Endodontic Practice US Fall 2018 Vol 11 No 3

clinical articles • management advice • practice profiles • technology reviews Fall 2018 – Vol 11 No 3 • endopracticeus.com

PROMOTING

EXCELLENCE

IN

ENDODONTICS

Study of preoperative administration of ketorolac and placebo on compromised teeth Drs. Jorge Paredes Vieyra, Fabian Ocampo Acosta, and Francisco Javier Jiménez Enriquez

Warm gutta-percha obturation with BC HiFlow™ Sealer Dr. Stephen Buchanan

Practice profile Practice insight

Dr. Richard A. Munaretto

Dr. Cameron Howard, Pinnacle Endodontics

Rotary versus Reciprocation: “How do I choose?”

Dr. John West

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What makes you so special?

Ability to perform highly complex procedures

The entire procedure from access opening to obturation can typically be completed in just one visit2

Less than 3% of dentists are endodontists1

Reaches into microscopic spaces3,4 that standard root canal treatments frequently cannot5

What makes you so special.

Helps save the structure and integrity of teeth by preserving more dentin2

Your specialized skills deserve our state-of-the-art technology.

Discover the GentleWave® difference at sonendo.com/special

AAE [https://www.aae.org/patients/why-see-an-endodontist/whats-difference-dentist-endodontist/] 2 Sigurdsson A et al. (2016) J Endod. 42:1040-48 3 Molina B et al. (2015) J Endod. 41:1701-5 Vandrangi P et al. (2015) Oral Health 72-86 5 Paqué F et al. (2010) J Endod. 36:703-7 © 2018. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo and SAVING TEETH THROUGH SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: www.sonendo.com/intellectualproperty. MM-0530 Rev 01 1

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

Training and education encourage full potential

I

n these times where changes in the field of endodontics are occurring at such a rapid rate, education is of prime importance.

We now have instruments that are anatomically driven — meaning that our instruments conform to the natural shape of the root canal as opposed to instruments that create their own shapes, which often alter or enlarge canals excessively. We now have imaging capabilities that allow us to view teeth in three dimensions, clearly seeing pathology where we could never be sure before and, therefore, helping us to better diagnose and treat complicated problems. 3D imaging acts as our GPS for endodontic microsurgery, keeping the osteotomies conservative Dr. Sam Kratchman and avoiding potential problems associated with the sinuses or mental foramen. Since 3D imaging allows us to accurately measure lesions, of equal importance will be follow-up imaging to view true healing.

For years, we have had the advantage of magnification and illumination through the operating microscope, and now the microscope application is expanding to be suited for use in other disciplines with the enhanced, augmented illumination modes (fluorescence, no glare, and composite filters) on the new EXTARO® 300 microscope from ZEISS. The light sources are easier on the eyes and last for thousands of hours without diminishing the quality/intensity of the light. The ability to focus at a greater distance and have all the controls on one button at your fingertips are other examples of improvements in technology. These are just some of the ever-changing advancements in the field, but without the proper training and education, clinicians will never work to their full potential.

Whereas years ago, endodontically treated teeth were being randomly extracted to be replaced by implants due to the “potential” for failure, now the realities of peri-implantitis are known, as well as the predictability of endodontic microsurgery; and the trends are now heavily in favor of saving natural teeth. The goal of the endodontist in today’s competitive environment is to be included in the discussion and treatment planning of compromised cases. What all too often happens is that a tooth may be failing endodontically, and before even given the opportunity to retreat the tooth conservatively or surgically, it gets extracted and replaced by an implant, without even being seen by the endodontist. This is due both to lack of education on the part of the restorative dentist as well as the inability for us as endodontists to proudly stand behind our work and offer predictable solutions to complicated cases. All we can ask for is to be invited to the table and included in the discussion, but we have to remain up-to-date and knowledgeable of all the advancements in our field.

Dr. Sam Kratchman

Sam Kratchman, DMD, received a BS in Biology and DMD at Tufts University in Boston, and his certificate in endodontics from the University of Pennsylvania, where he is an Associate Professor of Endodontics and Assistant Director of Graduate Endodontics, in charge of microsurgery. Dr. Kratchman co-authored Microsurgery in Endodontics, a textbook published in 2017, with Dr. Kim and developed a patented instrument called the S Kondenser for obturation of root canals. Both Main Line Today and Doctor of Dentistry magazines honored Dr. Kratchman as the cover story for their “Best of” issues. Dr. Kratchman lectures nationally and internationally as well as maintaining three private practices in Exton, West Chester, and Paoli, Pennsylvania.

ISSN number 2372-6245

Volume 11 Number 3

Endodontic practice 1

INTRODUCTION

Fall 2018 - Volume 11 Number 3

TABLE OF CONTENTS

Practice profile Richard A. Munaretto, DDS

6

Practice insight Dr. Cameron Howard, Pinnacle Endodontics His passion: transforming the patient experience.......................................16

A starring role at Cameo Dental Specialists

Clinical 12 Minimally invasive endodontics Dr. Peter Raftery evaluates the use of WaveOne® Gold files in minimally invasive canal preparation

2 Endodontic practice

Endodontic insight Rotary versus Reciprocation: “How do I choose?”

Dr. John West explores three critical distinctions of Rotary versus Reciprocation..................................20

Volume 11 Number 3

OPEN DESIGN? P URE GENIUS. TM

The Genius hybrid files can be used in both reciprocation and rotation, and most procedures can be completed using just two files. The Genius endodontic motor switches between reciprocation and rotation with the touch of a button, and the open design gives you the freedom to provide the best treatment for your patient. www.ultradent.com/genius

800.552.5512 | ultradent.com Š 2018 Ultradent Products, Inc. All Rights Reserved.

TABLE OF CONTENTS

Continuing education Study of preoperative administration of ketorolac and placebo on compromised teeth Drs. Jorge Paredes Vieyra, Fabian Ocampo Acosta, and Francisco Javier Jiménez Enriquez compare the effect of preoperative administration of single-dose ketorolac, a nonsteroidal anti-inflammatory drug and placebo on postoperative pain in teeth with irreversible pulpitis and apical periodontitis..................................... 26

Continuing education

Warm gutta-percha obturation with BC HiFlow™ Sealer

Dr. Stephen Buchanan discusses the advantageous properties of this bioceramic sealer

Small talk Rules for giving and receiving feedback

Practice management Communicating change in the dental practice Catherine Cheshire, SPHR, discusses the importance of keeping employees informed.......................................... 38

Product profile

32

Dr. Joel Small discusses methods for providing positive and generative feedback......................................... 44

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

Event news

NATIONAL ACCOUNT MANAGER | Carol Stagg Email: carol@medmarkmedia.com

....................................................... 46

CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com

Industry news

Bassi Logic™: The minimally invasive future of endodontics

....................................................... 47

Bassi Endo is passionately devoted to simpler, faster, and minimally invasive endodontics ................................... 42

Materials & equipment.......................... 48

CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com FRONT OFFICE ADMINISTRATOR | Melissa Minnick Email: melissa@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.endopracticeus.com | www.medmarkmedia.com SUBSCRIPTION RATES 1 year (4 issues) $129 | 3 years (12 issues) $349

4 Endodontic practice

Volume 11 Number 3

2018 AAE NEW PRODUCT LAUNCHES EndoSequence® BC Sealer™ HiFlow™ BC Sealer optimized for warm obturation techniques Higher heat resistance allows for better flow Won’t get chalky during down pack Higher radiopacity

"With over 10 years of evidence, I am now convinced that BC Sealer is the best sealer on the market. I have been working with Brasseler to develop a new version of BC Sealer that is optimized for warm obturation. BC Sealer HiFlow will allow clinicians who prefer thermoplastic techniques to fully embrace the biological benefits of BC Sealer."

— Steve Buchanan, DDS

EndoSequence® Scout Files Premium Brasseler quality Reduced max flute diameter for minimally invasive shaping Controlled memory NiTi for pre-bending Sterile blister packs At a glance the below NiTi instruments look fairly similar, but closer inspection reveals significant differences. These un-retouched, high-magnification images of unused instruments highlight what can be verified clinically:

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B-5113-EP-09.18

PRACTICE PROFILE

Richard A. Munaretto, DDS A starring role at Cameo Dental Specialists What can you tell us about your background?

I was born and raised in the western suburbs of Chicago, Illinois. I attended Benedictine University where I received my BS degree with honors. I was accepted into the University of Illinois at Chicago (UIC) College of Dentistry for my DDS and BSD. Fortunately, I was accepted into the endodontic program at UIC and completed my specialty degree in 2003. My next hurdle was completing my Diplomate from the American Board of Endodontics in 2008.

Since graduation, I have maintained an associate professor position at UIC College of Dentistry, and I was on the Alumni Board of Directors for the College of Dentistry.

Rick A. Munaretto, DDS

Dr. Munaretto with a patient

Is your practice limited to endodontics?

My personal practice is limited to endodontics and implant dentistry. After completion of my Diplomate in 2008, I started my implant practice after I realized I could do more for my patients. We were getting a lot of consultations on teeth with a very poor prognosis. Placing implants really makes a clinician see both sides of the coin.

6 Endodontic practice

I can make a very neutral decision for every case because I have no preference or bias. The problem for some specialists is like the old saying, “If all you have is a hammer — everything looks like a nail.” This ability makes the patients very comfortable because if the tooth requires extraction, I can perform this procedure, and they are not in limbo. It’s a very nice service to offer to our referrals, and we have been very successful with our outcomes.

father was sold on the dental operating microscope. Honestly, I explored every specialty in dentistry, so I spent as much time in those clinics as possible. I was fortunate enough to work in the periodontal clinic every Friday one-on-one with a periodontist during my fourth year of dental school. I really enjoyed it because I greatly increased my surgical knowledge, but I was drawn back to the endodontic department. Dr. Nijole Remeikis was my preclinical instructor, and he made a big impact on me going into endodontics at UIC College of Dentistry in 2001.

When did you decide to focus on endodontics?

Why did you decide to focus on endodontics?

During my college years, I started dental assisting at Cameo Endodontics for my father, Dr. Richard Munaretto, and my uncle, Dr. Raymond Munaretto. This opportunity really allowed me to experience private practice endodontics and learn about the specialty.

During that time in 1996, I went with my father to Dr. Kim’s course on using the microscope for surgical endodontics at the University of Pennsylvania School of Dental Medicine. That course was an eye-opener for me, and my

When I worked at Cameo Endodontics, it was a busy office, accepting emergencies, treating trauma cases, draining abscesses, and ruling out difficult diagnostic cases. My father and uncle were instructors at Loyola Dental School and were very well respected in the area. The introduction of the microscope to Cameo Endodontics in 1996 added to my interest in the field. The technical difficulty of endodontics, pain management, and endodontic microsurgery were my main Volume 11 Number 3

Reid Pullen, DDS

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PRACTICE PROFILE interests. Additionally, I observed the residents under Dr. Kim at Penn placing implants, and I thought that could be an option for me. I really liked the preclinical endodontic course, and I was able to see many endodontic cases during dental school which sealed the deal.

Do you get many practice referrals?

Cameo Dental Specialists, LLP, is a specialty dental practice that relies on general dentist referrals for 90% of our cases. We have been in business for 40 years, and we do receive patient referrals on a daily basis.

How long have you been practicing, and what systems do you use?

I have been in endodontic practice for 15 years. During that time, I have built very strong relationships with Dentsply Sirona, ZEISS medical technology, Nobel Biocare®, Carestream imaging, and Benco Dental. I have been a Key Opinion Leader (KOL) for Dentsply Sirona for the past 3 years, and I solely use their endodontic line. I primarily use ProTaper Gold®, Vortex Blue® and WaveOne® Gold for instrumentation. We utilize ZEISS microscopes in our endodontic operatories; we just bought two of their new EXTARO® 300 scopes. The new ZEISS EXTARO 300 design is great and ergonomic, so we have been very happy with it. For the past 5 years, the only implant system I place is the NobelActive® system. Our practice owns five Carestream CBCT units, and we have been really pleased with the integration into our system along with their digital sensors. Benco Dental has been great helping us design, equip, and build our four practice locations. We are fortunate to have wonderful representatives from each of these companies in our area.

What training have you undertaken?

I have been very active with CE from the day I left residency. I attend the AAE Annual

Dr. Richard Munaretto reviewing a CBCT

Session almost every year, Seattle Study Club national meetings, Edgar D. Coolidge Endodontic Study Club meetings, Windy City Seminars meetings, and when I can, the Chicago Dental Society meetings. In 2008, I completed an international hands-on course on implant placement through IMTEC Implant Systems and received 36 hours of CE credit. The course was an intense week where the four of us placed 54 implants and performed 12 internal sinus lifts. It is very difficult to get that kind of experience here in the states.

What is unique about your practice?

In 2003, I joined Cameo Endodontics, LTD, located in the western suburbs of Chicago, with my father, my uncle, and Dr. Keith Sommers. We had a single location with four endodontists, five operatories, and two microscopes. I had always been interested in being involved with a dental study club and the vision of multidisciplinary care.

Cameo Dental Specialists partners, from left: Dr. Keith Sommers, Dr. Michael Munaretto, Dr. Rick A. Munaretto, Dr. Vladana Babcic Tal, Dr. Raymond F. Munaretto, and Dr. Joseph Baptist 8 Endodontic practice

Then in 2007, my partner, Dr. Sommers, encouraged me to take a hands-on implant course because he wanted to purchase our first CBCT. We bought our first Carestream CS 9000 unit in 2008 after completing some implant courses and slowly integrated surgical implant placement into our practice.

Those two things dramatically changed the way we looked at dentistry. Nobel Biocare encouraged us to start a Seattle Study Club, and we called it Windy City Seminars. The Seattle Study Club opened our eyes to interdisciplinary care where clinicians work closely together to treatment plan every case. That type of care was the vision for our current practice Cameo Dental Specialists, LLP. Cameo Dental Specialists is an interdisciplinary practice with endodontics, periodontics, and oral maxillofacial surgery.

We have four practices located in the West Loop of Chicago, River Forest, Berwyn, and La Grange. We have 14 excellent clinicians including 9 endodontists, 2 oral surgeons,

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PRACTICE PROFILE and 3 periodontists. This model allows us to come together in one location in order to discuss and treatment plan cases for the most optimal outcome.

Who has inspired you?

There are several people in my life that inspired me to be my best. My mom always pushed me in school to work hard, and there was no excuse for not going to professional school. My grandfather came to this country from Italy and worked hard to raise four boys in Chicago. He was an amazing man and a barber who (along with my Nonna) raised two endodontists, a lawyer, and a CPA! My high school football coach, Chris Andriano, instilled the qualities of hard work, always leading by example, and no excuses. I have used these values in all aspects of my life and they are why I am here today.

Professionally, my father and uncle were inspiring to watch during those days assisting at the office. They have always been very progressive in endodontics with technology, microscopes, rotary instrumentation, ultrasonics, and CBCT. My father is a great “people person,” and his patients always love him! The faculty at the UIC

Department of Endodontics inspired me to achieve my Diplomate and stay on to teach at the department. I currently lecture on the topics of dental traumatic injuries and in the endodontic surgery course. Drs. Chris Wenckus and Brad Johnson encouraged us to reach the top of our profession with Diplomate status through the ABE. Drs. Martin Rogers and Mohammed Fayed were also great mentors in the clinic and with endodontic microsurgery.

manager about 14 months ago who has turned out to be a blessing. She has taken us to a new level, but we still struggle with office managers. We have not found the software that can handle three specialties, four locations, 14 doctors, and everything that goes into running our practice. Most of them work well for smaller practices and for clinical endodontics applications.

What is the most satisfying aspect of your practice?

I was very on the fence between dental and medical school in college. Ultimately, my decision came down to self-employment, life style, and living on my own schedule. I volunteered in the ER at a local hospital for my first 2 years of college, and I really liked the workflow. The medical fields I was most interested in were emergency medicine and ENT. I would have been a medical doctor.

I work with an amazing group of clinicians from three specialties in dentistry. My partner, Dr. Vladana Babcic, had the vision to open a brand-new addition to Cameo Dental Specialists in the West Loop of Chicago.

