sealing ability was demonstrated by both ProRoot MTA and CEM when used to repair furcal perforation of primary molar teeth (Haghgoo, et al., 2014).

Endodontic practice 27

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80% Portland cement and 20% bismuth oxide, with no addition of calcium sulfate, while ProRoot MTA is composed of 75% Portland cement, 20% bismuth oxide, and 5% calcium sulfate dehydrate (Hashem, et al., 2008). The constituents of the Portland cement are minerals, among which the most important are dicalcium silicate, tricalcium silicate, tricalcium aluminate, tetracalcium ironaluminate, and dehydrated calcium sulfate (Oliveira, et al., 2007; Asgary, et al., 2009). The only significant difference between the dominant compounds of white and gray MTAs and associated Portland cements is bismuth oxide, which is present in MTAs (Asgary, et al., 2009; Asgary, et al., 2004).

It has been reported that the sealing ability of MTA (Loma Linda University, Loma Linda, California) was significantly better compared to amalgam in preventing leakage of fusobacterium nucleatum through furcal perforations (Nakata, Bae, Baumgartner, 1998). When used to seal a large furcation perforation, ProRoot MTA with/without internal matrix and MTA-Angelus with internal matrix showed the lowest dye absorbance compared to zinc oxide-eugenol cement (IRM) with/without internal matrix and MTAAngelus without internal matrix. Additionally, the authors reported that IRM without internal matrix had the highest dye absorbance (Hashem, Hassanien, 2008). However, white and gray MTA (Dentsply Tulsa Dental) showed no significant differences in microleakage when used for furcal perforation repair (Ferris, Baumgartner, 2004; Hamad, Tordik, McClanahan, 2006). Furcal perforations have been repaired with ProRoot gray MTA (Dentsply) and GeristoreÂŽ (Denmat). Geristore has been used as a root end filling material and in the restoration of subgingival surface defects such as root surface caries and iatrogenic perforations, surgical repair of root perforations, and as an adjunct in guidedtissue regeneration (GTR) (Mehrvarzfar, et al.,

CONTINUING EDUCATION Non-surgical approach When a perforation repair is indicated, it is recommended to first attempt an intracoronal approach (non-surgical) to preserve the periodontium, thus increasing the chances of success (Regan, Witherspoon, Foyle, 2005). Generally, perforations coronal to the crestal bone fall into the category of a non-surgical approach. The use of a surgical microscope operated at high magnification and with ample illumination allows for better management of perforation repairs (Kratchman, 2004; Daoudi, Saunders, 2002).

A surgical approach may complicate the treatment and lead to loss of periodontal attachment, chronic inflammation, and furcal pocket formation (Arens, Torabinejad, 1996).

Experience has shown that buccally located perforations are easier to repair than lingual or proximal lesions. Lingual located perforations, especially in the mandible, should be treated non-surgically or orthodontically. If they are not responding to treatment, the tooth should be extracted (Regan, et al., 2005). If a tooth can be extruded orthodontically to a point where the perforation reaches a supragingival level, repair of the defect will be greatly facilitated (Smidt, LachishTandlich, Venezia, 2005). Whether clinically practical or not, one case of intentional reimplantation was reported after repair of the perforation was performed on the extracted tooth (Poi, et al., 1999).

In cases of large perforations, bleeding should be controlled first using sterile saline.

Alternatively, calcium hydroxide, calcium sulfate, or collagen has been used (Clauder, Shin 2009). For bleeding control, nonspecific intravascular clotting agents should be avoided as they may lead to alveolar bone damage and delay in healing (Lemon, Steele, Jeansonne, 1993). In cases of perforations that are infected or perforation sites that need further enlargement and cleaning, burs or ultrasonic tips may be used. However, ultrasonic tips are preferable as they are gentler to the adjacent periodontium tissues (Pitt Ford, et al., 1995; Arens, Torabinejad, 1996; Clauder, Shin, 2009). For cleaning of infected perforations, 2.5% sodium hypochlorite has been used (Arens, Torabinejad, 1996); however, sterile saline is indicated in large perforations (Clauder, Shin, 2009). To avoid blockage of the canals with repair material, gutta-percha points, paper points, cotton pellets, or an easily removable material (such as Cavit™, 3M) should be placed over the canal orifices (Clauder, Shin, 2009).

A resin-bonded material such as Geristore® (DenMat) is recommended to 28 Endodontic practice

Figure 4: This illustration depicts a furcation perforation repair using stem cells, scaffold, and growth factor. This method has the potential to open new avenues in furcation repair treatment in the foreseeable near future. This image relates to the text under “future perspectives for the perforation repair”

restore subgingival defects (Clauder, Shin, 2009), which also serves as an adjunct to GTR (Abitbol, et al., 1996; Behnia, Strassler, Campbell, 2000). It is less sensitive to moisture than conventional glass ionomer cement, while a drier environment improved the results (Cho, Kopel, White, 1995). Adhesive materials can be used in supracrestal perforations, whereas MTA is preferable in subcrestal perforations (Clauder, Shin, 2009). If a perforation defect involves bone destruction (intraosseus defect), a barrier is needed to facilitate controlled placement of the repair material. This is not necessaary if the defect does not include an intraosseus defect (Clauder, Shin, 2009). If MTA is used, a moist cotton pellet should cover the material to allow setting of the material. After perforation repair, the final restoration can be placed either after 1 day or 1 week. Once repair has been achieved, the root canal(s) can be cleaned, shaped, and filled (Pitt Ford, et al., 1995; Arens, Torabinejad, 1996).

If a perforation is present in the middle third of the root, the canal(s) should be prepared first before closing the defect to avoid blocking the canal. With the aid of an operating microscope, obturation of the canal apical to the defect should be done

Figure 5: MTA-Angelus

first, followed by filling the remainder of the canal and the perforation site with MTA (Clauder, Shin, 2009). Alternatively, the root space beyond the perforation can be maintained by means of a file or gutta-percha cone. In case a file is used, it should be loosened after finishing the repair procedure to allow easy removal before the MTA is fully set (Clauder, Shin, 2009). The other option Volume 11 Number 1

Surgical approach Surgical intervention (external approach) is indicated in areas that are not accessible by non-surgical means alone, cases that have not responded to non-surgical treatment, or in repairing a perforating resorption (Regan, et al., 2005). The surgical approach is performed by reflecting a flap at the perforation site followed by cleaning and preparing the perforated area and finally packing the repair material (Alhadainy, 1994).

During the surgical repair procedures, cortical bone damage is involved, which may result in reduced success of the corrective surgical procedure. Thus, a GTR technique has been recommended for successful treatment outcomes by using either non-resorbable or resorbable membranes as a barrier (Duggins, et al., 1994; Barkhordar, Javid 2000; Rankow, Krasner, 1996; Dean, et al., 1997; Leder, et al., 1997). This barrier guides selected cells to populate at the perforation defect — i.e., placing the barrier between the gingival tissue and the perforation defect — will facilitate the repopulation of the defect by periodontal ligament cells and other osteogenic cells and prevents the colonization by gingival cells (Linde, et al., 1993; Sandberg, Dahlin, Linde, 1993). A resorbable membrane is generally preferable, as it does not need a second surgical procedure to remove it.

However, in some cases, titanium-tented membrane or a supporting graft material is needed to prevent collapsing the membrane into the defect (Abitbol, et al., 1996).

Cementum regeneration and role in the periodontium reconstruction Cementum formation is very essential in the furcation perforation repair process (Pitt Ford, et al., 1995; Clauder, Shin, 2009; Samiee, et al., 2010; Zairi, et al., 2012).

Pitt Ford and colleagues (1995) evaluated the histologic response to experimentally induced furcation perforations in dog mandibular premolars repaired by either MTA or amalgam and found that most of the MTA samples showed no inflammation and cementum deposition, whereas with Volume 11 Number 1

Figure 6: The three key elements of dental tissue engineering are stem cells, scaffolds, and signals

the use of amalgam, moderate to severe inflammation with no cementum deposition was present.

Healing after intentional perforations in dogs’ teeth was evaluated after repair with either MTA or Sealapex™ (Kerr) (Holland, et al., 2001). Most samples sealed with MTA showed new cementum deposition and an absence of inflammation. In 2010, Samiee and colleagues reported that cementum-like hard tissue was formed using either MTA or CEM cement in the furcation perforation in dogs in the presence of a mild inflammatory response. The authors concluded that both materials showed a similar favorable biological response in furcation perforation repair.

Zairi, et al. (2012), compared the inflammatory reactions and tissue response of furcal perforations in dogs’ teeth to growth factors, TGFβ1, basic fibroblast growth factor (bFGF), osteogenic protein-1 (OP-1), and IGF-I, with MTA or IRM as controls. The authors reported that a clear stimulatory effect on cementum formation and inhibition of collagen capsule formation was exerted by the growth factors. However, MTA exhibited better results than the growth factors. Based on that, the authors suggested a further study comparing the effects of application of growth factor mixture with MTA and MTA alone on tissue healing and regeneration.

In a case report, Bains, et al. (2012), used tissue engineering principles for the furcation perforation repair of the pulpal floor of the right mandibular first molar of 39-yearold male patient using MTA and platelet-rich fibrin (PRF). The authors reported that this combination was able to repair the perforation defect and regenerate the lost periodontium in the furcation area effectively. A case report (Eghbal, Fazlyab, Asgary, 2014) was published describing the non-surgical endodontic management of an extensive perforation of the floor of the pulp chamber in a first mandibular molar of a 28-year-old Caucasian female using CEM cement. The authors reported that CEM was able to

induce hard tissue formation, i.e., bone and cementum.

Cellular tissue engineering approach for cementum regeneration A proposed therapeutic approach was reported by the removal of autologous cells from the patient’s periodontal ligament (PDL), culturing of the cells in vitro, which were then placed back onto the exposed root coated with chemo-attracting factors, subsequently covering the area with an artificial basement membrane (Terranova, 1990). However, it is unknown whether this method produced the desired effect. Lekic and colleagues (2005) reported that rat periodontal and bone marrow cells were able to differentiate into periodontal ligament fibroblasts, osteoblasts, and cementoblasts when transplanted into periodontal wounds in rats, thus contributing to periodontal regeneration.

Regeneration of cementum, PDL, and alveolar bone have been observed using auto-transplantation of bone marrowderived mesenchymal stem cells (BM MSCs) (Kawaguchi, et al., 2004) or periodontal ligament cell sheet (Akizuki, et al., 2005) into periodontal osseous defects in dogs.

However, the principle disadvantage of cell sheets is their delicate structure and difficult handling during surgery (Li, Jin, 2015).

Furthermore, the harvest of bone marrow (BM) is a highly invasive and a painful procedure for the donor. Moreover, it has been reported that the number, proliferation, and differentiation potential of BM MSCs decline with increasing age (Kern, et al., 2006).

It has been reported that cementoblastbiodegradable poly(lactic-co-glycolic acid) (PLGA) polymer sponge-treated defects showed complete bone bridging and PDL formation, whereas minimal evidence of osteogenesis was exhibited by follicle celltreated defects along the root surface of athymic rats (Zhao, et al., 2004). Periodontal ligament stem cells (PDLSCs) have the ability to differentiate into cementoblast Endodontic practice 29

CONTINUING EDUCATION

is to use a gutta-percha point and soften it with heat to the dentinal wall opposing the perforation. MTA is then placed at the defect site (Clauder, Shin, 2009). Perforations at the apical one-third are quite challenging and difficult to manage. Successful treatment cannot always be achieved for all cases necessitating apical surgery or extraction of the tooth to remedy the problem (Clauder, Shin, 2009).

CONTINUING EDUCATION and osteoblast (Isaka, et al., 2001; Seo, et al., 2004) and have shown potential therapeutic applications in periodontium regeneration. However, the very low number of these cells residing in the PDL is indicative of the difficulty acquiring a sufficient number for regenerative treatment remains and is an issue that remains unresolved (Maeda et al, 2011). Primary cultures of PDLSCs yielded small cell numbers, therefore before application, PDLSCs must proliferate at least 12 population doublings (Zhu, Liang, 2015). Additionally, it has been found that the proliferation and migration ability and differentiation potential of PDLSCs decreased with increasing age (Zhu, Liang, 2015).

Apical tooth germ cells conditioned medium were able to provide the cementogenic microenvironment and induced the cementoblastic differentiation of PDLSCs (Yang, et al., 2009). Hertwig’s epithelial root

sheath (HERS) cells, or their secreted products, were able to induce PDL cells differentiation along the cementoblastic lineage in vitro (Zeichner-David, et al., 2003). Several in vivo studies have also shown the potential capability of PDLSCs to form cementum and PDL-like tissues (Yang, et al., 2009; Liu, et al., 2008; Feng, et al., 2010; Park, Jeon, Choung, 2011).

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30 Endodontic practice

Regenerative therapy Tissue engineering is an interdisciplinary field that applies the principles of engineering and life sciences toward the development of biological substitutes that restore, maintain, or improve tissue function or a whole organ (Langer, Vacanti, 1993). Tissue engineering aims to stimulate the body either to regenerate tissue on its own or to grow tissue outside the body, which can then be implanted as natural tissue (Nadig, 2009).

Triad components Regenerative endodontics can be defined as biologically based procedures designed to replace damaged structures, including dentin and root structures, as well as cells of the pulp-dentin complex (Murray, GarciaGodoy, Hargreaves, 2007). This approach consists of the following interactive triad: 1) an appropriate cell source; 2) a supportive matrix (scaffold); and 3) inductive biological factors or signals (Figure 4). To create regenerative therapies, these disciplines are often combined rather than used individually (Murray, Garcia-Godoy, Hargreaves, 2007).

Future perspectives for the perforation repair Reconstruction of the lost attachment via regeneration of the periodontium components, such as cementum, PDL, and bone, is essential in the repair of perforated areas.

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25. Bryan EB, Woollard G, Mitchell WC. Nonsurgical repair of furcal perforations: a literature review. Gen Dent.

1999;47(3):274-278.

37. Haghgoo R, Niyakan M, Nazari Moghaddam K, Asgary S, Mostafaloo N. An in vitro comparison of furcal perforation repaired with Pro-root MTA and new endodontic cement in primary molar teeth - a microleakage study. J Dent (Shiraz).

2014;15(1):28-32.

38. Hamad HA, Tordik PA, McClanahan SB. Furcation perforation repair comparing gray and white MTA: a dye extraction study. J Endod. 2006;32(4):337-340.

39. Hashem AA, Hassanien EE. ProRoot MTA, MTA-Angelus and IRM used to repair large furcation perforations: sealability study. J Endod. 2008;34(1):59-61.

40. Holland R, Filho JA, de Souza V, Nery MJ, Bernabe PF, Junior ED. Mineral trioxide aggregate repair of lateral root perforations. J Endod. 2001;27(4):281-284.

26. Chng HK, Islam I, Yap AU, Tong YW, Koh ET. Properties of a new root-end filling material. J Endod. 2005;31(9):665-668.

41. Imura N, Otani SM, Hata G, Toda T, Zuolo ML. Sealing ability of composite resin placed over calcium hydroxide and calcium sulphate plugs in the repair of furcation perforations in mandibular molars: a study in vitro. Int Endod J. 1998;31(2):79-84.

27. Cho E, Kopel H, White SN. Moisture susceptibility of resin-modified glass-ionomer materials. Quintessence Int. 1995;26(5):351-358.

42. Isaka J, Ohazama A, Kobayashi M, et al. Participation of periodontal ligament cells with regeneration of alveolar bone. J Periodontol. 2001;72(3):314-323.

28. Clauder T, Shin SU. Repair of perforations with MTA: clinical applications and mechanisms of action. Endod Topics.

2009;15:32-55.

43. Jantarat J, Dashper SG, Messer HH. Effect of matrix placement on furcation perforation repair. J Endod. 1999; 25(3):192-196.

29. Coomaraswamy KS, Lumley PJ, Hofmann MP. Effect of bismuth oxide radioopacifier content on the material properties of an endodontic Portland cement based (MTA-like) system. J Endod. 2007;33(3):295-298.

44. Kawaguchi H, Hirachi A, Hasegawa N, et al. Enhancement of periodontal tissue regeneration by transplantation of bone marrow mesenchymal stem cells. J Periodontol.

2004;75(9):1281-1287.

30. Daoudi MF, Saunders WP. In vitro evaluation of furcal perforation repair using mineral trioxide aggregate or resin modified glass lonomer cement with and without the use of the operating microscope. J Endod. 2002;28(7):512-515.

45. Kern S, Eichler H, Stoeve J, Kluter H, Bieback K. Comparative analysis of mesenchymal stem cells from bone marrow, umbilical cord blood, or adipose tissue. Stem Cells.

2006;24(5):1294-1301

31. De-Deus G, Petruccelli V, Gurgel-Filho E, Coutinho-Filho T. MTA versus Portland cement as repair material for furcal perforations: a laboratory study using a polymicrobial leakage model. Int Endod J. 2006;39(4):293-298.

46. Kogan P, He J, Glickman GN, Watanabe I. The effects of various additives on setting properties of MTA. J Endod.

2006;32(6):569-572.

32. Dean JW, Lenox RA, Lucas FL, Culley WL, Himel VT. Evaluation of a combined surgical repair and guided tissue regeneration technique to treat recent root canal perforations. J Endod. 1997;23(8):525-532.

47. Kratchman SI. Perforation repair and one-step apexification procedures. Dent Clin North Am. 2004;48(1):291-307.

48. Langer R, Vacanti JP. Tissue engineering. Science. 1993; 260(5110):920-926.

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cementoblastic lineage in association with scaffold and growth factor. The suggested biomimetic approach is illustrated in Figure 6.

This will have the potential to open a new era and strategy in endodontic and periodontal tissue-engineering therapies.

49. Leder AJ, Simon BI, Deasy M, Fenesy KE, Dunn S. Histological, clinical, and digital subtraction radiographic evaluation of repair of periodontal defects resulting from mechanical perforation of the chamber floor using ePTFE membranes.

Periodontal Clin Invest. 1997;19:9-15.

65. Park, JY, Jeon, SH, Choung PH. Efficacy of periodontal stem cell transplantation in the treatment of advanced periodontitis. Cell Transplant. 2011;20(2):271-85.

hydroxyapatite and calcium sulfate on the sealing ability of mineral trioxide aggregate and light cured glass ionomer cement. J Conserv Dent. 2011;14(1):6-9.

66. Pitt Ford TR, Torabinejad M, McKendry DJ, Hong CU, Kariyawasam SP. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(0):756-763.

82. Terranova VP. Periodontal and bone regeneration factor, materials and methods. 1990; International patent WO 90/ 100017

50. Lekic PC, Nayak BN, Al-Sanea R, Tenenbaum H, Ganss B, McCulloch C. Cell transplantation in wounded mixed connective tissues. Anat Rec A Discov Mol Cell Evol Biol.

2005;287(2):1256-1263.

51. Lemon RR. Nonsurgical repair of furcation defects. Internal matrix concept. Dent Clin North Am. 1992;36(2):439-457.

52. Lemon RR, Steele PJ, Jeansonne BG. Ferric sulfate hemostasis: effect on osseous wound healing. Left in situ for maximum exposure. J Endod. 1993;19(4):170-173.

53. Li B, Jin Y. Periodontal tissue engineering: current approaches and future therapies. Tissue Eng Part B Rev. 2010;16(2):219-255.

54. Linde A, Alberius P, Dahlin C, Bjurstam K, Sundin Y. Osteopromotion: a soft-tissue exclusion principle using a membrane for bone healing and bone neogenesis. J Periodontol. 1993;64(suppl 11):1116-1128.

55. Liu Y, Zheng Y, Ding G, Fang D, et al. Periodontal ligament stem cell-mediated treatment for periodontitis in miniature swine. Stem Cells. 2008;26(4):1065-1073.

Conclusions Perforation of the pulp chamber floor of multi-rooted teeth constitutes a perplexing and frustrating problem. It is a major cause of endodontic treatment failure. A furcation perforation has to be regarded as an endodontic and periodontal problem. The inflammatory response in the periodontium, leading to irreversible loss of periodontal attachment in the area, can result in loss of the tooth if the perforation is not successfully repaired. To re-establish the periodontal tissue in the perforation site, surgical and non-surgical techniques have been utilized.

67. Poi WR, Sonoda CK, Salineiro SL, Martin SC. Treatment of root perforation by intentional reimplantation: a case report.

Endod Dent Traumatol. 1999;15(3):132-134.

68. Rafter M, Baker M, Alves M, Daniel J, Remeikis N. Evaluation of healing with use of an internal matrix to repair furcation perforations. Int Endod J. 2002;35(9):775-783.

69. Rankow HJ, Krasner PR. Endodontic applications of guided tissue regeneration in endodontic surgery. J Endod.

1996;22(1):34-43.