This is an incredible endo/perio office that was just featured in Benco Dental’s Incisal Edge magazine. Working with motivated and driven partners like Dr. Babcic is what keeps me going at work. I am so proud of the team we are putting together and the amazing care we can provide for our referrals. We have invested so much mental energy, sweat, stress, and money back into the practice to build something great. The future is looking fantastic for Cameo Dental Specialists.

Professionally, what are you proudest of today?

Dr. Richard Munaretto with Dr. Michael Cohen at Seattle Study Club meeting in Hawaii

Top 10 favorites 1. Zeiss microscopes 2. Apex ID™ electronic WL from Kerr Dental 3. CS 9000 CBCT from Carestream Dental 4. X-Smart IQ™ cordless motor from Dentsply Sirona 5. Dentsply Sirona rotary instruments 6. Good old 6% NaOCl and 17% EDTA 7. Activated irrigation 8. Bioceramic putty 9. Dental operating chair 10. My chairside dental assistants!

10 Endodontic practice

The Seattle Study Club we started 10 years ago, called Windy City Seminars, makes me very proud. I was very surprised and rewarded with an award from the Seattle Study Club at the 2016 Annual Meeting in Hawaii. The award was for “Best in Study Club Management.” My partner, Dr. Keith Sommers, and I started the first Seattle Study Club run by endodontists in the world. This was a very intimidating journey in a pool of outstanding specialists and an environment of implant-minded treatment planning. The majority of these clubs are fee-for-service doctors that strive for perfection in every case. Windy City Seminars is a diverse club of dentists that collaborates together, shares information, and learns from each other. I am proud to be a board-certified endodontist with a well-rounded dental background.

What has been your biggest challenge?

The biggest challenge for our practice is office management and software usage.

Our practice has grown into a larger business; thus, we need higher level management. We hired an exceptional business

What would you have become if you had not become a dentist?

What is the future of endodontics and dentistry?

The field of endodontics continues to develop new techniques, irrigation, instrumentation design, and delivery systems to improve our outcomes. Endodontists enjoy some of the highest success rates for root canal therapy in all of health care. The bigger problems are in orthograde retreatment where obturation materials and debris are obstructing canal space. The canal anatomy in mesial buccal roots of upper molars, maxillary second bicuspids, and lower incisors are main culprits. There are a lot of claims that activated irrigation systems can remove these issues, but it appears those systems are still more effective on initial RCT. We can still improve on our irrigation and delivery systems going forward. I think endodontic microsurgery outcomes have come a long way, and the new bioceramics materials for retrofilling cases are great. The future of dentistry is starting to feel the impact of Dental Service (or Support) Organization (DSO)-affiliated practices and insurance compensation. We will see how this impacts in the future.

What are your top tips for specialty practices?

I would advise picking up the phone and calling other specialists for interdisciplinary treatment. There are so many specialists that practice multidisciplinary care on patients, but the problem is that there is no direct communication. Too many people rely on email, messages, or letters. You would be surprised what you can learn from other general dentists or specialists.

Volume 11 Number 3

PRACTICE PROFILE

Dr. Munaretto with his family

Dr. Munaretto fly-fishing

What advice would you give to budding endodontists?

I would get involved in any local dental study clubs. I discussed my involvement with the Seattle Study Club, and I feel this group is on the top of international dentistry. Collaborating with all specialties, general dentists, lab technicians, non-dental leaders, practice experts management, and life coaches from around the world is awesome. I have learned so much with the Seattle Study Club over the past 10 years.

There are some great local endodontic clubs like our Edgar D. Coolidge Endodontic Study Club in Chicago. I have been on the board for the past 5 years; this upcoming year I am the president. The Coolidge Club allows younger doctors to meet local peers, discuss cases, see great speakers, and some years members debate controversial topics in our field. I believe the core of study clubs is the active and evidence-based discussion concerning decisions we face every day.

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What are your hobbies, and what do you do in your spare time?

I spend the majority of my spare time with my family and coaching youth sports.

I have coached travel hockey for the past 6 years for my boys. It has been a great experience for us, and all my work-related stress is gone after stepping on the ice with a bunch of great kids. My favorite hobbies are bow hunting in the mountains, fly-fishing, and martial arts training. EP Volume 11 Number 3

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Endodontic practice 11

CLINICAL

Minimally invasive endodontics Dr. Peter Raftery evaluates the use of WaveOne® Gold files in minimally invasive canal preparation

A

t the risk of stating the obvious — in most restorative situations, the more a tooth can be left untouched, the greater residual strength it retains, and hence, the better its prognosis. This is sometimes difficult to accept since the traditional undergrad teaching I recall was that the solution to most problems in restorative dentistry begins with a sharp new bur and a welloiled, fast handpiece.

The tide may be turning, however, since minimally invasive dentistry seems to be the “buzz” area of dentistry in recent years. A position paper in the British Dental Journal (May 2015) by the restorative dental societies read as a cautionary tale regarding the perils of poorly planned, poorly executed restorative dentistry. The piece highlighted for me how over-enthusiastic removal of tooth structure from around the outer aspect of a tooth (e.g., during crown preparation) can weaken the tooth and compromise pulp vitality.

Subsequent overzealous removal of tooth structure from around the inner aspect of a tooth (during pulp removal) can further weaken the tooth, jeopardizing tooth survival.

WaveOne® Gold Dentsply has addressed the idea of minimally invasive dentistry as it pertains to endodontics with the new WaveOne Gold file and range of accessory products. The distinctive color difference is the first thing you’ll notice about the new WaveOne Gold file — a result of proprietary heat treatment after file manufacture — but the revision of design goes a lot deeper than color alone.

The file range has been expanded to four with the inclusion of the medium (green) file. This improvement allows for a greater number of teeth to be prepared using a single Dr. Peter Raftery is the specialist at Hampshire Endodontics in Havant, Hampshire, United Kingdom. You can contact him at hantsendo. co.uk.

Disclosure: Dr. Raftery has no official links to the products mentioned in this article.

12 Endodontic practice

file; previously, there would be a few cases where I might have felt the canal was too large for the primary file, and selected the large only to discover this instrument was too big to take to length. I then ended up opening the primary file after all! With the increased choice of file sizes and a more gradual increment of size increase between them (with the large file now slightly larger), the clinician is better able to select the right file first time.

An improved nickel-titanium alloy means WaveOne Gold files are 80% more flexible compared to their predecessors, resulting in files with reduced tendency for removing excess dentin through the straightening of curved canals.

The taper of WaveOne Gold files reduces from the tip along their length. This gives rise to canal preparations, which are more slender compared to their predecessors.

Such preparations are more conservative of root dentin, which is the feature of the new file system that I like the most and proved most crucial in the following case report.

There is good evidence that canal preparation up to at least a tip size of 25 is essential for irrigant delivery to the canal apex and effective irrigant exchange in that portion of the canal. I love that these new files simultaneously permit the adequate opening of the canal for effective cleaning, while conserving maximal dentin at orifice level. Hopefully, in the following case, it may be appreciated how the final shape of the prepared canal is more conservative — minimally invasive endodontics indeed!

Figure 1: UL1 with no clear canal visible radiographically

Case study This previously crowned upper left lateral incisor was referred for root canal treatment with no clear canal visible radiographically (Figure 1). The referring dentist had removed the old crown to assess restorability, which he/she felt was touch-and-go after cleaning up the preparation (Figures 2 and 3).

During my patient consultation, we discussed the idea that surgical crown lengthening would probably not be a suitable

Figures 2 and 3: The referring dentist had removed the old crown to assess restorability Volume 11 Number 3

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We agreed that moving it further apically would create a disharmonious unappealing asymmetrical smile-line.

Figure 4: The gingival margin profile of UL2 was already more apically positioned than the UR2

Figure 5: Clues as to canal location (left) and Figure 6: Tapering the canal with the WaveOne Gold primary file

Figure 7: Obturation with warm vertical compaction of gutta percha cones coated in canal sealer 14 Endodontic practice

way to gain more supragingival tooth structure. The gingival margin profile of UL2 was already more apically positioned than the UR2; we agreed that moving it farther apically would create a disharmonious unappealing asymmetrical smile-line (Figure 4).

Instead, I selected the new WaveOne Gold primary file to rescue the case, preserving as it does the maximal amount of dentin. After anesthetizing and isolating the tooth, I scouted for the canal opening with magnification and illumination, careful not to overly weaken the tooth through poor access angulation or an excessively wide cavity. Once I had found some clues as to canal location (Figure 5), I flared the canal and established the glide path

with the ProGliderÂŽ file. After irrigating, I confirmed working length before tapering the canal with the WaveOne Gold primary file (Figure 6). I completed the case with warm vertical compaction of gutta-percha cones coated in canal sealer (Figure 7).

Conclusion The WaveOne Gold files represent a leap forward for canal preparation.

They make mechanical preparation of even curved canals safer, quicker, and easier than the already impressive files they supersede. The time saved can be dedicated to irrigation, which can only help success rates for the specialist and general practitioner alike, and I wholeheartedly recommend them. EP Volume 11 Number 3

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PRACTICE INSIGHT

Dr. Cameron Howard, Pinnacle Endodontics His passion: transforming the patient experience

Dr. Howard in the operatory

How did you become interested in dentistry?

I knew I wanted to be a dentist from the time I was a little kid. Even in kindergarten, I was drawing pictures of teeth. This passion for dentistry was actually a blessing because I was congenitally missing tooth No. 10. Once the pediatric tooth fell out, and there was no adult tooth coming in behind, I dealt with everything from a flipper to a Maryland bridge to braces — and eventually an implant. My childhood involved exposure to a number of facets of dentistry. I saw how rewarding a dental career could be and gained some amazing mentors in the process.

How did you decide to focus on endodontics?

I focused on endodontics for a couple of reasons. To me, in dental school, endodontics 16 Endodontic practice

was the hardest specialty. I couldn’t “see” what I was doing. I am a Type-A person and very detail oriented. The challenge of navigating an unknown apical anatomy was fascinating. A canal can have curves, hooks, and splits. Trying to figure out the anatomical complexities can be very humbling. Every case is different from the next.

I was also drawn to endodontics because I like to see quick results. To me, there’s nothing more satisfying than helping someone find relief from pain. A patient can come into my office in misery — and 45 minutes later — they can potentially leave with a smile and pain-free. I love breaking the stigma that root canals are scary. Every patient who walks in the door is scared and expects a terrible ordeal. I love to deliver an unexpected result — a quick, painless, and potentially fun endodontic procedure.

What’s unique about your practice?

I am not your typical endodontist. Our practice motto is “Endodontic Excellence Through Personalized Care.” I believe most endodontists can deliver a quality root canal treatment. The difference, oftentimes, is in the experience surrounding the treatment. I like to sing during a procedure, tell jokes, and keep the atmosphere light. I high-five patients when I’m able to navigate their tooth’s unique anatomy. I often call patients the night after treatment and give them my personal cell phone number if they need anything else.

We aim to go above and beyond. The true reward comes when the previously fearstricken patient walks out the door saying, “That was the best dental experience of my life. I can’t believe I laughed during the procedure!” When that happens, I know I am doing exactly what I’m called to do.

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PRACTICE INSIGHT What tools do you use?

My office is state-of-the-art and completely paperless. We utilize iPads® for check in, Global microscopes with assistant side ports, ASI treatment carts, and the NOMAD™ portable X-ray system. The jewel of both practice locations is the CS 8100 3D (Carestream Dental). It’s those complicated diagnosis/treatment cases that make me very thankful for my cone beam computed tomography system (CBCT). Every single day I say to my assistant, “Have I told you today how much I love my cone beam?” I’ve had the system for almost 4 years, and I honestly wish I’d added it to my practice sooner. It enables me to deliver treatment with greater precision. But it also enables me to determine which cases I shouldn’t treat — such as a tooth with an unforeseen perforation, complicated sinus involvement, crack, or a poor surrounding periodontal condition.

Discovering these clinical situations — where a root canal is not in the patient’s best interest — is important.

I also use RVG 6200 sensors (Carestream Dental). I have worked with other sensors on the market, and I am very happy with this sensor’s capabilities. Sometimes general practitioners send their own pre-op images to me, and I get to compare my pre-op images to the pre-existing images taken on a different system. The difference can be quite astonishing.

Professionally speaking, what are you proudest of?

I’m most proud of the fact that I’ve been able to create the endodontic practice of my dreams. In order to do that, I’ve had to build a hardworking and skilled team of employees to help bring life to my vision.

We started as a brand-new operation and expanded to two locations, two doctors, and 11 employees in just 4 years. It’s been a wild ride! My vision was simple: Create an

Dr. Howard’s lead assistant, assisting with taking a CBCT image 18 Endodontic practice

Dr. Howard’s new office location in Alpharetta, Georgia

endodontic office that has integrity, treats each patient by the golden rule, and aims to deliver a dental experience for a patient that is both rewarding through the removal of pain and enjoyable.

What has been your biggest challenge?

Hands down, running a business is my biggest challenge. You learn just enough dentistry in dental school to not be dangerous. Upon graduation, you’re magically supposed to know how to manage a profit-and-loss statement, run payroll, oversee a staff, hire and fire employees, and market your business. If dentists fail, it’s often not because they aren’t clinically competent.

It’s because they can’t manage people or run a business.

What are your top tips for maintaining a specialty practice?

Number 1: Build a team that makes you look really good, and treat them exceptionally well. I make it known that it’s not my practice; it’s our practice. I want everyone to have a sense of ownership. The team needs

to include a good office manager who can help you with the business side of dentistry.

Number 2: Do what’s right for the patient — even when it’s not fun or convenient.

Integrity, honesty, and trust are key goals in our office.

Number 3: Maintain good communication with the general dentist. It is so important. At the end of the day, you and the dentist are working for the patient. You need to meet — and try to exceed — patient expectations. Clear communication with the dentist can help you make sure the entire dentition is evaluated without getting tunnel vision on one tooth.

What’s your advice for a new endodontist?

Finding a mentor is top of my list. When you come out of endodontic residency, there’s still a lot to learn. A mentor can really help with that. Pinnacle Endodontics has been blessed that Dr. John Camba recently joined our practice. Dr. Camba was Chief Resident at The Dental College of Georgia and is an amazing addition to our team. I enjoy discussing cases and sharing with him

Dr. Howard’s new office location in Alpharetta, Georgia Volume 11 Number 3

Of all the cases you’ve treated, is there one that stands out?

I went to the University of Kentucky for dental school. I was sitting for the SRTA dental boards, which includes a live patient portion. To take the exam, you pay thousands of dollars. That’s on top of all the other loans you’ve taken out for your education.

Adding to the stress, if one of your patients doesn’t show up, you fail. Part of the exam included identifying and fixing a Class III lesion. My Class III patient was young — 20 years old — and I tried to impress upon him the importance of him being present the next day. I gave him gas money, did some pro bono dentistry for him beforehand, and we exchanged phone numbers. He assured me that I could count on him to be there. Four out of my five patients showed, but not him.

I repeatedly called his number without any luck of reaching him. Failure seemed inevitable, and there was nothing I could do.

Miraculously, one of my classmates — who had no idea of the ordeal I was facing — asked if I was interested in his back-up Class III patient that he didn’t need. “Absolutely!

What’s her name?” I asked. The answer was Angel, and I sincerely believed it was a sign from God. She sat for my board exam, I performed all of her dental work, and she headed out — but not before leaving a Bible verse in my chair. It was Jeremiah 29:11: “For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, to give you a hope and a future.”

I have been practicing for 10 years now, and never has a patient left a Bible verse in the chair after dental treatment — except for Angel — who came out of nowhere to help me pass my board exam. I am blessed. EP Volume 11 Number 3

My vision was simple: create an endodontic office that has integrity, treats each patient by the golden rule, and aims to deliver a dental experience for a patient that is both rewarding through the removal of pain and enjoyable.

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PRACTICE INSIGHT

the pearls of wisdom I’ve picked up over the past 10 years of practice.