70. Regan JD, Witherspoon DE, Foyle DM. Surgical repair of root and tooth perforations. Endod Topics.

2005;11:152-178.

71. Roda RS. Root perforation repair: surgical and nonsurgical management. Pract Proced Aesthet Dent. 2001; 13(6):467-472.

56. Maeda H, Tomokiyo A, Fujii S, Wada N, Akamine A. Promise of periodontal ligament stem cells in regeneration of periodontium. Stem Cell Res Ther. 2011;2(4):33.

72. Salman MA, Quinn F, Dermody J, Hussey D, Colaffey N. Histological evaluation of repair using a bioresorbable membrane beneath a resin-modified glass ionomer after mechanical furcation perforation in dogs’ teeth. J Endod.

1999;25(3):181-186.

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

73. Samiee M, Eghbal MJ, Parirokh M, Abbas FM, Asgary S. Repair of furcal perforation using a new endodontic cement. Clin Oral Investig. 2010;14(6):653-658.

58. Mehrvarzfar P, Dahi-Taleghani A, Saghiri MA, et al. The comparison of MTA, Geristore® and Amalgam with or without Bioglass as a matrix in sealing the furcal perforations (in vitro study). Saudi Dent J. 2010;22(3):119-124.

74. Sandberg E, Dahlin C, Linde A. Bone regeneration by the osteopromotion technique using bioabsorbable membranes: an experimental study in rats. J Oral Maxillofac Surg 1993;51(10):1106-1114.

59. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of current status and a call for action.

J Endod. 2007;33(4):377-390.

75. Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod. 2005;31(2):97-100.

60. Nadig RR. Stem cell therapy - Hype or hope? A review J Conserv Dent 2009;12(14):131-138.

61. Nakata T, Bae K, Baumgartner J (1998) Perforation repair comparing mineral trioxide aggregate and amalgam using an anaerobic bacterial leakage model. J Endod.24(0):184-186.

62. Noetzel J, Ozer K, Reisshauer BH, et al. Tissue responses to an experimental calcium phosphate cement and mineral trioxide aggregate as materials for furcation perforation repair: a histological study in dogs. Clin Oral Investig.

2006;10(1):77-83.

63. Oliveira MG, Xavier CB, Demarco FF, Pinheiro AL, Costa AT, Pozza DH. Comparative chemical study of MTA and Portland cements. Braz Dent J. 2007;18(1):3-7.

64. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review--Part III: Clinical applications, drawbacks, and mechanism of action. J Endod.

2010;36(3):400-413.

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76. Seo BM, Miura M, Gronthos S, et al. Investigation of multipotent postnatal stem cells from human periodontal ligament. Lancet. 2004;364(9429):149-155.

77. Sinai.1977; Endodontic perforations: their prognosis and treatment. J Am Dent Assoc. 1977;95(1):90-95.

78. Sinai IH, Romea DJ, Glassman G, Morse DR, Fantasia J, Furst ML. An evaluation of tricalcium phosphate as a treatment for endodontic perforations. J Endod.

1989;15(9):399-403.

79. Sluyk SR, Moon PC, Hartwell GR. Evaluation of setting properties and retention characteristics of mineral trioxide aggregate when used as a furcation perforation repair material. J Endod. 1998;24(11):768-771.

80. Smidt A, Lachish-Tandlich M, Venezia E. Orthodontic extrusion of an extensively broken down anterior tooth: a clinical report. Quintessence Int. 2005;36(2):89-95.

81. Taneja S, Kumari M. Effect of internal matrices of

For furcation perforation repair, several materials have been used with varying results.

However, the stem cell-based tissue engineering approach is very promising and is suitable for furcation perforation repair. This approach has the potential to revolutionize the practice of regenerative endodontics in the future, and may therefore, save many teeth that would otherwise have to be extracted due to a poor to hopeless prognosis. Moreover, it will help and assist in designing regenerative therapies based on sound biological principles, which can be applied in both endodontic and periodontal specialties.

Acknowledgments This study was financially supported by the Universiti Sains Malaysia Research University Grant 1001/ PPSP/813058, PRGS (1001/PPSG/8146005) and short-term grants (304/PPSG/ 61312012 and 304/ PPSG/61312018) from the School of Dental Sciences, Universiti Sains Malaysia. EP

83. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod. 1999; 25(3):197-205.

84. Torabinejad M, Higa RK, McKendry DJ, Pitt Ford TR. Dye leakage of four root end filling materials: effects of blood contamination. J Endod. 1994;20(4):159-163.

85. Torabinejad M, Hong CU, Lee SJ, Monsef M, Pitt Ford TR. Investigation of mineral trioxide aggregate for root-end filling in dogs. J Endod. 1995;21(0):603-608.

86. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR (1995) Physical and chemical properties of a new root-end filling material. J Endod.21(0):349-353.

87. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod. 1993;19(12):591-595.

88. Tronstad L, Wennberg A. In vitro assessment of the toxicity of filling materials. Int Endod J. 1980;13(3):131-138.

89. Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endod Topics. 2006;13:95-107.

90. Yang ZH, Zhang XJ, Dang NN, et al. Apical tooth germ cell-conditioned medium enhances the differentiation of periodontal ligament stem cells into cementum/periodontal ligament-like tissues. J Periodontal Res. 2009; 44(2):199-210.

91. Yildirim T, Gencoglu N, Firat I, Perk C, Guzel O. Histologic study of furcation perforations treated with MTA or SuperEBA in dog’s teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100(1):120-124.

92. Zairi A, Lambrianidis T, Pantelidou O, Papadimitriou S, Tziafas D. Periradicular tissue responses to biologically active molecules or MTA when applied in furcal perforation of dogs’ teeth. Int J Dent 2012;1-9.

93. Zeichner-David M, Oishi K, Su Z, et al. Role of Hertwig’s epithelial root sheath cells in tooth root development. Dev Dyn. 2003;228(4):651-663.

94. Zhao M, Jin Q, Berry JE, Nociti FH Jr, Giannobile WV, Somerman MJ. Cementoblast delivery for periodontal tissue engineering. J Periodontol. 2004;75(1):154-161.

95. Zhu W, Liang M. Periodontal ligament stem cells: current status, concerns, and future prospects. Stem Cells Int. 2015;(2015):1-11 96. Zhu YQ, Xia WW, Xia L. Histological evaluation of repair of furcation perforation in dogs using mineral trioxide aggregate. Shanghai Kou Qiang Yi Xue, 2003;12:47-50.

97. Zou L, Liu J, Yin S, Li W, Xie J. In vitro evaluation of the sealing ability of MTA used for the repair of furcation perforations with and without the use of an internal matrix. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2008;105(0):661-65.

Endodontic practice 31

CONTINUING EDUCATION

Replacement of the lost cementum (cementogenesis) is very critical and enhances the reattachment of the fibers of the periodontal ligament. Several studies have been published that demonstrate the ability of different materials to repair furcation perforations, albeit with variable success rates.

However, during recent years, there has been a paradigm shift from conventional to regenerative endodontic therapy, and repair of the periodontium is not an exception.

To date, to the best of our knowledge, no studies have been published in the literature reporting on the effect of the triad application (stem cells, scaffold, and growth factor) for furcal perforation repair and the response of surrounding tissues (cementum, PDL, and alveolar bone). We propose a stem cellbased tissue engineering approach for furcation perforation repair through enhancing of stem cell differentiation along the

REF: EP V11.1 FAREA, ET AL.

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Furcation perforation: current approaches and future perspectives FAREA, ET AL.

1. Perforation is defined by the American Association of Endodontics (AAE) Glossary of Endodontic Terms (2003) as a mechanical or pathological communication between the root canal system and the external tooth surface, which is caused by _______. a. caries b. resorption c. iatrogenic factors d. all of the above 2. It [perforation] has been identified as the second greatest cause of endodontic failure that accounts for ___ of all unsuccessful cases. a. 9.6% b. 15.7% c. 24.4% d. 31.2% 3. ________ is/are essential prerequisites for the success of a perforation repair. a. Controlling hemostasis b. Placement of the repair material in the perforation site without extrusion into surrounding periodontal structures c. Utilizing the External Matrix Concept d. both a and b

32 Endodontic practice

4. Thus, in an attempt to avoid extrusion of the repair material, internal matrices such as calcium sulfate, _______, and GELFOAMÂŽ (Pfizer) have been used. a. hydroxyapatite b. collagen c. demineralized freeze-dried bone d. all of the above 5. The internal matrix concept was introduced by ____ in order to adequately seal the furcation perforation and avoid extrusion of the material. a. Xia b. Yildirim c. Lemon d. Torabinejad 6. Generally, perforations coronal to the crestal bone fall into the category of a ____ approach. a. surgical b. non-surgical c. non-treatable d. complicated 7. Lingual located perforations, especially in the mandible, should be treated ______. a. surgically

b. non-surgically c. orthodontically d. both b and c 8. In cases of large perforations, bleeding should be controlled first using _______. a. sterile saline b. nonspecific intravascular clotting agents c. sodium hypochlorite d. tricalcium phosphate 9. If a perforation is present in the middle third of the root, the canal(s) should be prepared ___ closing the defect to avoid blocking the canal. a. after b. first before c. a few weeks after d. instead of 10. Surgical intervention (external approach) is indicated in areas that are ______. a. not accessible by non-surgical means alone b. cases that have not responded to nonsurgical treatment c. in repairing a perforating resorption d. all of the above

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Drs. Ricardo Machado, Emanuely da Silva Chrun, Luiz Fernando Tomazinho, and Lucas da Fonseca Roberti Garcia consider the possibility of endodontic treatment of a tooth with pulp necrosis and severe inflammatory external apical root resorption in a single session

R

oot resorption is characterized by an unregulated function between blastic and clastic cells, normally responsible for the maintenance and remodeling of the periodontal support tissues. This condition may lead to tooth loss from uncontrolled cell activity if adequate treatment is not given (Andreasen, 1985).

Particularly in regards to external inflammatory apical root resorption, several studies have shown a positive correlation between this disease, pulp necrosis, and the presence of periradicular lesions (Campos, et al., 2013; Vier-Pelisser, et al., 2013). Thus, performing proper endodontic treatment may interrupt the external inflammatory apical root resorption process by neutralizing microbiological content and inhibiting clastic action (BarrattoFilho, et al., 2009).

The number of sessions required to properly reduce the microbial population of a contaminated root canal system is still a controversial issue among researchers (Kvist, et al., 2004; Molander, et al., 2007; ParedesVieyra, Enriquez, 2012). In recent years, several clinical and meta-analysis studies have been performed to compare endodontic treatment with and without the use of an

Ricardo Machado runs a clinical practice limited to endodontics in Navegantes, Santa Catarina, Brazil.