Getting involved in organized dentistry is also important. New endodontists should consider becoming active with the American Association of Endodontics (AAE), for example. I was heavily involved with the AAE when I first got out of school. I joined the Resident and New Practitioners Committee, the Regenerative Endodontics Committee, and served on the AAE Foundation Fundraising Board. Establishing a network of seasoned endodontists whom I could turn to was invaluable. When my practice was under construction, it was so beneficial to call a dentist in Texas, Tennessee, or Ohio and ask, “What worked best for you in this scenario?” or “What kind of marketing activities have been the most successful for you?”

The endodontic community is small. I look forward to helping the next generation of endodontists in a similar manner.

ENDODONTIC INSIGHT

Rotary versus Reciprocation: “How do I choose?”

Dr. John West explores three critical distinctions of Rotary versus Reciprocation Introduction As a practicing endodontist and a clinical endodontic educator for more than 30 years, the most frequent question I am asked about technique is, “Is it predictable?” While every dentist wants his/her endodontic treatment to be easier, more efficient, simpler, and profitable, in the end, it is predictability that trumps all considerations. As dentists, we are built that way, and that’s how we think.

We have to do it right. We are a self-selected culture that yearns to be better and to be our best.

Endodontic success rarely depends on a dental lab or whether or not the patient even cleans his/her teeth! Endodontic success does depend on the thoroughness of cleaning, shaping, and 3D obturation — the classic and time-tested Endodontic Triad. This is where we, the dentists, come in.

Predictable endodontic success, therefore, depends on (1) our knowledge of what to do, (2) our skill set in doing what we need to do, and finally, and most essentially, (3) our willingness to do it right. We have a direct relationship to endodontic predictability. If we are careful and do it right, nature does the rest. The purpose of endodontics is to heal lesions of endodontic origin (LEOs) where they exist and prevent LEOs where they do not exist.1-3 When I am asked the question, “Rotary versus Reciprocation: How do I choose?” my answer is “Rotary and Reciprocation” John West, DDS, MSD, received his DDS from the University of Washington, where he is an affiliate professor. He earned his MSD in endodontics at the Boston University Henry M. Goldman School of Dental Medicine, where he is a clinical instructor and a member of the Alumni Board and was awarded with the Distinguished Alumni Award. He is the founder and director of the Center for Endodontics in Tacoma, Washington. He also mentors the world’s only stand-alone, 4-day mini-endodontic residency program at the Interdisciplinary Dental Education Academy in San Francisco. Dr. West is a Fellow and was the 2009 president of the American Academy of Esthetic Dentistry and the 2010 president of the Academy of Microscope Enhanced Dentistry and is a member of the former Northwest Network for Dental Excellence and the International College of Dentists. He was a 2010 consultant for the ADA Board of Trustees and the ADA Council on Dental Practice. Dr. West is in private endodontic practice in Tacoma. He can be reached via email at the address johnwest@centerforendodontics.com.

Disclosure: Dr. West is a co-inventor of the ProTaper and WaveOne® endodontic shaping systems. ®

20 Endodontic practice

because the predictability of both methods is similar; they are just different in sequence, purpose, and motion. The goal of this article is to explore and explain these three critical distinctions of Rotary versus Reciprocation so that the clinician is aware of these differences, understands his/her options, and makes the best choice for his/her particular practice and patient needs. This article is an invitation to be self-educated about your best way to produce endodontic preparations that can be easily obturated.

As a disclaimer, please note that I am a co-inventor of ProTaper® and WaveOne® file systems (Dentsply Sirona Endodontics). As such, I have an internal bias. However, if you take the self-test that I suggest at the end of this article, your choice of Rotary versus Reciprocation will be self-evident, perfectly scientific, and all about your and your patients’ needs. In this clinical article, the examples I use for Rotary versus Reciprocation are ProTaper Gold (PTG) and WaveOne Gold (W1G) (Figures 1 and 2). These are the file systems I helped design and know the most about. You can substitute any rotary brand for my ProTaper Gold distinctions and any reciprocation brand for my WaveOne Gold distinctions. The principles of The Challenge Testing essentially remain the same.

Definitions Rotary, in the context of this article, refers to mechanical radicular endodontic shaping where the cutting blades function in a continuous clockwise (CW) direction.

Put crudely, the motion resembles that of the common drill.4-7 Reciprocation, in the context of this article, refers to mechanical radicular endodontic shaping using unequal bidirectional clockwise/counterclockwise (CW/ CCW) directions. Put crudely, the motion resembles that of a Roto-Rooter. The ProMark® and X-Smart IQ™ endodontic motors and handpieces (Dentsply Sirona Endodontics) produce both continuous rotation and reciprocation motions within a single motor (Figure 2l).8-11

Literature Mechanical rotary and reciprocation articles are abundant in the literature. Using PubMed to search the keyword “ProTaper”

yields 912 published studies in the last 10 years. Using PubMed, there are also 19 studies returned from searching the term “ProTaper Gold” within the past 5 years. A search in the Journal of Endodontics from “all available dates” reveals 256 articles where “ProTaper” appears in the abstract.

A similar search using Google Scholar and the search term “ProTaper AND Dentistry” shows 7,530 results from 2007 to 2017.

Similarly, a search using PubMed and keyword “WaveOne” yielded 220 studies in the last 10 years. A search in the Journal of Endodontics from “all available dates” shows 75 articles where “WaveOne” appears in the abstract. A search using Google Scholar and the term “WaveOne AND Dentistry” reveals 2,590 results from 2007 to 2017.

Using membership surveys for the past 6 years, I have explored Rotary versus Reciprocation percentage usage among endodontists. Endodontists clearly prefer Rotary versus Reciprocation, but with the introduction of Gold technology, I am observing an increase in both Rotary and Reciprocation among endodontists.12

History The need to design and create smooth, funnel-shaped radicular preparations was void in clinical technique before the discovery of NiTi mechanical shaping files.

Since dentists could not see inside the root canal system, we could not “do and see” simultaneously, unlike other dental preparations. It might be said that in endodontics, “we do it in the dark.” Before mechanical shaping, manual shaping could not provide the smooth, funnel-shaped preparations because of their .02 taper. Manual shaping tends to carve and cut at unpredictable and often undesirable points along the file’s shaft rather than smoothly “connecting the dots” between the minimal apical canal physiologic diameter and the desired coronal canal width, which nature has identified between one fifth and one third of the root width (Figures 1 and 2).

The Moment before “The Moment” Every dentist that has ever mechanically shaped a radicular preparation knows and can emotionally recall the feeling of the moment before “The Moment” (Figure 3).

Volume 11 Number 3

D.

ENDODONTIC INSIGHT

A.

C.

B.

E.

F.

G.

H.

I.

J.

K.

L.

Figures 1A-1L: The features, sequence, purpose, and motion of ProTaper Gold (PTG) (Dentsply Sirona Endodontics). A. Convex triangular “cutting” blades have made Rotary shaping highly efficient, while Gold technology has made shaping safe. B. Animation of pretreatment image. C. Starting with the answer — the appropriate gutta-percha conefit is vividly imagined. The most common maximally appropriate shape is produced with the F2 (25/08) Finishing file. D. Soon-to-be discovered apical constriction width is identified by 2 dots, and the anticipated one-fifth to one-third of the coronal width (nature’s diameters for structurally successful teeth) is also identified by 2 dots. E. The shaping goal is to smoothly “connect the dots” apically with the dots coronally.

F. The ProGlider mechanical file (Dentsply Sirona Endodontics) may be used to expand the smooth, super-loose No. 10 file Glidepath. G. The PTG S1 carves away coronal third restrictive dentin from the inside out. H. The PTG S2 carves away restrictive dentin in the middle-third of the canal. The PTG S1 and PTG S2 are used in a Brush/Follow sequence to length. I. The PTG F1 is used in a follow/brush motion to length. If apical blades are nude of dentin shavings, this is a cue to progress to the next larger size (PTG F2) in order to confirm the apical shape. J. Dentin-loaded PTG F2 apical flutes prove the apical shaping is complete. K. An animation image illustrates PTG F2 blades cutting a perfect F2 radicular preparation shape. L. A successful PTG gutta-percha conefit means the root canal system is ready for 3D obturation

What is this moment? Following an unfettered canal access by first removing all coronal dentin triangles with a PTG SX shaping file (Dentsply Sirona Endodontics), for example, and following a confirmed reproducible Glidepath, the moment I am referring to is the very seconds before you ultimately reach length without breaking the file.13-17 In the moment before the Moment, the fear of fracture can take away the joy of endodontics, and like a self-fulfilling prophecy, sometimes we break the file in spite of our goal to shape with safety. Every endodontic clinician knows the sinking visceral feeling of a broken file. The energy level goes out of the operatory and often can kill the day’s enjoyment Volume 11 Number 3

level. Since the advent of Gold heat-treated mechanical shaping files, the moment before “The Moment” has completely changed for most practitioners. Gold-heated technology increases flexibility, improves cyclic fatigue, and is more efficient. The increased efficiency is because the Gold metallurgy, without distortion, snuggles more easily against dentin walls and, therefore, cuts more conservative funnel shapes. In the moment before the Moment, fear turns to fun, concern to confidence, and consternation to control. The positive possibilities of this clinical experience of the moment before the Moment makes it worth taking the “Rotary versus Reciprocation Challenge” at

the end of this article and to join the predictable shaping fun.

Clinical distinctions Rotary: Following a reproducible Glidepath, the clinical technique of Rotary is an “inside-out” concept. In the case of PTG, the Shapers specifically cut away restrictive coronal dentin by intentionally, precisely, and progressively brushing away the restrictive dentin in an essentially lateral motion. Think of the Shapers as a brush and not a drill! The Shapers first fit easily within the canal to be shaped and then cut the radicular coronal restrictive preparation by laterally brushing and then removing it. The PTG Finishers Endodontic practice 21

ENDODONTIC INSIGHT produce shapes similar to Reciprocationproduced shapes. However, the technique to create Rotary versus Reciprocation shapes is quite different. In PTG shaping, the radicular dentin preparation relies on the clinician’s commitment to progress through a sequence of Shaping instruments where each instrument’s preparation allows the next Shaper and Finisher to easily fit (Figure 1).

Reciprocation: Following a reproducible Glidepath, the clinical technique of Reciprocation has always been a “crown-down” concept. Where PTG has classically called for one to four instruments, one of W1G’s distinctive values is in selecting and using a single file such as Primary, which has similar, though not exact, geometries as PTG Finisher No. 2 (red). Because a single

A.

D.

Red and Red only ( ). The Red (Primary) file is used in a multipass sequence. Restraint and confirming patency are key watchwords during every pass in the multipass sequence, since a single file is replacing the workload of a multiple file sequence, such as Rotary shaping. Irrigation and confirming patency are also recommended with each separate W1G pass in order to prevent blocks, ledges, perforations, and transportations (Figure 2).

W1G file is being asked to produce a similar predictable conefit as with multiple PTG files, a different skill set is required and is described below (Figure 2).

Sequence Rotary: After the Glidepath is validated, the color sequence is unmistakable and never varies ( ,O, , , ). The color sequence is the recognizable ISO standard color sequence and is, therefore, easy to remember. No mixing and matching — just follow the color order as the optimal sequential geometries have been researched, calculated, and clinically tested (Figure 1).

Reciprocation: After the Glidepath is validated, the sequence is also unmistakable and even further simplified. The color is usually

Purpose Rotary: PTG S1 (purple) cuts away restrictive dentin in the coronal third, PTG S2 (white) cuts away restrictive dentin in the middle third, and PTG F1 (yellow) carves the perfect shape in the apical third, followed by PTG F2 (red) and PTG F3 (blue) if needed (Figure 1).

C.

B.

E.

F.

G.

H.

I.

J.

K.

L.

Figures 2A-2L: The features, sequence, purpose, and motion of WaveOne Gold (W1G) (Dentsply Sirona Endodontics). A. SEM of W1G, courtesy of Nova Southeastern University Bioscience Research, showing a parallelogram-shaped cross section enabling only two points of cutting contact during the file’s unequal bidirectional motion. B. Pretreatment animation. C. The imagined conefit before shaping begins. D. Anticipated apical and coronal preparation widths are identified. E. Apical and coronal dots are smoothly connected in an imagined preparation shape. F. After the manual super-loose No. 10 file is used, a Gold Glider (Dentsply Sirona Endodontics) is recommended to expand the Glidepath to more easily accommodate the W1G Primary (25/07) file.

G. The first pass with the W1G shapes the coronal portion of the radicular preparation. H. The second pass of the W1G Primary cuts the middle-third of the prep. I. Animation of a crown-down W1G preparation. J. A third pass of W1G finishes the apical prep. K. The desired shape is confirmed with the matching conefit. L. ASI’s (Advanced Systems Integration, Englewood, Colorado) endodontic cart houses the ProMark motor and, like the X-Smart iQ motor (Dentsply Sirona Endodontics), it can be set for either Rotary or Reciprocation 22 Endodontic practice

Volume 11 Number 3

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ENDODONTIC INSIGHT Reciprocation: The Primary W1G (which has similar external geometries to PTG F2) cuts the entire length of the radicular preparation using a multipass technique (Figure 2).

Motion Rotary: Shapers are first gently followed into the existing unrestricted orifice, then withdrawn in a paint-brushing motion, and then followed deeper into the preparation.

The mental chant is “Brush and Follow (deeper), Brush and Follow, Brush and Follow” to length. The Shaper file is only removed if the file bogs down with dentin shavings. If this were the situation, it is usually because the file’s blades are loaded with dentin carvings and/or remaining pulp.

Remove the file and irrigate with sodium hypochlorite or EDTA. Clean the blades and continue. The Shaper file will now progress easily after each Brushing motion as it had done before (Figure 1).

Once the Shapers have reached desired length, the Finishers prepare the final shape by connecting the dots (Figures 1E and 2E).

The Finisher’s motion is in reverse order of the Shapers. The Finisher’s chant is “Follow and Brush (coronally), Follow and Brush, Follow and Brush” to the desired preparation physiologic terminus length. Fit the PTG cone or verifier to confirm the shape.

Reciprocation: Because the crowndown approach with a single file is asking that single file to do the work of two or more files, different motions are needed. Also, since a single file is being asked to follow a narrower canal than the file itself, there is a greater possibility of blocking the canal with collagen or “dentin mud” (a mixture of detached necrotic pulp and dentin instrument filings).18 Typically two to six “passes” are required to reach length. The motion is simple and similar in chant as with Rotary Finishers in PTG technology: “Follow and Brush, Follow and Brush, Follow and Brush” to length. The big difference, however, is that with each “Follow and Brush,” or “pass,” the Reciprocation file should be removed, the file should be cleaned of dentin filings, the canal should be irrigated, patency should be confirmed with the No. 10 manual file, and the canal should be irrigated again.

Then proceed with “pass” No. 2 and so on until preparation physiologic terminus length is reached. Fit the W1G cone or Verifier to confirm the shape.

The greatest variable In all of dentistry, the greatest variable is always the clinician. While product and operatory infrastructure play a significant role, the answer to Rotary versus Reciprocation depends mostly on technique, and 24 Endodontic practice

Figure 3: The moment before “The Moment.” Every dentist knows this moment. The Moment refers to the dentist’s fleeting thought right before mechanical files engage the radicular root canal system walls as the file begins to cut its own shape. Until heat-treated and improved file geometries such as PTG and W1G, this Moment was filled with concern and fear of breakage.

Now with a reproducible Glidepath, proper mechanical directions for use (DFU), new files, and a gentle touch, the moment before the Moment has been changed from fear to energetic confidence and predictability. With confidence, endodontic shaping has truly become fun!

technique depends on the clinician’s skill, care, and judgment.

Q: How do I choose?

A: Take the challenge Here is a simple and revealing test for each clinician to determine his/her own preferred “Rotary versus Reciprocation” choice: Call your local dental sales representative (in my case it would be the Dentsply Sirona Endodontics sales representative).

Tell him/her you want to do this “challenge” test: Purchase enough Rotary files (PTG in my example) and enough Reciprocation files (W1G in my example) to treat 10 endodontic patients with Rotary and 10 endodontic patients with Reciprocation. You could treat every other patient alternately with Rotary and Reciprocation, or you could treat 10 patients in a row with Rotary and then 10 with Reciprocation. Reverse the order if you prefer. You can use this same telltale test for comparison with your current preferred system. Take good notes about what worked and did not work.

Your answer for Rotary versus Reciprocation will be right in front of you!

Albert Einstein did not read this article, but he knew oh so well the value of self-education and self-testing. The following quote from Einstein is the perfect takeaway for this article about using the scientific method to self-discover your answer to the question of Rotary versus Reciprocation: “The only source of knowledge is experience.” EP REFERENCES 1. West JD. Finishing: the essence of exceptional endodontics.

Dent Today. 2001;20:36-41.

2.

West JD. How do masters do it? Dent Today. 2012;31(31):102, 104-107.

3. West JD. Endodontic predictability: “what matters?” Dent Today. 2013;32(9):108-113.

4. West JD. Introduction of a new rotary endodontic system: progressively tapering files. Dent Today. 2001;20(5):50-57.

5. West JD. Progressive taper technology: rationale and clinical technique for the new ProTaper Universal system. Dent Today. 2006;25(12):64-69.

6. Ruddle CJ, Machtou P, West JD. Endodontic canal preparation: innovations in glide path management and shaping canals. Dent Today. 2014;33(7):118-123.

7. West JD. Ni-Ti goes gold: “ten clinical distinctions.” Dent Today. 2015;34(4):66-71.

8. West JD. Is the new WaveOne endodontic reciprocation for me? Dental Economics. 2011;101:32-33.

9. Kuttler S, West JD. Single file system: “the science of simplicity.” Dent Today. 2012;31(3):92-95.

10. Ruddle CJ. Canal preparation: single-file shaping technique.

Dent Today. 2012;31(1):124, 126-129.

Closing comments

11. Ruddle CJ. Single-file shaping technique: achieving a goldmedal result. Dent Today. 2016;35(1):98-103.

When properly performed, endodontics is highly productive and fun! Using predictability as your critical benchmark distinction, your own testing will reveal your best choice of “Rotary versus Reciprocation.” The result: clinical confidence, consistency, and control. The marketplace has actually already answered the question of Rotary versus Reciprocation. The market’s answer: “Rotary and Reciprocation.” Those clinicians who have done their own in-house, controlled homework and testing will be happy with their answers. Now it’s your turn!

12. West JD. New trends in endodontics and treatment planning.

Dent Today. 2017;36(4):64-69.

13. West JD. The endodontic Glidepath: “secret to rotary safety.” Dent Today. 2010;29(9):86-93.

14. West JD. Manual versus mechanical endodontic Glidepath.

Dent Today. 2011;30(1):136-140.

15. West JD. Glidepath implementation: “return to the beginning.” Dent Today. 2011;30(4):90-97.

16. West JD. The three Fs of predictable endodontics: “finding, following, and finishing.” Dent Today. 2016;35(3):90, 92-96.

17. West JD. Single versus multiple endodontic file use. Dent Today. 2016;35(1):62, 64-67.

18. West JD. Perforations, blocks, ledges, and transportations: overcoming barriers to endodontic finishing. Dent Today.

2005;24(1):68-73.

This article was originally printed in Oral Health and Dentistry Today.

Volume 11 Number 3

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CONTINUING EDUCATION

Study of preoperative administration of ketorolac and placebo on compromised teeth Drs. Jorge Paredes Vieyra, Fabian Ocampo Acosta, and Francisco Javier Jiménez Enriquez compare the effect of preoperative administration of single-dose ketorolac, a non-steroidal anti-inflammatory drug and placebo on postoperative pain in teeth with irreversible pulpitis and apical periodontitis

D

ental pain is a multifaceted process that is partially comprised of biological, biochemical, environmental, and psychogenic factors. Several factors can influence clinicians’ decisions to recommend analgesics in helping combat their patients’ postoperative pain. It is well recognized that, in general, preoperative pain is the principal factor in determining the level of postoperative pain (Sessle, 1986).1 Prevention and control of pain in endodontic treatment is an important issue (Cunningham and Mullaney, 1992).2 Pain is conceptualized as a complex sensation, and odontogenic pain is a multidimensional experience that involves sensory responses and cognitive, emotional, conceptual, cultural, and motivational aspects (Sessle, 1986).1 The incidence of postoperative pain of mild intensity is not an occasional event even when endodontic treatment has followed suitable standards (Arias, et al., 2013).3 This usually comprises acute pain, meaning the correct treatment can be rapidly applied.

Mild pain after chemo-mechanical preparation can develop in about 10%-30% of the cases (Siqueira, et al., 2002),4 and in most instances, the patient can bear the discomfort or can make use of common analgesics, which are usually effective in relieving symptoms.

Although ketorolac is a contentious drug in Europe, with the EU split over its safety, the authors have embarked on a comprehensive review of its efficacy in dentistry.

Dr. Jorge Paredes Vieyra is an endodontist and professor of endodontics and pulp therapy at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico.

Dr. Fabian Ocampo Acosta is a histopathologist and professor at Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico.

Dr. Francisco Javier Jiménez Enríquez is professor of oral surgeon and periapical surgery at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico.

Disclosure: The authors deny any conflict of interest.

26 Endodontic practice

Educational aims and objectives

This clinical article aims to compare the effect of preoperative administration of singledose ketorolac, a non-steroidal anti-inflammatory drug and placebo on postoperative pain in teeth with irreversible pulpitis and apical periodontitis.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 31 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify some previous studies regarding the management of postoperative pain.

•

Realize that there is a strong relationship between pulp status and postoperative pain and therefore a need to identify methods to alleviate that pain.

•

Compare the effect of preoperative administration of single-dose ketorolac with a NSAID and placebo on postoperative pain in teeth with irreversible pulpitis and apical periodontitis.

•

Discover that a single dose of ketorolac is as effective or as safe as NSAID for the relief of pain after operations on postoperative pain in teeth with symptomatic apical periodontitis.

Development of acute or severe pain, accompanied or not by swelling, has been demonstrated to be an unusual occurrence.

However, these circumstances usually constitute a true emergency and very often require an unscheduled visit for treatment (Pak and White, 2011).5 The management of postoperative pain has been the subject of many research studies, including preoperative explanations and instructions (Sathorn, Parashos, Messer, 2008),6 long-acting anesthesia (Parirokh, Yosefi, and Nakhaee, 2012),7 the glide path (Pasqualini, Mollo, and Scotti, 2012),8 occlusal reduction (Parirokh, Rekabi, and Ashouri, 2013; Rosenberg, Babick, and Schertzer, 1998),9,10 medication using salicylic acid (Morse, Esposito, and Furst, 1990),11 non-steroid anti-inflammatory drugs (NSAIDs) (Attar, Bowles, and Baisden, 2008),12 combination of ibuprofen and acetaminophen (Menhinick, Gutmann, and Regan, 2004),13 narcotic analgesics (Ryan, et al., 2008),14 a combination of narcotic analgesics with aspirin (Morse, 1987)15 or acetaminophen (Sadeghein, Shahidi, and Dehpour, 1999),16 and steroidal anti-inflammatory drugs (Pochapski, et al., 2009).17 Pain perception is a highly subjective and variable experience modulated by multiple physical and psychological factors, and pain reporting is influenced by factors other than

the experimental procedure (Bender, 2000).18 The extrusion of microorganisms or debris during endodontic treatment results in inflammatory response and inflammation (Oliveira, 2011).19 A recent systematic review showed that between 3% and 58% of patients were reported to have experienced endodontic postoperative pain (Sathorn, Parashos, Messer, 2008).6 Activation of nociceptive sensory nerve fibers may also be related to concentrations of inflammatory mediators like histamine (Dale and Richard, 1918).20 Also, histamine, an inflammatory mediator, is capable of sensitizing and activating nociceptive sensory nerve fibers (Hargreaves, et al., 1994).21 The management of pain is a critical and challenging part of dentistry, as pain is a major postoperative symptom after many dental procedures. There are various analgesics and techniques; patients want the best for managing their pain, and clinicians need to know them. Knowing how well an analgesic and technique works and its associated adverse effects is fundamental to clinical decision-making (Cunningham and Mullaney, 1992).2 The incidence and severity of postoperative pain are associated with specific dental treatments; the highest is with root canal therapy (Levin L, Amit A, Ashkenazi, 2006).22 Volume 11 Number 3

Materials and methods The institutional review board of the Facultad de Odontología Tijuana México approved the study protocol, and all the participants were treated in accordance with the Helsinki Declaration (www.cirp.org/ library/ethics/helsinki). The study started in February 2016 and ended in March 2017.

The main inclusion criteria were a) a diagnosis of pulpitis confirmed by positive response to hot and cold tests and b) clinical and radiographic evidence of symptomatic apical periodontitis. It was determined based on the clinical symptoms severe preoperative pain (VAS > 60) and severe percussion pain (VAS > 60), confirmed by positive response to hot and cold tests. Thermal pulp testing was performed by the author, and radiographic interpretation was verified by one certified oral surgeon.

Patient selection Fifty-four of 65 patients (29 women and 25 men), 18 to 60 years of age with 54 eligible teeth consented to participate in the study.

The study design is shown in Figure 1. The patients were randomly divided into three groups using a web program. The patient number and group number were recorded.

Informed consent was obtained from each patient, and the possible discomforts and risks were fully explained.

Volume 11 Number 3

Table 1: Demographic data (n) Age

Ketorolac/tramadol

Diclofenac Na

Placebo

30.69 ±7.35

28.12 ±5.99

31.87 ±7.35

Gender Male

25

8

9

8

Female

29

10

9

10

Tooth 3

13

4

5

4

Tooth 14

10

3

4

3

Tooth 18

7

2

3

2

Tooth 29

8

3

2

3

Tooth 13

7

2

2

3

Tooth 7

9

4

2

3

Total

54

18

18

18

Tooth number

P= 0.05

A total of 54 patients were divided into three groups (n =18) according to the type of preoperative drug administrated, as follows: Group A: ketorolac 10mg (Siegfried Rhein S.A. de C.V, Mexico,DF), Group B: Diclofenac Na 50mg (Voltaren, Novartis Mexico), and Group C: A placebo (capsule filled with sugar).

A registered pharmacist compounded identical-appearing capsules of the ketorolac, Diclofenac Na, and the placebo (opaque yellow size “0” capsules). All medications were placed in identical bottles so that they were indistinguishable to the investigator.

The administration of drugs and root canal treatment were performed by two different researchers. One researcher knew the allocation and the drug type in the capsules, but the operator and the patient did not know which drug type was administered.

Patient selection was based on the following criteria: 1. The aims and requirements of the study were freely accepted.

2. Treatment was limited to patients in good health.

3. Patients with symptomatic or asymptomatic teeth with vital pulps and apical periodontitis.

4. A positive response to hot and cold pulp sensitivity tests.

5. Presence of sufficient coronal tooth structure for rubber dam isolation.

6. No prior endodontic treatment on the involved tooth.

7. No analgesics or antibiotics were used 5 days before the clinical procedures began.

Exclusion criteria included the following: 1. Patients who did not meet inclusion requirements.

2. Patients who did not provide authorization for participation.

3. Patients who were younger than 16 years old.

4. Patients who were pregnant.

5. Patients who were diabetic.

6. Patients with a positive history of antibiotic use within the past month.

7. Patients whose tooth had been previously accessed or endodontically treated.

8. Teeth with root resorption.

9. Immature/open apex, or a root canal in which patency of the apical foramen could not be established were all excluded from the study.

Teeth with periodontal pockets deeper than 4 mm, or the presence of a periapical radiolucency more than 3 cm diameter also were excluded from the study. Also excluded were patients whose affected tooth and related work had any of the following issues: curved roots, problems in determining working length, broken files, over-instrumentation, and over or incomplete filling.

Once eligibility was confirmed, the study was explained to the patient by the authors, and the patient was invited to participate.

After explaining the clinical procedures and risks and clarifying all questions raised, each patient signed a written informed consent form and was randomly assigned to either of the three groups by using a block of random numbers generated by one of the investigators.

A medical history was obtained and a clinical examination performed. Of all teeth, 11 were asymptomatic and 43 symptomatic with a diagnosis of pulpitis determined by hot and cold sensitivity tests. Radiographically, all teeth showed a small and irregular radiolucency at the tooth apex (Schick Endodontic practice 27

CONTINUING EDUCATION

Postendodontic pain, particularly after initial endodontic therapy, should ideally be eliminated by the therapy; however, analgesics are frequently required to diminish pain (Cunningham and Mullaney, 1992).2 There is a strong relationship between pulp status and postoperative pain, influencing the experience of pain, which may undermine the patient’s confidence in the procedure and the clinician (Arias, et al., 2013).3 Ketorolac is an excellent acting analgesic used widely in surgery and medicine (Grond and Sablotzki, 2004).23 In dentistry, there have been several studies that used a single dose of ketorolac associated with tramadol for control of pain mainly in operations on the third molars.

However, its analgesic efficacy is controversial, with reports that its effect is similar (Mishra and Khan, 2012)24 or less good (Desjardines, et al., 1998)25 that that of nonsteroidal anti-inflammatory drugs (NSAID).

According to these studies, a single dose of tramadol has some relatively common adverse effects (Shah, et al., 2013).26 The purpose of this study was to compare the effect of preoperative administration of single-dose ketorolac, a non-steroidal antiinflammatory drug and placebo on postoperative pain in teeth with irreversible pulpitis and apical periodontitis.

CONTINUING EDUCATION Technologies; Long Island City, New York).

The diagnostic findings were checked by comparing the tooth’s response against that of an adjacent tooth with a vital pulp.

Periodontal probing revealed no increased probing depth (> 3 mm) around any of the teeth. The author performed all the clinical procedures.

Treatment protocol All treatment sessions were approximately 50 minutes in length to allow for acceptable time for completion of treatment in one or two visits. The author performed all the clinical procedures. The standard procedure for the three groups included local anesthesia with 2% lidocaine with 1:100,000 epinephrine (Septodont; Saint-Maur des Fossés, France) and rubber dam isolation.

The tooth was disinfected with 5.25% NaOCl (Ultra bleach; Bentonville, Arkansas).

Carious dentin was completely removed and endodontic access cavities prepared with sterile high-speed carbide burs No. 331 (SS White; Lakewood, New Jersey) and Zekrya Endo burs (Dentsply-Maillefer; Ballaigues, Switzerland). After gaining access, the canals were explored with No. 06, No. 08, and No. 10 K-type hand files (Flex-R® files; Moyco/ Union Broach, York, Pennsylvania) according to the initial diameter of the foramen, its degree of flattening, and its canal curvature using a watch-winding motion.

Working length (WL) was established by introducing a No. 10 K-file up to the apical foramen as determined by a Root ZX (J Morita; Irvine, California), and then by withdrawing the file and subtracting 0.5 mm from the length, which was measured with the aid of an endodontic ruler. The WL was confirmed radiographically (Schick Technologies; Clark Dental UK).

The root canals were negotiated and enlarged with hand instruments (Flex-R files; Moyco/Union Broach, York Pennsylvania) until reaching an ISO size No. 20 at working length. The coronal portions of the root canals were flared with sizes 2-3 GatesGlidden burs (Dentsply Maillefer). Irrigation with 2mL 2.5% sodium hypochlorite (NaOCl) was performed using a 24-G needle (Max-iProbe®; Dentsply Sirona) during access and a 31-G NaviTip® needle (Ultradent Products Inc., South Jordan, Utah) when reaching the WL after each file insertion.

Reciprocating files (VDW, Munich Germany) were used to complete root canal preparation. EDTA (Roth International Ltd, Chicago, Ilinois) served as a lubricant. All reciprocating files were driven by an electric micro motor with limited torque (VDW.Silver Reciproc® motor; QED UK). R25 files (25.08) were used in narrow and curved canals, and 28 Endodontic practice

R40 files (40.06) were used in large canals.