Emanuely Da Silva Chrun is from the department of Pathology, Health Sciences Center, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil.

Luiz Fernando Tomazinho is from the Department of Endodontics, Paranaense University, Umuarama, Paraná, Brazil.

Lucas Da Fonseca Roberti Garcia is from the Department of Dentistry - Endodontics Division, Health Sciences Center, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil.

Volume 11 Number 1

Educational aims and objectives

This article aims to present a case of a tooth with pulp necrosis, periradicular lesion and severe inflammatory apical root resorption, where endodontic treatment was performed in a single session.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize certain characteristics of the external inflammatory apical root resorption process.

•

Realize differences in endodontic treatment with and without the use of an intracanal medication.

•

Discuss the use of calcium hydroxide as an intracanal medication.

•

Recognize the involvement of cementum and dentin in healing of external root resorption.

•

Identify the steps that lead to the success of pulp necrosis and severe inflammatory apical root resorption in a single session after a 6-month follow-up.

intracanal medication and have reported similar results between these two treatment modalities (Kvist, et al., 2004; Molander, et al., 2007; Soltanoff, 1978). However, to date, no conclusive scientific evidence has been found on required use of an intracanal medication in cases of pulp necrosis, periradicular lesion, and severe associated inflammatory apical root resorption.

Thus, the purpose of this article is to report the clinical case of a tooth with pulp necrosis, periradicular lesion, and severe inflammatory apical root resorption, where endodontic treatment was performed in a single session. The 6-month follow-up shows clear signs of repair.

Case report A 24-year-old male patient was referred to the endodontic specialization course at Ingá University, UNINGÁ, Rio Branco, AC, Brazil, for analysis of tooth No. 36. The patient related episodes of pain and swelling in this region a few months prior. Clinical examination revealed an extensive carious

lesion and provisional sealing with temporary restorative material. Radiographic analysis showed communication of the temporary restorative material with the pulp chamber, periradicular lesions in both roots, and severe inflammatory apical root resorption in the distal root (Figure 1A).

After conducting clinical and radiographic analysis, it was decided that endodontic treatment should be performed. Initially, the tooth was anesthetized with 4% articaine and adrenaline 1:100.000 (DFL Indústria e Comércio), followed by the placement of a rubber dam. Then the temporary restorative material and the carious lesion were removed with spherical 1016 and Endo™ Z burs (KG Sorensen) coupled with a high-speed device (Extra Torque 605C, KaVo). Four canal orifices were identified with endodontic probes (MB, ML, DB, and DL) and prepared with number two Gates-Glidden burs (Dentsply Sirona).

Then each canal was irrigated with 2.5 ml of 2.5% sodium hypochlorite (Fórmula & Ação).

Afterwards, the working lengths were established at -0.5 (mesial canals) and Endodontic practice 33

CONTINUING EDUCATION

Endodontic treatment of a tooth with pulp necrosis and severe inflammatory external apical root resorption in a single session: Is it possible?

A case report

CONTINUING EDUCATION -1.0 mm (distal canals) from the point indicated by the electronic apex locator (Mini Apex Locator, SybronEndo) as “0.0.”

A manual glide path was created in the mesial root canals, with size 15 and 20 K-type files (Dentsply/Maillefer), followed by preparation using the two-system (VDW) full-sequence technique. The size of the distal canals required manual preparation to be performed up to size 60 K-type file (Dentsply/Maillefer), following the principles of the crown-down technique. The patency of the root canals was maintained by using a size 20 K-type file (Dentsply/Maillefer) up to the main foramen. The canals were irrigated at each change of file, with 2.5 ml of 2.5% sodium hypochlorite, and a final irrigation was performed with 2.5 ml of 17% EDTA (Fórmula & Ação) for 3 minutes to remove the smear layer.

The root canals were dried with absorbent paper cones (Dentsply/Maillefer) and filled with gutta-percha cones (Dentsply/ Maillefer) and Sealer 26 (Dentsply/Maillefer) (Figure 1B), using the lateral compaction technique.

Six months after the treatment, the patient returned for a follow-up and related no pain or any relevant symptomatology.

Radiographic examination showed clear evidence of tissue repair and containment of the resorptive process (Figure 1C).

Discussion Since no evidence of dental trauma, occlusal disharmony, or relevant associated systemic disease was observed in this case report, it was concluded that the severe inflammatory resorptive process evolved from carious lesion to pulp necrosis and periradicular disease. Complete necrosis of pulp tissue leads to colonization and proliferation of microorganisms within the root canal system, inducing periradicular inflammation, which promotes clastic cell activity, and, in turn, triggers an osseous and radicular resorptive process (Patel, et al., 2009).

Some studies have advocated the use of calcium hydroxide as an intracanal medication in cases of open apices caused by incomplete apexogenesis, over-instrumentation, and/or apical resorptions (Mente, et

Performing proper endodontic treatment may interrupt the external inflammatory apical root resorption process by neutralizing microbiological content and inhibiting clastic action.

al., 2009; Mente, et al., 2013). In addition to its antimicrobial activity, this substance acts as a physical-chemical barrier, preventing the proliferation of residual microorganisms, reinfection of the root canal by microorganisms originating from the oral cavity, and invagination of the granulation tissue of the area reabsorbed by the walls of the root canal. Furthermore, calcium hydroxide is capable of promoting necrosis of the resorptive cells present in Howship’s lacunae, thus neutralizing clastic cell acids, preventing the mineral dissolution of the root, and rendering the region unsuitable for acid hydrolases (Mohammadi, Dummer, 2011; Saad, 1989).

Healing of external root resorption, involving cementum and dentin caused by apical periodontitis also requires the recruitment of progenitor cells. Dentin-producing odontoblasts can be differentiated only from dental pulp stem cells (Gronthos, et al., 2000), and stem cells, from apical papilla (Sonoyama, et al., 2008). In mature teeth with apical periodontitis, the dental pulp is completely destroyed, and the apical papilla no longer exists. In addition, stem cells/progenitor cells in the periodontal ligament and alveolar bone marrow are not capable of differentiating into odontoblasts (Huang, Gronthos, Shi, 2009; Seo, et al., 2004). Therefore, the resorbed root dentin caused by the inflammatory process cannot be regenerated by odontoblasts and dentin formation (Ricucci. et al., 2014).

Resorbed root dentin is repaired by cementum and not by dentin (Lindskog, Blomlof, Hammarstrom, 1987). The mechanisms of repair by cementum formation, including the origin of cementoblasts and the molecules related to their recruitment

Figures 1A-1C: A. Initial periapical radiograph of tooth No. 36, showing periapical lesions in both roots, and severe apical root resorption in the distal root (circle). B. Tooth No. 36 after filling of root canal system. C. Radiograph after 6-month follow-up, with clear evidence of tissue repair and containment of the resorptive process (arrow) 34 Endodontic practice

Volume 11 Number 1

Six months after the treatment, the patient returned for a follow-up and related no pain or any relevant symptomatology. Radiographic examination showed clear evidence of tissue repair and containment of the resorptive process.

1999). Newly formed cementum usually covers areas of the root where cementum and dentin were lost (Ricucci, et al., 2014).

It seems much more “plausible biologically” that the entire immunological complex is activated after performing an adequate cleaning and shaping process of the root canal system and not only or necessarily after using calcium hydroxide. This argument is based on the absence of statistically significant differences in the success rates of necrotic teeth with radiographically visualized periradicular lesions treated with or without the use of this substance as an intracanal medication (Molander, et al., 2007; ParedesVieyra, Enriquez, 2012; Penesis, et al., 2008).

With this in mind, it was decided that appropriate endodontic treatment could be

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5. Gronthos S, Mankani M, Brahim J, Robey PG, Shi S. Postnatal human dental pulp stem cells (DPSCs) in vitro and in vivo. Proc Natl Acad Sci U S A. 2000;97(25):13625-13630.

6. Grzesik WJ, Narayanan AS. Cementum and periodontal wound healing and regeneration. Crit Rev Oral Biol Med. 2002;13(6):474-484.

7. Huang GT, Gronthos S, Shi S. Mesenchymal stem cells derived from dental tissues vs. those from other sources: their biology and role in regenerative medicine. J Dent Res. 2009;88(9):792-806.

8. Kvist T, Molander A, Dahlen G, Reit C. Microbiological evaluation of one- and two-visit endodontic treatment of teeth with apical periodontitis: a randomized, clinical trial. J Endod.

2004;30(8):572-576.

9. Lindskog S, Blomlof L, Hammarstrom L. Cellular colonization of denuded root surfaces in vivo: cell morphology in dentin resorption and cementum repair. J Clin Periodontol.

1987;14(7):390-395.

concluded in a single session, based on the certainty that correct cleaning and shaping could be performed, and that all the canals could be completely dried after this phase.

The success of this treatment was observed after the 6-month follow-up, at which time no pain, sinus tract, swelling, or discomfort was observed or related by the patient. Although it is thought that randomized clinical studies must be conducted to compare the results of endodontic treatment performed in a single or more sessions for teeth with pulp necrosis, periradicular lesion, and severe inflammatory apical root resorptions, the clinical case related in this article demonstrates the feasibility of performing endodontic treatments for these cases in a single visit. EP

14. Mente J, Leo M, Panagidis D, et al. Treatment outcome of mineral trioxide aggregate in open apex teeth. J Endod. 2013;39(1):20-26.

15. Mohammadi Z, Dummer PM. Properties and applications of calcium hydroxide in endodontics and dental traumatology. Int Endod J. 2011;44(8):697-730.

16. Molander A, Warfvinge J, Reit C, Kvist T. Clinical and radiographic evaluation of one-and two-visit endodontic treatment of asymptomatic necrotic teeth with apical periodontitis: a randomized clinical trial. J Endod. 2007;33(10):1145-1148.

17. Paredes-Vieyra J, Enriquez FJ. Success rate of single- versus two-visit root canal treatment of teeth with apical periodontitis: a randomized controlled trial. J Endod. 2012;38(9):1164-1169.

18. Patel S, Dawood A, Wilson R, Horner K, Mannocci F. The detection and management of root resorption lesions using intraoral radiography and cone beam computed tomography — an in vivo investigation. Int Endod J. 2009;42(9):831-838.

19. Penesis VA, Fitzgerald PI, Fayad MI, Wenckus CS, BeGole EA, Johnson BR. Outcome of one-visit and two-visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation. J Endod. 2008;34(3):251-257.