Three in-and-out (pecking) motions were applied with stroke lengths not exceeding 3 mm in the cervical, middle, and apical thirds until attaining the established WL. All the files were used in only one tooth (single use) and then discarded. Patency of the apical foramen was maintained during all the techniques by introducing a No. 10 K-type file at WL. The preparations for all the groups were finished using a No. 45 file for narrow or curved canals and a No. 60 file for wide canals.

After completion of instrumentation, all root canals were irrigated with 2.5 mL 17% EDTA acid (Roth International) for 30 seconds followed by a final irrigation with 5.0 mL 5.25% NaOCl using the EndoVac® irrigation system (Discus Dental; Culver City, California). The root canals were dried with sterile paper points and obturated at the same appointment using lateral condensation of gutta percha and Sealapex® sealer (SybronEndo). Access cavities of anterior teeth were etched and restored with Fuji IX (GC UK). For posterior teeth, a buildup restoration was placed using the same etching technique and Fuji IX. After completing the endodontic treatment procedure, all patients were given postoperative instructions to take analgesics (400 mg ibuprofen) in the event of pain at a dosage of one tablet every 6 hours.

The level of discomfort was rated as follows: no pain; mild pain, which was recognizable but not discomforting; moderate pain, which was discomforting but bearable (analgesics, if used, were effective in relieving pain); flare-up, which was difficult to bear (analgesics, if used, were ineffective in relieving pain). Cases with severe postoperative pain and/or the occurrence of swelling were classified as flare-ups and treated

accordingly (Table 2). After completion of RCT, patients were instructed to return to their referring dentist for definitive restoration as soon as possible.

Patients were contacted by telephone by the clinical assistant after 24 hours, 48 hours, 72 hours, and 7 days and asked to provide the following information: their perceived pain rating and whether they had taken the analgesic medication prescribed and, if so, the quantity of tablets and the number of days required to control the pain. All the patients were instructed to contact the clinic or the dentist in charge of their treatment if the analgesic medication failed to provide pain relief or in the event of any other type of emergency.

The Kruskal-Wallis nonparametric test was applied to compare the incidence of postoperative pain. The level of significance adopted was 5% (p = 0.05). The final scale was as follows: None: 0-6.0, Faint: >6.0-17.0, Weak: >17.0-27.0, Mild: >27.0-42.3, Moderate: >42.3-60.3, Strong: >60.3-74.7, Intense: >74.7-90.6, and Maximum: >90.6 – 100.

Results A summary of the study can be seen in the Consort diagram. There were no statistically significant differences among the groups in terms of demographic data (Table 1) or pulp and periapical status (Table 2) (P >.05). Ketorolac and diclofenac Na showed clinically significant relief in pain for the next 3 days compared with the placebo group. In addition, no significant differences were demonstrated between ketorolac and diclofenac Na (Table 3). Similarly, there were no significant differences among the groups in terms of preoperative pain levels and percussion pain levels, but there was a difference in postoperative pain in placebo group.

Table 2: Pulp and periapical status of teeth and postoperative pain (n)

Ketorolac/tramadol

Diclofenac Na

Placebo

54

18

18

18

Pulp status Vital Periapical status Score 1

44

16

14

14

Score 2

10

2

4

4

Preoperative palpation

0

0

1

Preoperative swelling

0

0

0

Presence of:

Preoperative sinus tract

0

0

0

Postoperative palpation

0

0

1

Postoperative swelling

0

0

0

Postoperative sinus tract

0

0

0

P= 0.05

Volume 11 Number 3

Discussion The purpose of this study was to evaluate the effect of preoperative administration of single-dose ketorolac, non-steroidal anti-inflammatory drug and placebo on postoperative pain in teeth with irreversible pulpitis and apical periodontitis. Practice background was significant for analgesic preferences relating to severe pain with an endodontic diagnosis of irreversible pulpitis with acute periradicular periodontitis (Gatewood, Himel, and Dorn, 1990).27 Our findings agree with Nusstein (Nusstein and Beck, 2003)28 relating to prescribe analgesic in teeth with irreversible pulpitis and symptomatic apical periodontitis.

Many local and systemic factors such as age, gender, general health, group of teeth, pulp and periapical status, and occlusal contacts, among others, may interact and modulate the occurrence of pain of endodontic origin (Hargreaves, Cohen, and Berman, 2011).29 Knowing those factors as predictors may contribute to defining preventive oral health strategies to manage this undesirable condition, minimizing pain incidence and/or intensity, and reducing patient suffering at the individual and population levels. Additionally, clinicians may use this information to advise patients about pain outcomes related to RCT (Law, Nixdorf, and Aguirre, 2015).30 The results of the present study indicated that some clinicians were more likely to choose medication before and after endodontic treatment to manage this painful clinical scenario, whereas other educators and residents were much more likely to prescribe combination drugs in addition to instrumentation (Litkowski, et al., 2005).31 Prescribing a drug before start root canal in patients with irreversible pulpitis will reduce postoperative pain or sensitivity. The Volume 11 Number 3

results from this present study are consistent with the findings of Law (Law, Nixdorf, and Aguirre, 2015)30 that to avoid severe postoperative pain in endodontic therapy, preemptive analgesia strategies before initiation of treatment are necessary and with Krasner and Jackson (Krasner and Jackson, 1986)32 who noted from their study that although pulpectomy eliminates endodontic pain, postoperative pain and discomfort.

Two previous investigations have reported that the prophylactic use of analgesics at the end of the treatment visit had a positive influence on postoperative pain felt by the patients (Morse, Esposito, and Furst, 1990; Mehrvarzfar, 2012).11,33 Therefore, in the present study, all patients were instructed to take the first dose of the drug 15 minutes before start the treatment visit.

Considering the multifactorial nature of preoperative pain and postoperative pain, prevention and treatment strategies should depend on the identification and management of key predisposing factors (Siqueira, et al., 2002; Ng, Mann, and Gulabivala, 2011).4,34 Pain intensity is therefore influenced by various factors, including environmental, previous experience, mental health, and attitude making it a challenge to measure.

Numerous scales have been used for pain intensity evaluation. Of these, the numerical rating scale (NRS), is a scale with end points of the extremes of no pain and as bad as it could be or the worst pain. There is also the visual rating scale (VRS), which is made up of a list of descriptors that represent the level of pain intensity. It is subjective, and its association with disease may be indirect; however, it is a personal qualitative judgment of patients’ perception of pain strength (Pasqualini, 2012).8 In this study, the visual analogue scale (VAS) was used that is a 10 cm line arrangement that relates to verbal parameters. Its value as a measurement is well-documented and another form to evaluate the response of the patients’ pain to the analgesics.

To show the real amount/perception of postoperative pain felt by patients, it appears to be reasonable for researchers to provide

two evaluation forms: one to include the conventional VAS and another form to evaluate the response of the patients’ pain to the analgesics (Lund, et al., 2005; Lara-Munoz, et al., 2004).35,36 Additionally, visual analogue scales (VAS) and numeric rating scales (NRS) for assessment of pain intensity agree well, are equally sensitive in assessing acute pain, and are superior to a four-point verbal categorical rating scale (Breivik, et al., 2008).37 Hence, in the present study, patients were given one such form, and the results showed that some patients reported severe pain that was unbearable and not interfered with the patient’s daily activities with no significant difference between the groups A and B. Our findings agree with Wells (Wells, et al., 2011)38 that reported the presenting initial moderate pain level is representative of emergency patients with symptomatic teeth, a pulpal diagnosis of necrosis, and a periapical radiolucency. Postoperative pain or sensitivity is often used to assess the quality of analgesics because of its consistency and intensity.

Preoperative examination, interpretation of symptoms, and diagnosis are crucial factors in long-term success of endodontic therapy. No controversies exist regarding the fact that teeth diagnosed with irreversible pulpitis should be treated in one session, if no technical complications arise (Paredes-Vieyra and Enriquez, 2012).39 However, in cases of pulp necrosis with or without periradicular periodontitis, the literature is more controversial. Although preoperative administration of analgesics has been found to be effective in reducing postoperative pain (Hargreaves, Cohen, and Berman, 2011; Law, Nixdorf, and Aguirre, 2015),29,30 there have been various studies related to the effect of the preoperative administration of antihistamines on postoperative pain.

Wells (38) found that there were decreases in postoperative pain levels with the preoperative administration use of ibuprofen, a finding in harmony with ours.

The decreased pain levels in the analgesic group can be explained by the ability of analgesics to eliminate pain resulting in blocking

Table 3: Pain levels according to the groups

Preoperative percussion

Ketorolac

Diclofenac Na

Placebo

13 (I)

15 (I)

14 (I)

Preoperative pain

16 (I)

15 (I)

12 (I)

Postoperative 1-day pain

1 (M)

3 (M)

7 (I)

Postoperative 2-day pain

0 (W)

1 (W)

4 (Mi)

Postoperative 3-day pain

0 (N)

0 (F)

1 (F)

P= 0.05

Endodontic practice 29

CONTINUING EDUCATION

Results from this study indicated that preoperative pain with the diagnoses of irreversible pulpitis with apical periodontitis were the most common for respondents to choose analgesics to relieve their patients’ pain. A total of seven patients needed analgesics postoperatively: five of these were in the placebo group, one in the ketorolac/ tramadol group, and one in the diclofenac Na group. Table 3 shows lower pain levels in all groups.

In the present study, two patients experienced a flare-up. Two cases of flare-up were from the placebo group. Both required an intra-appointment visit. The flare-up from the patient in the placebo group showed no signs of swelling, but caused extreme pain. Upon opening the tooth, inflammatory drainage was established.

CONTINUING EDUCATION of nociceptive sensory nerve fibers (Dale, et al., 1918; Hargreaves, et al., 1994).20,29 An interesting finding in the present study was that while the preoperative administration of ketorolac resulted in less pain than that of a diclofenac Na, there was no significant difference between ketorolac and diclofenac Na administration. This finding suggests that the preoperative administration of ketorolac as a single dose before the treatment is beneficial in reducing postoperative pain.

Pain of endodontic origin depends on the multidimensional interrelationship between host, pulp, and periapical tissues, and the nature of endodontic procedures. The measurement of pain intensity is a reasonable way to evaluate treatment efficacy.

Assessed for eligibility (n=65 patients) Excluded (n=9 patients)

Randomized (n=54 teeth)

Received allocated intervention (n=18 teeth)

Received allocated intervention (n=18 teeth)

Received allocated intervention (n=18 teeth)

Lost to follow-up: 0

Lost to follow-up: 0

Lost to follow-up: 0

Analyzed (n= 18) None excluded

Analyzed (n= 18) None excluded

Analyzed (n= 18) None excluded

Conclusion A single dose of ketorolac was as effective or as safe as NSAID for the relief of pain after operations on postoperative pain in teeth with symptomatic apical periodontitis. EP

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1986;12(10):435-444.

2. Cunningham CJ, Mullaney TP. Pain control in endodontics.

Dent Clin North Am. 1992;36:(2)393-408.

3. Arias A, de la Macorra JC, Hidalgo JJ, Azabal M. Predictive models of pain following root canal treatment:(0)a prospective clinical study. Int Endod J. 2013;46:(8)784-793.

4. Siqueira JF Jr, Rôças IN, Favieri A, et al. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod. 2002;28:(6)457-460.

5. Pak JG, White SN. Pain prevalence and severity before, during, and after root canal treatment: a systematic review.

J Endod. 2011;37:(4)429-438.

6. Sathorn C, Parashos P, Messer H. The prevalence of postoperative pain and flare-up in single- and multiple-visit endodontic treatment: a systematic review. Int Endod J. 2008;41:(2)91-99.

7. Parirokh M, Yosefi MH, Nakhaee N, Manochehrifar H, Abbott PV, Reza Forghani F. Effect of bupivacaine on postoperative pain for inferior alveolar nerve block anesthesia after singlevisit root canal treatment in teeth with irreversible pulpitis. J Endod. 2012;38:(8)1035-1039.

8. Pasqualini D, Mollo L, Scotti N, et al. Postoperative pain after manual and mechanical glide path: a randomized clinical trial. J Endod. 2012;38:(1)32-36.

9. Parirokh M, Rekabi AR, Ashouri R, Nakhaee N, Abbott PV, Gorjestani H. Effect of occlusal reduction on postoperative pain in teeth with irreversible pulpitis and mild tenderness to percussion. J Endod. 2013;39:(1)1-5.

10. Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal reduction on pain after endodontic instrumentation. J Endod. 1998;24:(7)492-496.

11. Morse DR, Esposito JV, Furst ML. Comparison of prophylactic and on-demand diflunisal for pain management of patients having one-visit endodontic therapy. Oral Surg Oral Med Oral Pathol. 1990;69(6):729-736.

12. Attar S, Bowles WR, Baisden MK, Hodges JS, McClanahan SB. Evaluation of pretreatment analgesia and endodontic treatment for postoperative endodontic pain. J Endod.

2008;34:(6)652-655.

13. Menhinick KA, Gutmann JL, Regan JD. The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled study. Int Endod J. 2004;37(8):531-541.

Figure 1: Flow diagram of the progress of phases of the trial combination in the management of patients having one-visit endodontic therapy. Clin Ther. 1987;9:(5)500-511.

irreversible pulpitis or teeth with necrotic pulps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:(2)207-214.

16. Sadeghein A, Shahidi N, Dehpour AR. A comparison of ketorolac tromethamine and acetaminophen codeine in the management of acute apical periodontitis. J Endod.

1999;25:(4):257-259.

29. Hargreaves KM, Cohen S, Berman LH. Cohen’s Pathways of the Pulp. 10th ed. St. Louis, MO: Mosby Elsevier; 2011.

17. Pochapski MT, Santos FA, de Andrade ED, Sydney GB. Effect of pretreatment dexamethasone on postendodontic pain. Oral Surg Oral Med Oral Pathol. 2009;108(5):790-795.

19. Oliveira SM, Drewes CC, Silva CR, et al. Involvement of mast cells in a mouse model of postoperative pain. Eur J Pharm. 2011;672(1-3):88-95.

31. Litkowski LJ, Christensen SE, Adamson DN, Van Dyke T, Han SH, Newman KB. Analgesic efficacy and tolerability of oxycodone 5 mg/Ibuprofen 400 mg compared with those of oxycodone 5 mg/acetaminophen 325 mg and hydrocodone 7.5 mg/acetaminophen 500 mg in patients with moderate to severe postoperative pain: a randomized, double-blind, placebo-controlled, single-dose, parallel-group study in a dental pain model. Clin Ther. 2005;27(4):418-429.

20. Dale HH, Richards AN. The vasodilator action of histamine and of some other substances. J Physiol. 1918; 52(2-3):110-165.

32. Krasner P, Jackson E. Management of posttreatment endodontic pain with oral dexamethasone: a double-blind study. Oral Surg Oral Med Oral Pathol. 1986;62:(2)187-190.

21. Hargreaves KM, Swift JQ, Roszkowski MT, Bowles W, Garry MG, Jackson DL. Pharmacology of peripheral neuropeptide and inflammatory mediator release. Oral Surg Oral Med Oral Pathol. 1994;78:(4)503-510.

33. Mehrvarzfar P, Abbott PV, Saghiri MA, et al. Effects of three oral analgesics on postoperative pain following root canal preparation: a controlled clinical trial. Int Endod J. 2012;45:(1)76-82.

22. Levin L, Amit A, Ashkenazi M. Post-operative pain and use of analgesic agents following various dental procedures.

Am J Dent. 2006;19:(4)245–247.

34. Ng YL, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of nonsurgical root canal treatment: part 1: periapical health. Int Endod J. 2011;44:(7)583-609

18. Bender IB. Pulpal pain diagnosis—a review. J Endod.

2000;26:(3)175-179.

23. Grond S, Sablotzki A. Clinical pharmacology of tramadol.

Clin Pharmacokinet. 2004;43:(13)879-923.

24. Mishra H, Khan FA. A double-blind, placebo-controlled randomized comparison of pre- and postoperative administration of ketorolac and tramadol for dental extraction pain.

J Anaesthesiol Clin Pharmacol. 2012;28:(2)221-225.

25. Desjardins PJ, Fricke JR, Mardirossian G, Seng GF, Beirne OR. Bromfenac, a nonopioid analgesic, compared with tramadol and placebo for the management of postoperative pain. Clin Drug Investig. 1998;15:(3)177-185.

26. Shah AV, Arun-Kumar KV, Kumar-Rai K, Rajesh-Kumar BP. Comparative evaluation of pre-emptive analgesic efficacy of intramuscular ketorolac versus tramadol following third molar surgery. J Maxillofac Oral Surg. 2013;12:(2)197-202.

14. Ryan JL, Jureidini B, Hodges JS, Baisden M, Swift JQ, Bowles WR. Gender differences in analgesia for endodontic pain. J Endod. 2008;34:(5)552-556.

27. Gatewood RS, Himel VT, Dorn SO. Treatment of the endodontic emergency: a decade later. J Endod.

1990;16:(6)284-291.

15. Morse DR, Furst ML, Koren LZ, Bolanos OR, Esposito JV, Yesilsoy C. Comparison of diflunisal and an aspirin-codeine

28. Nusstein JM, Beck M. Comparison of preoperative pain and medication use in emergency patients presenting with

30 Endodontic practice

30. Law AS, Nixdorf DR, Aguirre AM, et al. Predicting severe pain after root canal therapy in the National Dental PBRN. J Dent Res. 2015;94(suppl 3):37S-43S.

35. Lund I, Lundeberg T, Sandberg L, Budh CN, Kowalski J, Svensson E. Lack of interchangeability between visual analogue and verbal rating pain scales: a cross sectional description of pain etiology groups. BMC Med Res Methodol. 2005;5:31 36. Lara-Munoz C, De Leon SP, Feinstein AR, Puente A, Wells CK. Comparison of three rating scales for measuring subjective phenomena in clinical research: I. Use of experimentally controlled auditory stimuli. Arch Med Res. 2004;35:(1)43-48.

37. Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. Br J Anaesth. 2008;101(1):17-24.

38. Wells LK, Drum M, Nusstein J, et al. Efficacy of ibuprofen and ibuprofen/acetaminophen on postoperative pain in symptomatic patients with a pulpal diagnosis of necrosis.

J Endod. 2011;37(12):1608-1612.

39. Paredes-Vieyra J, Enriquez FJ. Success rate of singleversus two-visit root canal treatment of teeth with apical periodontitis: a randomized controlled trial. J Endod.

2012;38:(9)1164-1169.

Volume 11 Number 3

REF: EP V11.3 VIEYRA, ET AL.

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Study of preoperative administration of ketorolac and placebo on compromised teeth VIEYRA, ET AL.

1. Dental pain is a multifaceted process that is partially comprised of biological, __________ factors. a. biochemical b. environmental c. psychogenic d. all of the above 2. The incidence of postoperative pain of mild intensity is _______ even when endodontic treatment has followed suitable standards. a. is an occasional event b. not an occasional event c. rarely occurs d. never occurs 3. Mild pain after chemo-mechanical preparation can develop in about ________ of the cases, and in most instances, the patient can bear the discomfort or can make use of common analgesics, which are usually effective in relieving symptoms. a. 10%-30% b. 40%-45% c. 50%-55% d. 60%-75% 4. Development of acute or severe pain,

Volume 11 Number 3

accompanied or not by swelling, has been demonstrated to be a/an ______ occurrence. a. frequent b. expected c. unusual d. non-emergent 5. Activation of nociceptive sensory nerve fibers may also be related to concentrations of inflammatory mediators like ______. a. histamine b. serotonin c. prostoglandin d. beta blockers 6. The incidence and severity of postoperative pain are associated with specific dental treatments; the highest is with _______. a. extraction b. caries treatment c. root canal therapy d. implant placement 7. _______ is an excellent acting analgesic used widely in surgery and medicine. a. Ketorolac b. Acetaminophen c. Naproxen

d. Tramadol 8. Results from this study indicated that preoperative pain with the diagnoses of irreversible pulpitis with apical periodontitis were _______ for respondents to choose analgesics to relieve their patients’ pain. a. the most common b. the least common c. equal to other procedures d. was non-existent 9. Many local and systemic factors such as age, gender, general health, group of teeth, ______, among others, may interact and modulate the occurrence of pain of endodontic origin. a. pulp status b. periapical status c. occlusal contacts d. all of the above 10. Our findings agree with Wells that reported the presenting initial moderate pain level is representative of emergency patients with _______. a. symptomatic teeth b. a pulpal diagnosis of necrosis c. a periapical radiolucency d. all of the above

Endodontic practice 31

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Warm gutta-percha obturation with BC HiFlow™ Sealer Dr. Stephen Buchanan discusses the advantageous properties of this bioceramic sealer

I

just changed the sealer that I use in practice after successfully using Kerr Pulp Canal Sealer (KPCS) for 40 years — for an endodontist, this is a big move.

If you asked endodontists what part of their RCT procedure they are least willing to change, a majority of them would say they are most anxious about changing their filling materials because that is the greatest longterm risk to an endodontic specialty practice.

If you change filling materials because somebody convinced you that the new sealer is better because of the customary reasons, or if you are a typical endodontist who does 800-1,000 cases a year, and the new material starts failing after 3 years, you could have thousands of cases coming back to haunt you! Practices have failed over less.

Although this may sound like an overdramatization, it is not. The last new obturation material to flame-out was Resilon®, a polycaprolactone-based endodontic composite filling material.1 Designed by Pentron Dental to replace traditional gutta percha and sealers, this insidious material began failing after 6 years, doubling the failures in the preceding example because, over the additional 3 years, 3,000 more cases were treated with it before the backlash.

Let’s be conservative and say the fees averaged $500 per RCT. $500 X 3,000 potential failures = $1,500,000 of liability. And that one is not a made-up number.

What would convince me to change from the sealer I’ve successfully used with my Continuous Wave (CW) Obturation Technique for 40 years? Am I throwing Rickert’s sealer (KPCS) — formulated over a century

Educational aims and objectives

This clinical article aims to examine the beneficial aspects of a certain bioceramic sealer.

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: •

Identify some previous research on BC HiFlow Sealer.

•

Identify some functional characteristics of this particular bioceramic sealer.

•

Realize the importance of sealers as a needed component of a successful RCT fill.

•

Recognize differences in single-cone obturation when using BC Sealer compared to lateral condensation.

Figure 1: Brasseler’s BC HiFlow Sealer, designed for warm gutta-percha obturation techniques. This sealer is chemically identical to BC Sealer; the differences are heat resistance up to 220ºC and an additional 20% radiopacity

ago — over for a new trophy sealer?

Absolutely not.

I changed to BC HiFlow Sealer (Brasseler USA®, Savannah, Georgia) because our best researchers have proved all of Brasseler’s claims for more than a decade. Drs. Spangberg, Haapasalo, Kim, Setzer, Kohli, and scores of others have shown BC Sealer to be completely biocompatible to pulp cells,2-15 to be an excellent pulp capping agent that incites odontoblastic proliferation, mineralization, and osteogenesis,9-11,15-19 and

Stephen Buchanan, DDS, FICD, FACD, Dipl. ABE, was valedictorian of his class at the University of the Pacific School of Dentistry and completed the Endodontic Graduate program at Temple University in Philadelphia, Pennsylvania, in 1980. Dr. Buchanan began pursuing 3D anatomy research early in his career, and in 1986, he became the first person in dentistry to use micro CT technology to show the intricacies of root structure. In 1989, he established Dental Education Laboratories and subsequently built a state-of-the-art teaching laboratory devoted to hands-on endodontic instruction, where he continues to teach today. Through Dental Education Laboratories he has lectured and conducted participation courses around the world, published numerous articles, and produced an award-winning video series, “The Art of Endodontics.” In addition to his activities as an educator and practicing clinician, Dr. Buchanan holds a number of patents for dental instruments and techniques.

Disclosure: Dr. Buchanan does not have financial interest in the products mentioned in the article, but he has received financial compensation for writing this article.

32 Endodontic practice

somehow, at the same time, this bio-ceramic material has significant anti-bacterial properties20-22 — all of this in a material that seals like MTA23-30 but doesn’t stain dentin.31-34 I changed to this sealer because Brasseler reformulated BC Sealer™ to meet my warm gutta-percha obturation needs.

The new BC HiFlow Sealer (Figure 1) was designed for higher heat resistance (good to 220ºC), and it also has 20% greater radio-opacity.

I changed to this sealer because the functional characteristics of these bioceramic materials profoundly change everything in endo obturation — in more ways than first meets the eye.

This changes everything The literature tells us that BC Sealer has a slight (0.2%) net expansion when it sets,35 instead of the significant shrinkage (up to 6.5% for AH+) seen in all sealers before. How does this change things in profound ways?

Volume 11 Number 3

B.

C.

Figures 2A-2C: 2A. Continuous Wave electric heat plugger being fit prior to cementation of GP and downpack (left). 2B. CW Plugger at apical extent of the downpack (center). 2C. Backfill gap between apical mass of GP at canal diameter of .4 mm and the .65 mm diameter of a 23 Ga. backfill cannula (right)

As a practitioner, I value this sealer because it streamlines Continuous Wave Obturation36 (CW), increasing my practice productivity.

As an educator, I value this sealer because it simplifies the technique, making warm gutta-percha obturation more accessible to dentists of all skill and experience levels.

The most complex parts of traditional warm gutta-percha condensation methods have always been: 1. The need to downpack within 4 mm6 mm of the terminus, even when obturating small, curved molar canals.

2. Syringe backfilling these narrow spaces without leaving voids.

Continuous Wave Obturation — with its dead-soft stainless steel electric heat pluggers (elements™Free; by Kerr Endodontics, Orange, California) and its nickel-titanium hand pluggers (Buchanan Pluggers also by Kerr Endodontics) — enables clinicians to downpack within 4 mm-6 mm of the end of most any small, curved canal — a huge improvement over the Schilder technique with its rigid pluggers. However, the CW technique, as done with traditional sealers, requires pre-fitting the electric heat pluggers in the canals before cementing the master cone in the canal with sealer. This pre-fitting routine is done by pressing the appropriate size plugger into the canal as it is rocked back and forth. This rocking action causes the plugger to work its way into the canal; in the process, the canal very accurately bends the plugger to match its curvature (Figure 2A). It was this improvement that enabled a much deeper downpack than the Schilder Warm Vertical Technique, while filling all lateral canals in less than 2 seconds (Figure 2B).

Why have clinicians felt compelled to downpack that far into the canal? Sealers are a needed component of a successful RCT fill, as gutta percha is not an effective sealing medium; however, all conventional sealers shrink as they set. Because of this Volume 11 Number 3

Figure 3. TrueTooth Replica of maxillary central incisor filled with single cone technique and BC HiFlow Sealer. Note the buccal and lingual fins, the mid-root lateral canal, and the apical accessory canal all filled due to the extremely low surface tension of BC HiFlow Sealer. With this in mind, there is no longer any credible rationale for Lateral Condensation, an obturation technique that requires overcutting coronal shapes to create intra-canalar space for inconsequential accessory points

sealer shrinkage, clinicians’ best procedural workaround to prevent this shrinkage from pulling the sealer off canal walls, has been to downpack deeply into even small curved canals to thermo-plastically move the heatsoftened gutta percha into the intaglio of the canal, thereby thinning the sealer layer.

This is a well thought-out procedure, considering previous sealer constraints; however, this is also setup to backfilling voids. Despite voids being clinically the least important part of the CW procedure, seeing a backfill void on a post-RCT radiograph leaves clinicians with disappointment instead of the “thrill of the fill.”

Good riddance condensation

to

lateral

Change 6.5% shrinkage to 0.2% expansion, and suddenly nobody cares how thick the sealer layer is; clinicians only care if they can move it into all the lateral irregularities that have been cleaned out. Combine net expansion on setting with extremely low surface tension and high wettability,40 and suddenly we find that just a 3 mm-4 mm downpack will fill every nook and cranny in the most complicated anatomy. This pivot

in the Continuous Wave Obturation procedure simplifies the downpack as electric heat pluggers no longer need to be prefit and bent before cementing master cones.

This reduced need to achieve depth in the downpack also means it is much easier to backfill without voids.

An easy way to explain the importance of the wetting characteristics of BC HiFlow Sealer over traditional sealers is to consider the difference in technique sensitivity between flowable and traditional composite materials. This surprising ability of BC Sealer to flow into lateral spaces with very little pressure needed has significantly changed the dynamic around cold gutta-percha filling techniques in general practices. Dr. Herbert Schilder was known to say, “Lateral condensation of cold gutta percha is single-cone technique with a conscience.” Now we can say that single-cone obturation with BC Sealer is far better than lateral condensation because: 1. This sealer will fill the primary canal next to the master cone and lateral canals 1 mm-2 mm long by simply cementing the master cone into a BC Sealer-laden canal (Figure 3).

Endodontic practice 33

CONTINUING EDUCATION

A.

CONTINUING EDUCATION 2. Lateral condensation of cold gutta percha requires over-cutting coronal canal shapes, so a spreader (basically a thin wedge) can be forced into the canal (an enormous root-splitting force) to push the master cone aside and allow an inconsequential accessory cone to be placed in that space.

For these reasons, lateral condensation of cold gutta percha — a technique that requires the weakening of teeth to allow a filling method that doesn’t improve the result — should be extinct. It is a technique without rationale.

Continuous Wave Obturation 2.0

If BC Sealer fills lateral canals 1 mm-2 mm in length when doing single-cone obturation, why do we need to heat gutta percha and downpack at all? Unfortunately, lateral

canal spaces in molars are way bigger than that. Forget about the 4 mm-wide isthmus forms found in mesial roots of lower molars.

Forget about the fins, webs, loops, and lateral canals that commonly project off of single primary canals. Be worried about MB2 and MB3 canals in upper molars that bifurcate midroot off the MB1, turn 90º, and bifurcate before exiting (Figures 4A and 4B).

These can be 7 mm-8 mm in length, so I’m still a warm gutta-percha user. With BC HiFlow Sealer, I just don’t have to work as hard to get the 3D results I expect to see on post-obturation radiographs.

How does this simplify warm guttapercha obturation? Primarily by shortening the required downpack distance into the canal. As previously mentioned, with net expansion of bioceramic sealers,

the warmed gutta percha and the sealer beneath it need just half the previous depth of Continuous Wave downpack to move sealer into the full apical and lateral extents of root canal systems (Figure 5B). The shortening of the downpack means that pluggers no longer need to be pre-fit in canals before cementation of the master cone, and it also means that backfilling can be done with a small squirt of GP from a backfill syringe, or better yet, with a sealer-coated backfill cone. (Autofit Backfill Gutta Percha, Kerr Endodontics).

BC HiFlow Sealer also works well for carrier-based obturation. A 3 mm aliquot of sealer is syringed into the orifice of each canal, an XP-Finisher (Brasseler USA®) is used to spread a thin coat of sealer on canal walls, then the oven-heated obturator is placed 1 mm short of full length. With the heat resistance of HiFlow, carrier placement with bioceramic sealer is identical to placement of carriers with traditional sealers, except patients have little or no postoperative discomfort due to BC HiFlow Sealer’s complete biocompatibility (Figure 6).

Conclusion

A.

Changing sealers is a very important decision for an endodontist because thousands of patients could be hurt if the new sealer fails before a couple of decades go by. BC HiFlow Sealer checks all the required safety boxes such as biocompatibility, antibacterial, etc., however, the greatest advantage

B.

Figures 4A and 4B. 4A. Master GP points cemented in canals with BC HiFlow Sealer. Note the short apical lateral canals filled just by cementing a single GP cone in the palatal root; also note the incomplete lateral fill of the MB root complex (left). 4B. Continuous Wave electric heat plugger in its final position after a modified CW downpack to midroot. Note the MB2 and MB3 complexities filled by bioceramic sealer after the shortened hydraulic wave of condensation (right)

A.

B.