20. Ricucci D, Siqueira JF Jr, Loghin S, Lin LM. Repair of extensive apical root resorption associated with apical periodontitis: radiographic and histologic observations after 25 years. J Endod. 2014;40(8):1268-1274.

21. Saad AY. Calcium hydroxide in the treatment of external root resorption. J Am Dent Assoc.

1989;118(5):579-581.

22. Seo BM, Miura M, Gronthos S, et al. Investigation of multipotent postnatal stem cells from human periodontal ligament. Lancet. 2004;364(9429):149-155.

10. Liu HW, Yacobi R, Savion N, Narayanan AS, Pitaru S. A collagenous cementum-derived attachment protein is a marker for progenitors of the mineralized tissue-forming cell lineage of the periodontal ligament. J Bone Miner Res. 1997;12(10):1691-1699.

23. Soltanoff W. A comparative study of the single-visit and the multiple-visit edodontic procedure.

J Endod. 1978;4(9):278-281.

11. MacNeil RL, Somerman MJ. Development and regeneration of the periodontium: parallels and contrasts. Periodontol 2000. 1999;19:8-20.

24. Sonoyama W, Liu Y, Yamaza T, et al. Characterization of the apical papilla and its residing stem cells from human immature permanent teeth: a pilot study. J Endod.2008;34(2):166-171.

12. McCulloch CA. Basic considerations in periodontal wound healing to achieve regeneration.

Periodontol 2000. 1993;1(1):16-25.

25. Vier-Pelisser FV, de Figueiredo JA, Reis Só MV, Estivallet L, Eickhoff SJ. Apical resorption in teeth with periapical lesions: correlation between radiographic diagnosis and SEM examination. Aust Endod J. 2013;39(1):2-7.

13. Mente J, Hage N, Pfefferle T, Koch MJ, Dreyhaupt J, Staehle HJ, Friedman S. Mineral trioxide aggregate apical plugs in teeth with open apical foramina: a retrospective analysis of treatment outcome. J Endod. 2009;35(10):1354-1358

Volume 11 Number 1

26. Wu D, Ikezawa K, Parker T, Saito M, Narayanan AS. Characterization of a collagenous cementum-derived attachment protein. J Bone Miner Res. 1996;11(5):686-692.

Endodontic practice 35

CONTINUING EDUCATION

and differentiation, remain unclear (Grzesik, Narayanan, 2002). Cementoblast progenitors have their origin in the periodontal ligament (usually in a paravascular location) or the endosteum (Liu, et al., 1997; McCulloch, 1993). In periradicular tissue healing, periodontal ligament cells adjacent to the affected root area may start to proliferate and populate the region in which the periodontal ligament and cementum were changed or lost by inflammation. It has been suggested that the cementum matrix and associated molecules can recruit cementum-forming stem/progenitor cells in the periodontal ligament (Grzesik, Narayana, 2002), and that the dentin matrix may also be able to signal progenitor cells in the periodontal ligament (Diekwisch, 2001) to differentiate into cementoblasts.

Initially, cementoblast progenitors have to be selected, possibly by specific integrins and signaling events (Grzesik, Narayanan, 2002; Wu, et al., 1996). Then the selected cells adhere to the root surface and are activated by growth factors previously sequestered in the cementum and dentin matrix and released as a consequence of root resorption. These factors include bone morphogenetic proteins, transforming growth factor beta, insulin-like growth factor one, and epidermal growth factor (Grzesik, Narayanan, 2002; MacNeil, Somerman,

REF: EP V11.1 MACHADO, ET AL.

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Endodontic treatment of a tooth with pulp necrosis and severe inflammatory external apical root resorption in a single session: Is it possible? A case report MACHADO, ET AL.

1. Root resorption is characterized by an unregulated function between blastic and clastic cells, normally responsible for the _________ of the periodontal support tissues. a. maintenance b. remodeling c. mutation d. both a and b

root canal system, inducing periradicular inflammation, which promotes clastic cell activity, and, in turn, triggers an osseous and radicular resorptive process. a. Slight necrosis b Medication c. Complete necrosis d. Inflammation

2. Particularly in regards to external inflammatory apical root resorption, several studies have shown _________ between this disease, pulp necrosis, and the presence of periradicular lesions. a. a positive correlation b. a negative correlation c. no correlation d. a very subtle connection

5. Some studies have advocated the use of calcium hydroxide as an intracanal medication in cases of open apices caused by __________. a. incomplete apexogenesis b. over-instrumentation c. apical resorptions d. all of the above

3. Since no evidence of ________ was observed in this case report, it was concluded that the severe inflammatory resorptive process evolved from carious lesion to pulp necrosis and periradicular disease. a. dental trauma b. occlusal disharmony c. relevant associated systemic disease d. all of the above

6. Furthermore, calcium hydroxide is capable of promoting necrosis of the resorptive cells present in ___________, thus neutralizing clastic cell acids, preventing the mineral dissolution of the root, and rendering the region unsuitable for acid hydrolases. a. Cartilage lacunae b. Howship’s lacunae c. Vascular lacunae d. Volkmann’s canals

4. __________ of pulp tissue leads to colonization and proliferation of microorganisms within the

7. Healing of external root resorption, involving cementum and dentin caused by apical perio-

36 Endodontic practice

dontitis also requires the recruitment of _______. a. dendritic cells b. microglial cells c. progenitor cells d. Langerhans cells 8. In mature teeth with apical periodontitis, the dental pulp is completely destroyed, and the apical papilla _________. a. no longer exists b. is elongated c. becomes inflamed d. is slightly reduced 9. Newly formed cementum usually covers areas of the root where ________ were lost. a. stem cells b. cementum c. dentin d. both b and c 10. It seems much more “plausible biologically” that the entire immunological complex is __________ after performing an adequate cleaning and shaping process of the root canal system and not only or necessarily after using calcium hydroxide. a. unaffected b. activated c. inactivated d. rendered non-vital

Volume 11 Number 1

CE CREDITS

ENDODONTIC PRACTICE CE

PRODUCT PROFILE

Freedom without compromise Ultradent’s Endo-Eze™ Genius® reciprocation and rotary endodontic system

W

ith so many endodontic motor options available to general dentists and endodontists today, it’s no wonder that clinicians can have a difficult time initially selecting the right one for them. On the other end of the spectrum, some clinicians can end up stockpiling multiple endodontic motors in their supply closets due to changes and advancements in technology, discontinuation of files, or simple dissatisfaction with the motor or system they’re using due to excessive file breakage, malfunction, or other issues. Selecting the Endo-Eze™ Genius® endodontic system instantly solves all of these issues. The Genius system is designed to switch between reciprocation movement to rotation, preventing file breakage that is so common in rotary-only endodontic motors. Although the Genius® files are designed specifically for the Genius® motor, in that they are compatible with both reciprocating and rotary movement, the motor’s open design allows for clinicians to use any files with the motor that they choose. Let’s further explore the reasons the Genius endodontic system is the last endo system clinicians will ever need.

Freedom Ultradent’s Genius endodontic system’s open design allows the clinician the freedom to do what’s best for the patient when it comes to files, file length, and brand. While the Genius endodontic system features the Genius files, which are especially designed to work with the Genius motor, Ultradent Products, Inc. believes in giving dentists and endodontists the power to choose. Additionally, the Genius endodontic system’s open

design allows Ultradent and endodontic researchers to continue innovating, which in turn allows clinicians the ability to take advantage of new files and technologies that may become available in the future without having to purchase a new motor to accommodate them.

Simplicity The scariest thing for dentists and endodontists when it comes to performing endodontic procedures is file breakage.

That is why, upon dental school graduation, so many general practitioners refer their endodontic business out to specialists. The Genius endodontic system brings simple endodontics back to the dental practice thanks to its straightforward technology and the many options it leaves open to the clinician. The Genius motor not only comes with preprogrammed speed, torque, and angle settings to provide the ideal balance for endodontic procedures, but its reciprocation and rotary modes can be accessed and switched between during a procedure by the clinician with the touch of a button.

The reciprocation movement used in the Genius system, which cuts 90° and releases 30°, takes the tension off the file, helping to prevent breakage unlike many systems that only offer rotary. The beauty of being able to switch between reciprocation and rotary with the touch of a button is that clinicians get the best of both worlds — they are able to reach the working length of the canal through reciprocation safely, while finishing the procedure in rotation (rotary) mode in order to best remove any remaining debris from the canal without ever having to change the file.

Figures 1 and 2: 1. Ultradent’s Endo-Eze Genius reciprocation and rotary endodontic system. 2. Endo-Eze Genius files are compatible with both the reciprocation movement and rotary movement of the Endo-Eze Genius motor Volume 11 Number 1

Figure 3: The Genius endodontic motor features reciprocation movement, which cuts 90° and releases 30°, which takes the tension off the file, helping to prevent file breakage

The Genius files are the only file designed to be used both in reciprocation and rotary movements.

Additionally, reciprocation and rotary systems like the Genius system further simplify endo-dontics by allowing most procedures to be completed with just two files. Ultradent recommends shaping the canal with a 25.04 file until working length is achieved and then completing the procedure with the finishing file of choice.

A sound investment How many endodontic motors do clinicians have sitting, unused, on their storage shelves? The answer to that question for most would be “many.” So many times, doctors invest in a motor they believe in, only to find out later that the company that makes the motor has gone out of business or discontinued the product, or that the files have been discontinued, or even worse, that technological advances in endodontics have rendered the motor and its offerings obsolete. Also, many companies allow only their proprietary files to be used with the motor they sell, holding the clinician hostage to their pricing, their research and advancement (or lack thereof) in technology, and their techniques. Choosing the Genius endodontic system prevents these extremely common pitfalls, ensuring that the clinician’s investment in an open motor system can be his/her last.

To learn more about the Endo-Eze Genius endodontic system, call 800-5525512, or visit ultradent.com. EP This information was provided by Ultradent Products, Inc.

Endodontic practice 37

TECHNIQUE

Effectively treating the complex anatomies of root canal systems Sonendo® discusses eliminating infections from intricate root canal systems and preventing reinfection

T

he tooth is one of the most individual and complex anatomical, as well as histological, structures in the body,1 so much so that radiographic examination has its limitations in imaging their imperceptible tubules and isthmi. Because of this, eliminating infections from intricate root canal systems and preventing reinfection prove to be the most crucial challenges remaining for most root canal protocols.