Figures 5A-5B: 5A. Mesial CBCT view of an MB root of a maxillary molar after a fruitless search for the MB2 canal. 5B. Post-op CBCT imaging showing MB2 canal filled with a shortened CW downpack. Note how the 4 mm long MB2 canal bifurcates midroot off the MB1 canal, makes a 90º turn, and exits. Single-cone obturation with BC Sealer won’t fill this anatomy 34 Endodontic practice

Figure 6. Mandibular molar with severe, multi-planar curvatures of all canals. The D canal was instrumented with a single 3D Shaper; the mesial canals were shaped with a 15-.06 rotary file. All the canals were filled with BC HiFlow Sealer and EdgeCore gutta-percha carriers (Edge Endo, Albuquerque, New Mexico) Volume 11 Number 3

CONTINUING EDUCATION Figure 7. Mandibular premolar with extensive internal resorption. This case was treated in a single visit using Gentle Wave multi-sonic cleaning and BC HiFlow bio-ceramic sealer. Note the wild resorptive pattern filled by a short Continuous Wave downpack.

of this sealer (besides 10-year history of success) is its net-expansion upon setting.

Single cone obturation with BC HiFlow Sealer can provide much better results than lateral condensation and will replace it as the most efficient endodontic sealing method. EP

10. Shi ZF, Bao Y, Liu DD, Zhang X, Chen LM, Jiang, Zhong M. Comparison of in vivo dental pulp responses to capping with iRoot BP Plus and mineral trioxide Aggregate. Int Endod J. 2015;49(2):154-160.

11. Öncel Torun Z, Torun D, Demirkaya K, Yavuz ST, Elçi MP, Sarper M, Avcu F. Effects of iRoot BP and white mineral trioxide aggregate on cell viability and the expression of genes associated with mineralization. Int Endod J. 2015; 48(10): 986-993.

12. Liu S, Wang S, Dong Y. Evaluation of a bioceramic as a pulp capping agent in vitro and in vivo. J Endod.

2015;41(5):652-657.

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17. Zhang W, Li Z, Peng B. Effects of iRoot SP (aka BC Sealer™) on mineralization-related genes expression in MG63 cells.

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32. Kohli MR, Yamagucbi M, Setzer FC, Karabucak B. Spectrophotometric analysis of coronal tooth discoloration induced by various bioceramic cements and other endodontic materials. J Endod. 2015;41(11):1862-1866.

5. Ruparel NB, Ruparel SB, Chen PB, Ishikawa B, Diogenes A. Direct effect of endodontic sealers on trigeminal neuronal activity. J Endod. 2014;40(5):683-687.

6. Chang SW, Lee SY, Kang SK, Kum KY, Kim EC. In vitro biocompatibility, inflammatory response, and osteogenic potential of 4 root canal sealers: Sealapex, Sankin apatite root sealer, MTA Fillapex, and iRoot SP root canal sealer. J Endod. 2014;40(10):1642-1648.

7. Ciasca M, Aminoshariae A, Jin G, Montagnese T, Mickel A. A comparison of the cytotoxicity and proinflammatory cytokine production of EndoSequence root repair material and ProRoot mineral trioxide aggregate in human osteoblast cell culture using reverse-transcriptase polymerase chain reaction. J Endod. 2012;38(4):486-489.

8. Hirschman W, Wheater M, Bringas J, Hoen M. Cytotoxicity comparison of three current direct pulp-capping agents with a new bioceramic root repair putty. J Endod.

2012;38(3):385-388.

9. Zhou HM, Du TF, Shen Y, Wang ZJ, Zheng YF, Haapasalo M. In vitro cytotoxicity of calcium silicate–containing endodontic sealers. J Endod. 2015;41(1):56-61.

Volume 11 Number 3

19. Chen I, Salhab I, Setzer FC, Kim S, Nah HD. A new calcium silicate–based bioceramic material promotes human osteoand odontogenic stem cell proliferation and survival via the extracellular signal-regulated kinase signaling pathway. J Endod. 2016;42(3):480-486.

20. Zhang H, Shen Y, Ruse ND, Haapasalo M. Antibacterial activity of endodontic sealers by modified direct contact test against Enterooccus faecalis. J Endod.

2009;35(7):1051-1055.

21. Lovato K, Sedgley M. Antibactieral activity of EndoSequence root repair material and ProRoot MTA against clinical isolates of Enterococcus faecalis. J Endod. 2011;37(11):1542-1546.

22. Wang Z, Shen Y, Haapasalo M. Dentin extends the antibacterial effect of endodontic sealers against Enterococcus faecalis biofilms. J Endod. 2014; 40(4):505-508.

33. Shokouhinejad N, Nekoofar MH, Pirmoazen P, Shamshiri AR, Dummer PM. Evaluation and comparison of occurrence of tooth discoloration after the application of various calcium silicate–based cements: an ex vivo study. J Endod. 2015; 42(1):140-144.

34. Marconyak LJ Jr, Kirkpatrick TC, Roberts WH, et al.

A Comparison of Coronal Tooth Discoloration Elicited

by Various Endodontic Reparative Materials. J Endod.

2015;42(3):470-473.

35. Richardson IG. The calcium silicate hydrates. Cement and Concrete Research. 2008;38(2):137-158.

36. Ingle JL, et al. Continuous Wave of Obturation. In Ingle JI, Bakland LK, eds. Endondontics. 5th ed. London, England, UK: BC Decker; 2002.

Endodontic practice 35

REF: EP V11.3 BUCHANAN

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Warm gutta-percha obturation with BC HiFlow™ Sealer BUCHANAN

1. Drs. Spangberg, Haapasalo, Kim, Setzer, Kohli, and scores of others have shown BC Sealer to be completely biocompatible to pulp cells, to be an excellent pulp capping agent that incites _______. a. odontoblastic proliferation b. mineralization c. osteogenesis d. all of the above 2. And somehow, at the same time, this bioceramic material (BC Sealer) has _______. a. significant antibacterial properties b. a material that seals like MTA c. a material that does not stain dentin d. all of the above 3.

The literature tells us that BC Sealer has a slight ____ net expansion when it sets instead of the significant shrinkage (up to 21%, AH+) seen in all sealers before. a. (0.2%) b. (0.6%) c. (2.0%) d. (4.0%)

4. The most complex parts of traditional warm guttapercha condensation methods have always been (1) the need to downpack within ______ of the terminus, even when obturating small, curved molar canals, and (2) syringe backfilling these narrow spaces without leaving voids.

36 Endodontic practice

a. b. c. d.

1 mm-2 mm 3 mm 4 mm-6 mm 7 mm-8 mm

5. It was this improvement (the rocking action with the CW technique) that enabled a much deeper downpack than the Schilder Warm Vertical Technique, while filling all lateral canals in less than ___ seconds. a. 2 b. 4 c. 6 d. 8 6.

This pivot in the Continuous Wave Obturation procedure simplifies the downpack, as electric heat pluggers no longer need to be _____ before cementing master cones. a. prefit b. bent c. cooled d. both a and b

7. _____ was known to say, “Lateral condensation of cold gutta percha is single cone technique with a conscience.” a. Dr. Edgar D. Coolidge b. Dr. Herbert Schilder c. W. Clyde Davis d. Louis I. Grossman

8. This sealer (BC Sealer) will fill the primary canal next to the master cone and lateral canals ______ long by simply cementing the master cone into a BC Sealerladen canal. a. 1 mm-2 mm b. 3 mm-4 mm c. 5 mm-6 mmm d. 7 mm-8 mm 9. BC HiFlow Sealer also works well for carrier-based obturation. A 3 mm of sealer is syringed into each canal, an XP-Finisher (Brasseler USA®) is used to spread a thin coat of sealer on canal walls, and then the oven-heated obturator is placed _____ short of full length. a. 1 mm b. 2 mm c. 3 mm d. 4 mm 10. With the heat resistance of HiFlow, carrier placement of bioceramic sealer is identical to placement of carriers with traditional sealers, except patients experience ____ due to BC HiFlow Sealer’s complete biocompatibility. a. great postoperative discomfort b. some sensitivity c. little or no postoperative discomfort d. none of the above

Volume 11 Number 3

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PRACTICE MANAGEMENT

Communicating change in the dental practice Catherine Cheshire, SPHR, discusses the importance of keeping employees informed

M

ost of us go to great lengths to manage communications with patients and referring dentists. Nurturing your internal messaging for your practice team is mission-critical too, especially during times of growth and change.

Regular, transparent, and considerate messaging keeps your team engaged and keeps your practice’s culture thriving. Especially if your crew is growing, or some kind of organizational change is afoot (such as adding a satellite office or new employees), it’s time to get strategic about internal communication.

In our technology-filled lives, every day, we live and breathe the power of messaging.

So we take note of the immediate impact and the on-going ripple effect communications have within our own workspace. If any lesson rings the truest during times of growth and transition as well as in an everyday well-run practice, it’s that communicating any kind of change, and keeping communication constructive when you grow, requires a good and proper plan.

Three company culture steps are needed to be sure that your team is ready to receive your messaging.

1. Align your leadership ... and gather intel You need buy-in from your practice team, both the office and the clinical associates.

Make sure you have a connected team that gets the “why” behind the changes. Support your leaders, and show them their place in the practice’s future. Your team is critical to the success of your communication strategy.

You need them to be ready to reinforce the practice’s internal messaging and to embody

Catherine Cheshire, SPHR, is a people operations and communications consultant, specializing in executive and employee coaching, culture development and employer branding. As a certified practitioner in the Coaching Mindset Index, she helps managers develop self-awareness and enhance their effectiveness as coaches. She has over 10 years of experience as an HR and communications executive, and has a degree in Psychology.

You can reach Catherine Cheshire through LinkedIn or via email: catcheham@gmail.com

38 Endodontic practice

Regular, transparent, and considerate messaging keeps your team engaged and keeps your practice’s culture thriving. the company culture. Integrate their experience and opinions about your operation and communications — they will be critical in helping you with the next step.

2. Create a culture of communication You already have a communication culture in your company. But is it a good one? When you bring a message of change to your team, is your message going to be received from a place of established respect and openness? It’s time to assess where your communications stand. Take a look at how communication flows through your practice. Break down your info-share into “bottom-up” and “top-down” methods.

Bottom up: Is there a stronger tendency for your team to communicate upward to the owner/clinician or the office manager, rather than the other way round? For example, do you have feedback programs or open-door managers always ready for questions and employee feedback?

Top down: Does most information filter down from the top to the team? For example, internal emails from management and clinician/office manager intranet updates?

Ask your team what communication channels are working, which aren’t, and which are missing.

Will your current methods continue to work in your new world order? This includes, a move, addition of a satellite office, or expansion of a current practice? And are those pathways and communication styles constructive? A practice with an organic and non-formalized communication style might find itself stuck when a new hierarchy is introduced or new folks are added to the mix.

You might be consumed with new patients and new hires, with a mess of crossed messages, yet-to-be-written processes, and good intentions.

You need to identify how your messages will be best communicated to your team, and create a proactive schedule that preemptively Volume 11 Number 3

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PRACTICE MANAGEMENT answers questions you know are coming.

And then you need to be ready for the questions you didn’t foresee.

3. Give your team a voice Sounds elementary? Most of us who are into employee engagement in the modern era assume that our team is heard. The truth is that is not always the case. Consider those personalities who don’t speak up — ever.

Consider the workplace whirlwind. As you grow, or there is a period of uncertainty, make sure you are ready to hear your team.

Set the importance of team input and feedback as a culture priority.

And remember to prep your leaders to foster an atmosphere of openness and real communication (you might need to source some coaching!)

You want to make sure that information is being shared from the top effectively, and that your team’s valuable inputs are heard and acted on. There’s a recent trend for companies to turn top-down communication on its head. Many company-wide meetings are taking on the traditional townhall approach — a short leader-led presentation followed by ample time for questions and comments from the team.

The result? Cohesive, high-morale, highfunctioning companies where ground-level business intelligence is making its way to the top, and making them better.

Be patient while everyone adapts Establishing new behaviors takes time.

It can take months for your team to get the hang of asking questions, especially if they are not used to doing so. If it feels like a slow start, stay the course! Be consistent.

Encourage feedback — and provide different communication pathways for different personalities. Follow up on that feedback.

Act on it, fast, and always reply — as you would for a patient. EP Originally published on Bigsea.co.

40 Endodontic practice

Key traits to develop your communications Know yourself and your goals.

What are your practice’s core values? What are its goals? Integrate what will remain the same, or how the changes reinforce and support the company mission.

If there is a culture change afoot, explain how things will be different and why.

Be considerate, meaningful, and genuine.

Ask yourself and your leaders what impact your team members experience as a result of the changes — operationally, financially, personally, and interpersonally. How will teams and individuals fit into the changes? Note those impacts, and address them in your communications.

Deliver clarity and transparency.

People are more likely to get onboard if they are treated with respect, and they see the reasoning behind the decisions. Share your business intelligence and clarify how that information links to your mission. What are your expectations of the team? Provide (and communicate) structure and support your people for success.

Make updates regular and timely.

Foster the expectation that you will be forthcoming with updates and feedback.

Surprises are for birthdays, not for major life changes. Put your team communications on a schedule, and hold yourself or your office manager to it. Your people will come to know they can expect an on-going stream and trust you all the more for it. Think about the timing of the information you are sharing. Are you prepared to follow up with updates or lack of updates, and to handle the questions that follow?

Are you being transparent while at the same time taking care not to overburden your team with too much information?

Say thank you.

Recognize the challenges, the sacrifices (family impacts, disruption, comfort zone bursting). Share the tangible results and accomplishments that result from the team’s rally. Who has been instrumental in your recent positive change, or who has helped you go through the challenges — whether it’s teams or individuals, take time to recognize those contributions in a way that is beneficial and meaningful to them.

Loop it back!

Feedback is your friend. (Constructive) feedback/rich environments are where truly cohesive teams emerge. Establish a means for the team to ask questions, share information to you from the ground. You’ll gain critical insight, and your team will be heard — it’s a base requirement that is directly related to performance and positive associations.

Communicating uncomfortable change can be hard. Positive change can come with challenges too, especially if there is confusion from half-baked communication, or parts of your team are going to meet new challenges without the support or resources they need.

The good news is that a people-first communication strategy primes you for better understanding between you and your team, and the opportunity to course-correct as you receive feedback.

And the ultimate result of people-first communications? A practice team that understands and buys into your mission, stronger engagement, and a vibrant, intact corporate culture.

Here’s to your growth!

Volume 11 Number 3

AUTHOR GUIDELINES Endodontic Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world.

Endodontic Practice US is designed to be read by specialists in Endodontics, Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Endodontic Practice US requires original, unpublished article submissions on endodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education.

Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Endodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available.

Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research.

Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to endodontics.

Clinical and continuing education articles include an abstract of up to 250 words.

Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.

Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 11 Number 3

Pictures/images

Disclosure of financial interest

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

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

Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text.

Number tables consecutively and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques.

Aesthetic & Implant Dentistry. 2000;1(1):92-96.

(Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

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

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity.

Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkmedia.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors.

The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide.

London: Martin Dunitz; 2001.

Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011.

Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

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

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

Endodontic practice 41

PRODUCT PROFILE

Bassi Logic™: The minimally invasive future of endodontics Bassi Endo is passionately devoted to simpler, faster, and minimally invasive endodontics The minimally invasive goal Minimally invasive endodontics is defined by access and shaping procedures that preserve dentin but allow chemical disinfection to the highest standard. Retention of tooth structure is correlated with reduced fracture and preservation of the natural tooth.

Previously, limitations in instruments and technologies have challenged clinicians to achieve these goals. Past instruments have not been flexible enough to address canal anatomy, preserve tooth structure, and yet shape canal systems to an appropriate diameter.

The advent of dental microscopes and controlled memory NiTi has, for the first time, made minimally invasive techniques possible that are at the heart of the Bassi Logic™ philosophy.

“When we think about minimally invasive procedures, we should not only think about the coronal aspects of the tooth but saving dentin throughout the entire canal system — our endodontic shaping files must reflect this reality predictably, efficiently, and safely,” says Dr. Henrique Bassi, endodontist, and founder of Bassi Endo.