Relying heavily on mechanical instrumentation, standard root canal therapy employs a series of files to shape the canal space in preparation for delivery of disinfecting irrigants as well as to remove vital and necrotic tissue and microorganisms.2,3 Not surprisingly — due to the complex nature of root canal anatomy — mechanical preparation alone cannot sufficiently remove soft tissue debris or kill microorganisms,4,5 which necessitates the irrigation of the root canal system with disinfecting fluids.

Limitations of standard root canal treatment The traditional job of the file is to biomechanically remove infected tissue from the canals. Filing is followed by irrigants that serve as a chemo-mechanical means to first remove infected tissue and debris left behind by files, and then, more vitally, to reach into the crevices inaccessible through mechanical instrumentation to provide disinfection throughout the root canal system. The efficacy of irrigation depends on the working mechanisms of the irrigant and the ability to bring the irrigant in contact with those elements, materials, and structures within the canal system that must be removed.6 The introduction of ultrasonic technology in 1957 offered a much more effectual method over previous irrigant delivery systems. In a histological study that assesses root canal cleanliness, conventional techniques cleaned only 29% of the canal, whereas contemporary techniques involving passive ultrasonic irrigation cleaned 80%.5 Standard root canal 38 Endodontic practice

therapy has made only incremental advancements since.

not previously visualized through radiographic examination to save important tooth structure.

Multisonic Ultracleaning® technology of the GentleWave® System

Clinical Case Study 1

In 2016, after years of research and development, Sonendo® introduced us to Multisonic Ultracleaning® with the GentleWave® System, offering a minimally invasive7 procedure that reaches into the microscopic spaces7,8 that standard root canal treatments often cannot.9 The proprietary closed-loop Multisonic Ultracleaning technology found in the GentleWave System’s Molar and Anterior/Premolar Procedure Instruments represents an entirely new way of thinking about root canal therapy. Relying less on files,8 the GentleWave Procedure redefines the job that the file is hired to accomplish.

The mechanism of action used in the GentleWave Procedure consists of the constant refreshing and removal of optimized procedure fluids (i.e., sodium hypochlorite, EDTA, and distilled water) in a closed-loop system, combined with Multisonic Ultracleaning technology, where multisonic acoustic waves deliver useful cavitation throughout the root canal system to enhance cleaning and disinfection through advanced fluid dynamics, broad spectrum acoustic energy, and tissue-dissolution chemistry.10 The GentleWave Procedure delivers irrigants deep into complex anatomies, reaching lateral canals and microscopic tubules and providing an incredible level of clean — removing biofilm11 and smear layer from the crown to the apex.8 The Multisonic Ultracleaning difference has been demonstrated in numerous case studies and publications, as evidenced in the following selections.

GentleWave® Procedure case studies: discovering complex anatomies In this grouping of recent GentleWave Procedure case reviews, clinicians were able to reach and clean the deepest, most complex portions of the root canal system7,8

Complex Apical Anatomy Following Minimal Endodontics by Michael W. Ford, DDS, MS Diagnosis: Symptomatic irreversible pulpitis with symptomatic apical periodontitis.

Figure 1: Pre-GentleWave® Procedure

Figure 2: Post-GentleWave® Procedure Images courtesy of Michael W. Ford, DDS, MS

After utilizing the GentleWave System, postoperative radiographic examination revealed multiple lateral canals within the apical third of the palatal and distobuccal canals, as well as an isthmus between the mesiobuccal canals.

Volume 11 Number 1

Clinical Case Study 2

Clinical Case Study 3

6-month Healing of a Mandibular First Molar with Complex Anatomy by Khang T. Le, DDS Diagnosis: After clinical and radiographic examinations, the subject tooth was diagnosed as necrotic pulp with symptomatic apical periodontitis.

Locating Complex Apical Anatomy Post GentleWave Procedure by Brian T. Wells, DMD Diagnosis: Pulpal necrosis of the mandibular left second molar with acute apical periodontitis.

In each case study, post-procedure radiographic examination discovered previously undetected complex anatomies found through the delivery of Multisonic Ultracleaning technology from the GentleWave Procedure. Bacteria that would have been left behind — and allowed to spread post-treatment — were removed, and tooth structures were maintained.12 Results were consistent and conclusive that the GentleWave System provided a more thorough, more effective cleaning that potentially helped reduce the need for retreatments over time.12 Sonendo is dedicated to Saving Teeth Through Sound Science®. That means that our technology has been rigorously tested before it has reached the marketplace, and that we continue to innovate to deliver remarkable results for endodontists, referring dentists and patients. To learn more about introducing the minimally invasive7 GentleWave Procedure to your practice, contact a Sonendo representative today. EP

REFERENCES 1. Anatomy of the Tooth. Kenhub Web site. https://www. kenhub.com/en/library/anatomy/anatomy-of-the-tooth.

Published April 15, 2014. Accessed February 26, 2018.

Figure 3: Pre-GentleWave® Procedure

Figure 5: Pre-GentleWave® Procedure

2. Ricucci D, Siqueira JF Jr. Anatomic and microbiologic challenges to achieving success with endodontic treatment: a case report. J Endod. 2008;34(10):1249-1254.

3. Basrani B, Haapasalo M. Update on endodontic irrigating solutions. Endod Topics. 2012;27(1):74-102.

4. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review. J Endod.

2004;30(8):559-567 5. Zandbiglari T, Davids H, Schäfer E. Influence of instrument taper on the resistance to fracture of endodontically treated roots. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2006;101(0):126-131.

6.

Rosenfeld EF, James GA, Burch BS. Vital pulp tissue response to sodium hypochlorite. J Endod.

1978;4(5):140-146.

7. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement of human molars using the GentleWave System. J Endod. 2015;41(10):1701-1705.

8. Vandrangi P, Basrani B. Multisonic ultracleaning in molars with the GentleWave System Oral Health. 2015;72-86.

9. Paqué F, Balmer M, Attin T, Peters OA. Preparation of oval-shaped root canals in mandibular molars using nickeltitanium rotary instruments: a micro-computed tomography study. J Endod. 2010;36(4):703-707.

Figure 4: Post-GentleWave® Procedure Images courtesy of Khang T. Le, DDS

Figure 6: Post-GentleWave® Procedure Images courtesy of Brian T. Wells, DMD

After the GentleWave Procedure and post obturation, a complex root canal system was visible with two intercanal isthmi and a lateral canal.

Post obturation, a complex apical anatomy was visible between the mesial and distal canals. This anatomy was not known prior to the GentleWave Procedure, and therefore, additional shaping was not completed for preparation of these complexities.

Volume 11 Number 1

10. Ford MW. Complex Apical Anatomy Revealed Following Endodontic Treatment of a Maxillary Molar Using the GentleWave System: A Case Report. Dentistry. OMICS International Web site.

11. Nair PN. Endodontic biofilm, technology, and pulpal regenerative therapy: where do we go from here? Int Endod J. 2014;47(11):1003-1011.

12. Sigurdsson A, Garland RW, Le KT, Woo SM. 12-month healing rates after endodontic therapy using the novel GentleWave System: a prospective multicenter clinical study. J Endod. 2016;42(7):1040-1048.

This information was provided by Sonendo®.

Endodontic practice 39

TECHNIQUE

In a histological study that assesses root canal cleanliness, conventional techniques cleaned only 29% of the canal, whereas contemporary techniques involving passive ultrasonic irrigation cleaned 80%.5

The GentleWave Procedure: conclusive cleaning results in complex anatomies

PRODUCT PROFILE

The evolution of the taper

E

ndodontic practices took a major leap forward with the introduction of nickeltitanium rotary files. With its amazing properties, the alloy we’ve come to know as NiTi has been setting new standards for the profession ever since.

NiTi heat treatment technology has continued these improvements to enable today’s endodontists to harness NiTi’s full potential with ever-greater success.

With the EdgeTaper Platinum™ from EdgeEndo, NiTi gives endodontists far greater control over the root canal procedure. The file series breaks new ground for flexibility and cyclic fatigue resistance, and it costs half of what endodontists are accustomed to paying for similar products.

EdgeEndo’s proprietary heat treatment process, Firewire™, allows for the manufacture of files that are incredibly flexible and superelastic. The process gives the files their revolutionary contouring ability, allowing endodontists to follow the canal curvature with remarkable precision, even in challenging cases with curves up to 90°.

While the benefits of flexibility are well known, some endodontists are unfamiliar with files that don’t have “shape memory.”

Though shape memory may seem beneficial, it can cause a file to “bounce back” and straighten in curved canals, fighting the natural canal anatomy and causing canal transportation. EdgeTaper Platinum files are

more flexible, which prevents transportation and can also be pre-bent in situations where entry into the canal is difficult.

The Firewire heat treatment process also produces instruments that are incredibly resistant to separation. EdgeTaper Platinum files exhibit 2 to 8 times the resistance to cyclic fatigue of other NiTi files, allowing them to navigate severely curved canals with greater ease than previously possible.

The EdgeTaper Platinum series is used just like ProTaper Gold® but designed to

safely unwind instead of breaking if extreme torsional forces are encountered.

EdgeTaper Platinum is available in 21 mm, 25 mm, and 31 mm lengths. The files are designed to be used with the same speeds, torques, and techniques as ProTaper Gold®, making for an easy and seamless transition.

EdgeEndo also has knowledgeable customer service representatives available by phone to answer any questions that arise.

As readers know, the practice of endodontics is becoming more competitive, with root canal reimbursements decreasing and patients finding it harder to pay their part of the cost. In this environment, overhead control is a major factor — not only for success, but also for survival.

EdgeEndo has eliminated many of the overhead costs associated with traditional manufacturers, which helps keep their pricing extremely low. Over the years, the opportunity to save substantially on premium rotary files can make a big difference in the financial success of today’s endodontic practice.

Because of heat treatment technological innovations and advancements, NiTi rotary file systems have profoundly increased their safety and performance.

Endodontists can now perform procedures that were unimaginable with standard nickel-titanium files. The EdgeTaper Platinum allows you to reap all of NiTi’s incredible potential at half the cost. EP This information was provided by EdgeEndo.

40 Endodontic practice

Volume 11 Number 1

W

hen endodontists invest in a CBCT system, they should seek to partner with a company that advances technology at the same pace as their field evolves.

Carestream Dental not only designed its CS 8100 3D system with the endodontic workflow in mind, but is continually making updates in response to changing demands in the industry. Recent improvements to hardware and software, developed based on feedback from endodontists, help doctors practice at the highest level.

From the very beginning, the CS 8100 3D focused on the needs of endodontists with its HD mode (5 cm x 5 cm), which allows for even the finest details of root and canal morphology to be captured in ultra-high resolution for diagnostic and treatment planning with no additional dose to the patient above the standard 5 cm x 5 cm exam. This gives endodontists flexibility when striving to meet the AEE/AAOMR’s latest recommendations on dosage — i.e., “if a low-dose protocol can be used for a diagnostic task that requires lower resolution, it should be employed.”* Another powerful software update that improves workflow for endodontists is the ability to open scans faster than ever before, in as little as 15 seconds, due to the fullfunction “preview” mode available while the full data set is being loaded. Additionally, 3D initial reconstruction times are now faster.

These pertinent changes reflect Carestream Dental’s understanding of endodontists’ need for a timely and efficient workflow and its commitment to deliver meaningful updates for existing customers.

The CS 8100 3D also delivers enhanced image quality through an algorithm change that updates the preset exposure parameters on all 3D programs. The parameters have been modified to maximize diagnostic effectiveness while maintaining adherence to ALARA. In regards to hardware updates, a new 3D bite block has been designed to better position more posteriorly in the mouth, such as for third molars more centrally in the field of view when acquiring 5 cm x 5 cm exams.

The new 3D bite block is offset both forward and laterally, as opposed to the standard 3D bite blocks, so larger patients can be imaged more effectively.

For extraoral bitewing positioning (and for panoramic X-rays), images often show large differences in head positioning from one patient to another; heads are tilted too far back, while others are too far forward.

Improper positioning generates blurriness and deformations in the anterior region of the jaw. To address this, a new Frankfort guide bite block combines the existing 3D bite block design and the existing panoramic bite block to align the patient automatically

Carestream Dental CS 8100 3D

with the Frankfort horizontal plane for optimal positioning of the anterior region of the jaw, thus ensuring optimal sharpness in this area.

Of course, with so many updates and advancements, Carestream Dental has equipped its 3D users with resources to help them take full advantage of their system. An educational web page, carestreamdental. com/learn3d, includes many helpful videos. It also now features four all-new how-to videos focused on capturing and sharing images as well as customizing and sharing oneclick reports. This focus on education not only allows endodontists to continue to take advantage of new features or expand upon their current features, but also helps their referring doctors easily access diagnostic information on mutual patients.

All endodontists strive to practice at the highest level and offer the best patient care.

When they invest in the CS 8100 3D, they’re ensuring that their technology advances just as quickly as their own workflow and changing industry standards. EP

*

CS 8100 3D 5 cm x 5 cm scan of mandibular left posterior with finding of buccal fenestration and periradicular lesion (tooth No. 20) Volume 11 Number 1

American Association of Endodontics, American Academy of Oral and Maxillofacial Radiography. (2016), Use of Cone Beam Computed Tomography in Endodontics 2016 Update.

Chicago, Ill.: Special Committee to Revise the Joint American Association of Endodontists/American Academy of Oral and Maxillofacial Radiology Position on Cone Beam Computed Tomography.

This information was provided by Carestream Dental.

Endodontic practice 41

PRODUCT PROFILE

New updates to CS 8100 3D help endodontists practice at the highest level

PRACTICE DEVELOPMENT

Endodontic engagement: the GP and endodontist can achieve more as a team Dr. Brett E. Gilbert discusses the important interaction between generalists and specialists The pulse To truly feel the current pulse in dentistry, you must listen to what other dentists are thinking and saying. Online message boards are a great place to participate in the conversations that dentists are having.

These forums give us a sense of the current trends. Social media is the emerging wave of communication for the younger generation of dentists. New grads are active participants online, focusing a light on what all dentists are thinking and feeling. Seasoned dentists also take advantage of this digital age by being able to readily share and learn from dentists far outside their local circles.

When the digital conversation turns to endodontics, it is clear that there are two overwhelming trends regarding endodontic treatment. First, there is a recognizable disparity in the competence and confidence between endodontists and general practitioners in performing successful root canal treatment. Second, new dental grads do not feel they have had enough clinical experience doing root canals in school to be confident in their endodontic skills. After dental school, general dentists have a limited amount of focus and energy to devote to endodontics with so much else to learn. Endodontic growth must be sought out by the clinician, and there are only so many hours in a day.

The pulse online also confirms the general consensus, which is that endodontists are really great at doing root canals! The advanced study and training, along with the implementation of new technologies, allow endodontists to master root canal therapy.

Brett E. Gilbert, DDS, graduated from the University of Maryland Dental School in 2001 and completed his postgraduate training in Endodontics from the University of Maryland Dental School in 2003. He is currently a clinical assistant professor in the Department of Endodontics at the University of Illinois at Chicago, College of Dentistry and on staff at Resurrection Medical Center in Chicago. He is a past-president of the Illinois Association of Endodontists. Dr. Gilbert is boardcertified, a Diplomate of the American Board of Endodontics. He lectures nationally and internationally on clinical endodontics. Dr. Gilbert has a full-time private practice limited to endodontics in Niles, Illinois.

42 Endodontic practice

This is evident in the quality of treatment and successful outcomes that save patients from losing their natural teeth.

I believe that these two trends — 1) a disparity in the quality of treatment and 2) a lack of clinical experience upon graduation — are reliant on each other. This lack of sufficient undergraduate training has been ongoing for much of the past few decades. I certainly do not mean to criticize the undergraduate endodontic curriculums as there are only so many root canal patients that walk through the doors of our nation’s dental schools.

However, the mention of a lack of experience is a common thread online as new grads shy away from attempting endodontics in practice as fear and anxiety replace confidence. This leads to poor outcomes and may lead to the loss of patient trust. We all know that it is hard to hide the feelings of uncertainty when you are treating patients. Patients can smell uncertainty like a shark smells blood.

The opportunity to respond the pulse I believe that the referral relationship between the general dentist and endodontist has much more to offer than may appear on the surface. An endodontist depends on referrals to maintain his/her practice, but there can be so much more to a strong referral relationship. Endodontists are passionate about their craft and are teachers at heart. Many endodontists, myself included, are teaching in dental schools, providing online continuing education, writing articles, performing research, presenting live courses, and thinking endodontics 24/7/365.

Teaching is a part of every hour of the day as an endodontist must “teach” every patient

about best practice treatment options. This creates a great opportunity for general dentists to continue their endodontic learning by growing their relationship with their local endodontist.

Endodontists are looking to engage colleagues as confidants, advisors, teachers, mentors, friends, and emergency backup in all things endo! Our primary role is to treat referred patients but to also be a resource to help guide treatment planning, case selection, and clinical techniques for the root canal cases appropriate to accomplish in general practice. The statistics are clear — only about 25% of the 25 million root canals performed in the United States are completed by endodontists. Endodontists could not possibly do all of the root canals alone. Our general dentist colleagues are key partners in helping patients save their teeth. Let’s find a balance in using realistic case selection to assure that any given patient is having root canal therapy performed in the chair most appropriate for the clinical situation at hand.

The pendulum is swinging back from implants to saving natural teeth due to clear evidence that peri-implant mucositis and peri-implantitis are more prevalent than we previously understood. There is a great opportunity for general dentists and endodontists to partner in saving more natural teeth. This relationship is about more than referral of patients, but a sharing of knowledge and resources with each other to promote better care for our patients. Patients want to keep their natural teeth, dentists love to keep teeth healthy, and endodontists are passionate about saving teeth. These three desires create a perfect triad of care. EP Volume 11 Number 1

PRODUCT PROFILE

What does neuroscience have to do with dentistry?

A lot!

Sandra Marlowe discusses a method of achieving a profound mental state of peak performance

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magine a new way to practice dentistry — where your patients look forward to visits and arrive calm and relaxed. Where you are far more to your patients than just a way to prevent or get out of pain or have a more attractive smile. At your practice, patients are discovering a healthier, happier life in ways they never dreamed possible. Some patients have lost weight, others have found relief from anxiety and fear, and some even have you to thank for lower golf scores.

Imagine, in this new dental practice, patients schedule recommended treatment because they trust you. They complete treatment plans because they feel safe in the office, and they regularly refer friends and family because you are more than just their dentist; you are their hero.

How do you create such a practice? The surprising answer for a large and growing number of dentists has been found in the burgeoning field of neuroscience and new discoveries in brain wave entrainment. These methods work by balancing and harmonizing the brain in a way that creates a profound mental state of peak performance.

BrainTap Technologies is leading the charge in delivering brain wave entrainment technology in an easily consumable manner.

The benefits of braintapping include relaxation, stress reduction, restorative sleep, and lifestyle improvements that directly contribute to an enhanced patient experience.

BrainTap uses five mind technologies that, combined, create a powerful tool for you to use both in-office and for home care to help improve quality of life for your patients in every aspect of their lives.

• Beats and tones — Imbedded tones emulate relaxed brain waves, guiding the brain to an extraordinary level of focus and performance that would

•

•

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• Sandra Marlowe has authored, co-written, or ghostwritten eight self-improvement books, including an award-winning bestseller.

She has earned a Pushcart Prize nomination in literature. She regularly writes and speaks on topics related to brain health and self-development.

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otherwise take years of practice to achieve.

Audio Library — Patrick K. Porter, PhD, BrainTap’s founder, created guided-visualization audio sessions to help people become the designers of their own lives. With a selection of more than 700 titles — all encoded to work with the BrainTap headset — users learn how to focus on everything they want out of life.

10-cycle holographic music — The music on the Audio Library audiorecordings is designed to create a full 360-degree experience that delights the mind with calming thoughts and images.

Light frequencies — The BrainTap headset adds the dimension of light pulses that train the brain to produce a healthy balance of brain wave activity, transforming the listener into a mental powerhouse with the right mindset to accomplish just about any goal.

Auriculotherapy — The BrainTap headset also delivers light frequencies through the ears. There are specific points in the ears, called meridians, known to directly affect the body’s organs and systems. These are typically activated using acupuncture

needles, but light frequencies are known to have the same effect. The headset’s earphones are uniquely equipped with nine LED lights set at the optimum frequency for providing a sublime feeling of serenity and balance, all without needles.

The benefits to patients are innumerable and can be immeasurable. Virginia Beach home-care provider Carol Hooper is a great example. “I had been overweight nearly my entire life,” Hooper says, “Food was my comfort when I was sad, tired, or happy. In 1996, I met Dr. Patrick Porter (BrainTap’s founder), and my life changed forever. Dr. Porter taught me how to balance my brain, visualize my goals, and stay motivated for life.

I took off 95 pounds and, best of all, I kept it off for 20 years.”

Stories like Hooper’s are not uncommon.

But how do dentists benefit from providing BrainTap in their practices?

By becoming licensees of the BrainTap system, any dentist can have the ability to increase income and build a more varied practice in at least five different ways: 1. BrainTap services can be offered to patients in the dental practice for profit. Now dentists can offer programs for sleep, weight loss, smoking cessation, stress reduction, pain reduction, or choose a more Volume 11 Number 1

monthly payment. Which means, if just four patients a week become members, this alone can add $7,000 to the bottom line with virtually no effort. And dentists who prescribe the membership service to stressed-out clients for home care see a growing residual income.

4. Use BrainTap Technologies products and services as your entrée for drawing in new patients, conducting training sessions, demos, seminars, and shows. Free demonstrations of the BrainTap headset provide you a unique way to introduce prospective new patients to your practice. They experience an immediate shift in how they feel and function, making it easy to convert them for long-term care.

5. Improve retention and increase referrals. Patients experiencing brain wave entrainment through the BrainTap headset and the membership tend to respond better to care and overall are happier and more compliant — which translates to patients that stay and refer.

To make it simple for the practitioner, BrainTap allows dentists to gift patients a 15-day trial for FREE. Getting brain wave patterns back to normal, or closer to normal, during that 15-day free trial allows patients’ brains to start self-regulating and the autonomic nervous system to balance, helping all unconscious activity to function optimally.

This helps regulate the functions that have

been under control of the central nervous system (CNS). Patients feel the results in a short amount of time, allowing them to recognize the long-term benefit.

So how do you apply this neuroscience to the real life dental practice?

Consider for a moment how many dentists are now offering and profiting from treatment for sleep apnea, a disorder that causes breathing to frequently stop and start that has been associated with significant health risks, including high blood pressure, diabetes, obesity, and heart disease. In the national effort to understand, diagnose, and treat this disorder, dental professionals have emerged as an important part of the community aimed at alleviating human suffering due to sleep apnea. This specialized area of practice has become a rewarding and highly profitable part of those dental offices.

Now, thanks to new advances in neuroscience, BrainTap is providing dentists unique and specialized tools for branching out into other arenas such as weight loss, stop smoking, stress management, chronic pain, and may more. And, for the dental sleep practice, BrainTap is the logical complement to existing treatments for sleep apnea.

The first step in discovering all that BrainTap can do for you and your practice is to try braintapping for yourself. Simply sign up for a complimentary trial here: www.mybrainoffer.com EP

This information was provided by BrainTap.

Stay Connected Between Issues Like us on Facebook at facebook.com/EndodonticPracticeUS Watch our DocTalk Dental videos at doctalkdental.com Check out our Webinars at endopracticeus.com/webinars Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

Volume 11 Number 1

Endodontic practice 45

PRODUCT PROFILE

unique route of care by choosing from any of 700 single audio sessions offered on the BrainTap mobile app.

You can also use BrainTap to add value (and higher fees) to some or all of your existing practice’s services.

2. Offer the BrainTap headset in office as a retail item. BrainTap offers the dental professional a generous wholesale rate. Dentists who retail just one BrainTap headset a week can drop an additional $12,500 to their bottom line. And, once clients own their own BrainTap headset, they will likely opt for the mobile app membership, which adds to monthly income as well.

3. Sell the membership service to clients for added monthly revenue.

For every client set up for membership, dentists earn 30% of the $30

PRODUCT PROFILE

Star® ETorque™ Electric System Power, performance, and flexibility

L

aunched at Chicago midwinter, DentalEZ introduces the new Star® ETorque™ Electric System. The ETorque Electric Motor System combines the power and performance you have come to expect from StarDental. With customizable settings for prep and endodontic procedures, the StarETorque seamlessly combines power with performance. From caries removal to root canal treatment, you can seamlessly move from high-speed to low-speed settings with one touch. The StarETorque’s lightweight, brushless motor delivers powerful, consistent speed, all with less noise and vibration — a real plus for both patient and dentist. The motor is also compliant with CDC Guidelines and can be autoclaved.

The StarETorque’s redesigned touch screen and color display provide a simple, intuitive user interface to reduce time spent making adjustments. Flexibility is built-in.

46 Endodontic practice

The overall size of the Motor Control Unit has also been reduced and provides all the performance you need. So, if you are looking for a new product that brings all the power, flexibility, and performance you need, look no further than StarETorque.

Features • • • • •

60 W Brushless Motor Lightweight at 62 g to minimize fatigue 100–40,000 rpm motor speed Fully autoclavable User-friendly display with customizable operative modes • Compact design for stand-alone or detachable display for modular mounting • Multiple attachments cover a broad range of operatory needs • Textured finish on attachments for comfortable grip

Top: Endodontic mode for powerful low-speed cutting Bottom: Preparation mode for high-speed procedures

• 3 customizable operative modes • Programmable motor torque accommodates all rotary file requirements • 5 customizable endo settings: autostop, auto-reverse, auto-forward, autoreverse, auto-reverse-forward • Presets for all common handpiece transmissions plus 2 customizable transmissions • Displays actual bur rotation speed EP This information was provided by DentalEZ.

Volume 11 Number 1

Higher expectations, better performance.

Find your Power.

The Power of Performance Š2018 DentalEZ, Inc. DentalEZ, Star, and StarDental are registered trademarks and StarETorque is a trademark of DentalEZ, Inc.

DentalEZ.com/StarETorque

SMALL TALK

A critical distinction: problem solver versus people developer Dr. Joel C. Small offers a technique for creative problem-solving

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often encounter doctor clients who are frustrated by their team’s lack of ability to achieve a pre-defined, desired result. The scenario goes something like this: Coach: I hear that you are frustrated.

Give me more detail.

Doctor: Okay. Well, no matter how many times I tell my staff what I want them to do, they are unable to consistently get it right.

Even worse, they are constantly coming to me with problems that they should be able to manage. It seems as if they can’t make decisions on their own. I’m too busy to keep repeating myself, and I get frustrated when they come to me needlessly to solve every simple problem. I’ve tried everything I know to change this situation, but to no avail.

Coach: Everything? Have you tried becoming a “People Developer”?

Doctor: I don’t know what that means.

Tell me more please.

Any coach, in any industry, will recognize this scenario because the premise knows no boundaries. The good news is that even though the problem is universal, so is the solution. The answer lies in understanding the distinction between a “problem solver” and a “people developer.”

The doctor in the above scenario is a problem solver. By this I mean that he/ she issues directives without tying them to the foundational principles of the practice.

Secondly, he/she has failed to create a practice environment that is conducive to ongoing personal development. How do I know this to be true? Simple. If the doctor had been a “people developer,” he/she would not be plagued with these problems. As we shall see, it is the doctor, not the staff, who has created the problem.

Almost invariably, problem solvers fail to define the purpose of their directives and how the specific purpose correlates with the fundamental practice purpose and values.

This is assuming that the doctor has even defined and shared these ideals with the staff. This lack of communication leaves a void that is filled by each team member’s own interpretation of purpose. Purpose is a strong determinant of action, so we can only imagine the confusion and frustration when a team with varying interpretations of purpose tries to achieve a common goal.

Furthermore, problem solvers will always be plagued with never-ending questions from their team. Frankly, the problem and solution revolves around our expectations of our staff.

Do we expect them to be helpless? Are we okay with their unwillingness and apparent inability to answer even the simplest of questions? I would expect that even the most devout problem solvers would say “No!” and yet they fail to see that they impose the very environment that promotes these forms of learned helplessness. The more we continue to answer questions, the more we become entrenched in the problem solvers’ mentality, and the more our staff is willing to abrogate their creative ability to solve problems on their own.

The answer is for us to commit to developing these God-given skills in those who serve our cause. We do this by seeking their input to creative problem solving. We do this by becoming people developers. I am reminded of the old Chinese proverb, “Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime.”

And so it is with people developers. We must first believe that someone is able to fish, or

Joel C. Small, DDS, MBA, 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 Dr. Small’s “Core Values Exercise,” please contact the author at joel@joelsmall.com. He is also available for a complimentary coaching session to discuss your practice-related issues.

48 Endodontic practice

in this case, solve problems on his/her own.

Believing that something can be done will eventually become an expectation that it will be done, and expectations have been shown to be powerful self-fulfilling prophesies.

Our team looks to us for answers when we fail to develop their problem-solving skills.

If we find ourselves in this situation, here’s a simple solution. First, let the team know that you will be seeking their input to problem solving; then immediately quit answering questions. When someone comes to you seeking a solution to a problem, tell him/her that you have a solution, but you would like to hear their solution first. In many cases, that staff member’s solution will work quite well or will require minimal adjustments. Always make a clear correlation between the solution and the guiding practice values and purpose.

Over time, staff members will realize that you will not be answering questions without their input. More importantly, they will realize that their solutions are good solutions, and with your support and encouragement, they will begin to solve problems independently within the confines of the practices purpose and values. It is important at this juncture to be clear regarding decisions that you feel require your input. Surprisingly, as the people development process progresses, you will find that your input is required less and less.

Fundamental to the people development process is a willingness by the leader to encourage input, acknowledge it when received, and affirm its value.

People developers will tell you that they have grown to rely on their staff’s problemsolving capabilities. I can tell you that I have personally observed very positive changes in practices that have adopted a peopledevelopment mentality. EP Volume 11 Number 1

Experiencing the power of digital communication.

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• Benefit from a digital workflow • Easily educate your patients • Demonstrate the value of your work

Tour EXTARO 300 at the upcoming meetings.

AACD, April 18-21, ZEISS Booth 416 | AAE, April 25-28, ZEISS Booth 1009

SUR.9424 ©2018 Carl Zeiss Meditec, Inc. www.zeiss.com/med All copyrights reserved.

DRIVING DIAGNOSTIC EXCELLENCE IS MORE THAN WHAT WE DO IT´S IN OUR DNA

2014: CS 8100 3D Carestream Dental

1960s: Dental X-ray Unit Trophy Radiologie

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

Carestream Dental. Now 100% Digital.

Carestream Dental may be a new dental digital company, it has a long history of defining imaging and practice management technology. Strong legacy brands—which include Eastman Kodak, Trophy and PracticeWorks—have paved the way to bring dental workflows into the new realm of digitalization. And, as an independent company solely focused on the oral healthcare market, Carestream Dental will continue to drive innovation and deliver new solutions for practices.

From consultation to final treatment, we have the solution that’s right for you.

© 2018 Carestream Dental LLC. 16907 DE CS 8100 3D Family AD 0318 Trophy and PracticeWorks are trademarks of Carestream Dental Technology Topco Limited.

Kodak is a trademark of Eastman Kodak Company.

For more information, call 800.944.6365 or visit carestreamdental.com