Designed to save dentin All Bassi Logic™ files are designed to preserve dentin. Bassi Logic™ is a true

single shaping file system, one that provides a quantum leap in functionality beyond other “single file” systems. Bassi Logic™ system features files for glidepath preparation and a single file for shaping. In many cases, Bassi Logic™ eliminates the need for K files.

Designed with the most advanced heat treatment process and state-of the-art manufacturing, Bassi Logic™ Glidepath files have a consistent .01 taper that is both strong and flexible for canal scouting and glidepath preparation. Bassi Logic™ Shaping files feature a conservative .03, .04, and .05 taper, any one of which can be used as in a single file technique.

Proven and trusted The real world performance of Bassi Logic™ is impressive. Globally, there are approximately 7,000 astute clinicians using the files with minimally invasive concepts.

The Brazilian Dental Journal1 found it to complete preparation time in 1/4 of the time of other single file systems. Another scientific research study2 found Bassi Logic™ able to complete instrumentation 30% faster than the WaveOne Gold©. The same study found Bassi Logic™ to be 33% more resistant to cyclic fatigue, and no Bassi Logic™ file fractured, regardless of the rigorous testing.

Getting started with Bassi Logic™ Getting started with Bassi Logic™ is simple. Bassiendo.com has a full line of videos, articles, instructions for use, and additional helpful information. In addition to Bassi Logic™, retreatment files, heat tips, and the Bassi Clean™ irrigation activation system are available for purchase. Bassi Logic™ is an incredible value with one of the lowest costs per file in the industry. A free Practice Kit is available at Bassiendo. com, for just the shipping fee.

Experience the difference Coronal minimally invasive access. Buccal canals shaped with Bassi Logic™ 25/.03 and palatal canal with 30/.05. Case submission by Key Fabiano, DDS, Brazil 42 Endodontic practice

When describing Bassi Logic in minimally invasive endodontics, Dr. Catherine Hebert of Mandeville, Louisiana, says, “Life changing!

Bassi Logic™ Shaping: .03 tapers, sizes 25-40, 25/.04; .05 tapers, sizes 25-40 and 25/.06 Bassi Logic™ Glidepath: .01 taper sizes 25-50, 15/.03 and 15/.05 Bassi Logic™ Shaping & Glidepath Kits: .01 taper, sizes 25-40 for Glidepath .05 taper, 25-40 sizes for Shaping

I’ve practiced endodontics for over 30 years, and Bassi Logic instruments have transformed my practice, both in performance and profits.”

For more studies, see BassiEndo.com/ research/. EP

REFERENCES 1. Coelho BS, Amaral RO, Leonardi DP, et al. Performance of three single instrument systems in the preparation of long oval canals. Braz Dent J. 2016;27(2):217-222.

2. de Menezes SEAC, Batista SM, Lira JOP, de Melo Monteiro GQ. Cyclic Fatigue Resistance of WaveOne Gold, ProDesign R and ProDesign Logic Files in Curved Canals In Vitro. Iran Endod J. 2017;12(4):468-473.

WaveOne®Gold is a registered trademark of Dentsply Sirona®

This information was provided by Bassi Endo.

Volume 11 Number 3

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SMALL TALK

Rules for giving and receiving feedback Dr. Joel Small discusses methods for providing positive and generative feedback

F

eedback, both positive and remedial, can be a powerful tool for developing people and enhancing the performance of organizational teams. However, when used improperly, feedback can become a demoralizing and dehumanizing weapon that destroys teams. Given this distinction, it would be wise for all leaders to learn the basic principles for providing feedback that is both positive and generative.

It is important to realize that even remedial feedback need not be negative. Somehow, today’s society has made the terms “remedial” or “corrective” synonymous with terms like “negative” or “punishing,” when in fact, corrective feedback can be both rewarding and positive. As an example, large organizations are beginning to embrace the concept of a coaching culture in which leaders are trained in facilitating positive behavioral change by leading team members to a place of positive empowerment through increased personal awareness and positive corrective feedback. If done properly, those trained in this technique are reporting both immediate and sustainable behavioral change in their organizations.

Before we discuss the rules for providing feedback, it is important to acknowledge the critical role of purposeful leadership as the stabilizing factor in any organizational culture. More often than not, I find that offices suffering from default leadership are the ones that experience the most severe, and often irreversible, staff problems. Without the guidance and clarity provided by purposeful leadership, an organization is more likely to descend into anarchy as everyone is left to create his/her own set rules within the workplace. When an organization descends to this level, feedback is at best meaningless.

So here are my rules for giving and receiving feedback:

1. Behavior should manifest organizational values This is critical. Once mutually accepted, organizational values become the benchmark for what is acceptable behavior within the organization. When giving feedback, either positive or corrective, we should always use organizational values as the background for our comments.

2. Direct communication Triangulation occurs when complaints are made to a third party rather than directly to the offending party. This is a very common scenario in organizations and is one of the reasons ill feelings exist and tend to linger.

Triangulation should be banned from our organizations. Leaders must avoid the

Joel C. Small, DDS, MBA, ACC, FICD, is an endodontist, author, and board certified executive leadership coach. 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.

44 Endodontic practice

tendency to become part of the triangle by insisting that all feedback take place directly between the involved parties.

3. Positive focus All corrective feedback should be given with the intention of creating new and positive behaviors that align with the organizational values. To be an agent for change, the one providing the feedback must highlight the positive consequences of the new desirable behavior. We are most effective when we paint a positive vision of a brighter future for the feedback recipient.

4. Provide feedback for the good and not so good Corrective, or remedial feedback, is much more effective when the leader is also willing to provide positive feedback that highlights a job well done. The recipient of corrective feedback is more likely to take the comments to heart when the leader has historically praised them for the good things they have done. Many of us are guilty of forgetting to offer positive feedback when we should. Even worse, we often try to soften the corrective feedback by including praise for past positive behavior that went unmentioned when it occurred.

The recipient of this feedback can easily see Volume 11 Number 3

5. Feedback should be given often Waiting for a yearly performance review to offer feedback is the worst possible method for facilitating sustainable change in our team members. If we were to ask our staff, I feel certain that they would overwhelming agree that they benefit more from ongoing performance feedback as opposed to a yearly feedback session.

SMALL TALK

through this duplicity, and the net intended effect of the feedback is seriously diminished.

6. Remain future focused Nothing is gained by dwelling on past negative behaviors. Instead we should facilitate change by creating a vision of a brighter future based on the desired positive changes.

Again, it is always wise to recognize how these desired changes are consistent with the mutually accepted practice values.

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S’ CHOICE AWARD

7. Follow-up If corrective feedback is to be effective, we must acknowledge when positive change occurs. Nothing is more disheartening than an earnest effort to change that goes unrecognized. This is the time to offer positive feedback on a job well done. Without this follow-up feedback, change becomes unsustainable, and future corrective feedback becomes ineffective.

8. If you give, be willing to receive The very best organizations have leaders that encourage feedback from their team regarding their effectiveness as leaders. By asking for feedback regarding our leadership, we create an openness that promotes a healthy feedback loop.

Furthermore, research has shown that our staff is the best prognosticator of our future success as leaders. Their assessment of our leadership capabilities has proven to be more accurate than a host of professionally designed and administered leadership assessments. Given this finding, it would be wise if we listened closely to what our staff has to say.

In summary, feedback is important. It is our means for facilitating individual change as well as organizational stability. Learning to give and receive both positive and remedial feedback is one of the most important steps in becoming the leader of an exceptional organization. Utilizing these rules for effective feedback will enable us to bring out the best in the people we serve. EP Volume 11 Number 3

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EVENT NEWS American Academy of Periodontology to hold its 104th Annual Meeting The American Academy of Periodontology (AAP) will hold its 104th Annual Meeting October 27-30, 2018, at the Vancouver Convention Centre in Vancouver, British Columbia. The event is presented in collaboration with the Canadian Academy of Periodontology, the Japanese Academy of Clinical Periodontology, and the Japanese Society of Periodontology. All dental professionals — including students, early-career periodontists, hygienists, office staff, and members of the dental media — are encouraged to attend.

This year’s meeting, which provides up to 25.5 continuing education credits, features 45 courses and more than 30 new speakers. Ten redesigned program tracks include oral pathology, oral medicine, and oral diagnosis; emerging concepts and innovative therapies; implant surgery and prosthetic rehabilitation; and periodontal plastic and soft tissue surgery.

To register for the 104th Annual Meeting or for more information, please visit members.perio.org/am2018, call 1-800-282-4867 ext.

3213, or email meetings@perio.org.

Registration open for 2018 Global Oral Health Summit — user-centered educational program takes center stage Along with open registration for its 2018 Global Oral Health Summit that takes place at the Gaylord Texan Resort and Convention Center, just outside Dallas, Texas, November 9-11, Carestream Dental announced a unique educational program that was designed with the guidance of real practice management software users.

New course formats — such as sessions led by seasoned software users sharing results-based, real-life cases and “Future Views,” which gives attendees access to product line managers and other Carestream Dental leaders for the latest updates on their software and equipment — provide attendees with new perspectives on the technology that powers their practices. The 2018 educational program was designed to give attendees the knowledge and resources they need to immediately apply what they learn at the Summit in their practices. The full educational program includes more than 70 courses being led by a combination of real software users; Carestream Dental developers and designers; CS OrthoTrac, CS PracticeWorks, CS SoftDent, and CS WinOMS practice management software trainers; doctors; and consultants.

For more information, call 1-800-944-6365, or visit carestream dental.com.

Youth Services Tulsa recognizes Dentsply Sirona Endodontics with its Youth Champion Award Each year, Youth Services of Tulsa (YST) awards an organization or individual donor who has gone above and beyond to support youth in need with its coveted Youth Champion Award. The organization’s 2018 award was recently presented to Dentsply Sirona. In choosing Dentsply Sirona, Youth Services Tulsa recognized it as a “driven company” that is working to make a real difference for Tulsa’s youth and future leaders.

Over the past year, employees collected hundreds of items to make a brighter future for Tulsa’s youth in need. Employees held an April donation drive where they collected 650 pairs of socks, 250 rain ponchos, 55 pairs of shoes, cash, and more. Most recently, employees stopped by the YST office and donated an additional 363 items.

Each month, Tara Brown, one of the leaders of the company’s outreach efforts with YST, and other Dentsply Sirona employees in Tulsa also reach out proactively to YST to see if there is an urgent need — and then start organizing efforts to fulfill those needs immediately. This has even included developing internal contests and new ideas to help spur efforts for item collection. For the latest donation effort, the Dentsply Sirona team Dentsply Sirona Endodontics employees attend the Blank Canvas came up with a “Grab Bag” concept that allowed employees to purchase a mystery banquet supporting Youth Services Tulsa bag of snacks that could also contain a gift card. By spending only $100, Dentsply Sirona was able to raise $1,600 for YST. For more information, visit https://www.dentsplysirona.com/en-us/products/endodontics.html.

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Volume 11 Number 3

Carestream Dental has announced that Lea Al Matny, DDS, MS, recently joined the company as the clinical specialty director. Dr. Al Matny will work closely with the sales organization to develop and implement effective scientific training on the company’s imaging solutions, such as cone beam computed tomography (CBCT). She will also serve as an educator, consulLea Al Matny, DDS, MS tant, and instructional expert for clinical development. Dr. Al Matny is an Oral and Maxillofacial Radiologist from the University of Texas Health in San Antonio (UTHSA) and holds a Master of Science degree from the same institution. She earned her Doctor of Dental Surgery degree from Lebanese University in Beirut, Lebanon.

Dr. Al Matny joins Carestream Dental from the University of Texas Health San Antonio, where she served as a teaching assistant focused on developing the technical and diagnostic radiology skills of pre-doctoral dental students. She is also a member of the American Association of Oral Maxillofacial Radiology (AAOMR) and a co-chair of the association’s residents committee.

For more information about Carestream Dental, call 800-9446365, or visit www.carestreamdental.com.

Dentsply Sirona announces expansion of its technology sales team Dentsply Sirona, the Dental Solutions Company™, announced its plan to grow its technology sales team in key U.S. markets to better serve customers and dealer partners nationwide. Clients and dealers can expect to see more than twice the number of representatives in each of the technologies divisions when the staff expansion is complete. This increase will create a better bridge between those divisions. An emphasis will be put on building better relationships to improve the company’s already top-tier customer support and buying process. Customers will also see more in-field support personnel, allowing a renewed focus be put on salesrelated matters with dealer representatives. Dentsply Sirona sees the growing demand for dental implants and single-visit dentistry and is working to provide better CAD/CAM coverage to address this growth.

For more information, visit www.dentsplysirona.com.

BillingTree® acquires iPayX expanding healthcare and B2B portfolio offerings BillingTree®, payment technology and services provider, announced the integration of additional digital payment solutions into its suite following the acquisition of Toledo-based electronic payment firm, Internet Payment Exchange (iPayX). The iPayX XprsPay and CareView payment platforms are now fully supported BillingTree offerings, aimed to help organizations in the B2B and healthcare sectors to drive revenue through a flexible, easily manageable digital platform handling invoicing, bill presentment, customer communications and multi-channel payment acceptance.

BillingTree CareView is an end-to-end solution to the healthcare market which improves patient payment experience by enabling providers to set up a range of payment channels across text, phone, online, live agents, and point-of- care. It delivers a billing and payment process based on individual patient preferences and offers the freedom to pay via debit, credit, ACH, e-check, FSA, or HSA. When it comes to capturing payments, providers can immediately begin billing and processing patient payments via a HIPAA, PCI, and SSAE compliant platform.

BillingTree XprsPay is an eBilling solution designed to digitize the previously time-consuming method of making and accepting commercial payments. Commercial organizations can offer customers an electronic billing platform to facilitate the delivery, management, and ultimate payment of invoices between business partners. Customers have a simple channel to settle and manage their accounts with email and/or text reminders to prompt timely payments. The solution automatically posts payments to inventory systems and general ledgers, vastly reducing paper-based expenditure and FTE time by allowing more accurate cash flow reporting and reduced days sales outstanding (DSO) figures.

For more information, visit https://mybillingtree.com/.

Share your good (endodontic) news!

Submit your press release for consideration to managing editor Mali Schantz-Feld via email at Mali@medmarkmedia.com.

Volume 11 Number 3

Endodontic practice 47

INDUSTRY NEWS

Carestream Dental announces Dr. Lea Al Matny as Clinical Specialty Director

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Brasseler Endo Solutions Brasseler USA® has recently expanded its product offering to include a full line of endodontic irrigation supplies and organizational systems. The irrigation offering includes sodium hypochlorite, chlorhexidine, and EDTA, which feature a novel luer-lock cap to improve solution efficacy and reduce cross-contamination. Brasseler has also introduced a full line of irrigation syringes, side vented irrigation needles (27g and 31g), endo sponges, vitality spray, and various organizational systems. These accessory endodontic products round out Brasseler’s already robust line of endodontic products making Brasseler a full service endo provider.

For more information, please contact Brasseler USA at 800-841-4522, or visit www.BrasselerUSA.com.

J. MORITA USA announces availability of Veraview X800 in Canada J. MORITA USA announced the availability of Veraview X800 in the Canadian market. Released earlier this year in the United States, Veraview X800 is a total performance imaging system. Multifunctional, it offers superior image quality for both 3D and 2D evaluation.

An innovative sensor positioning system automatically sets the optimal X-ray beam angle, horizontal for 3D, or raised 5° for 2D panoramic images, improving clarity. This unit also offers a voxel size of 80µm and a resolution of 2.5 LP/mm. Additional features include 360° or 180° rotation, panoramic scout for easy and precise positioning, dose reduction mode, zoom reconstruction (reduces retakes), and a free 3-year warranty.

For more information, call 877-JMORITA (566-7482), or visit www.morita.com/usa.

48 Endodontic practice

nothing changes if

Hu-Friedy launches new powder for AIR-FLOW® Therapy system

nothing changes

Hu-Friedy announced the release of a revolutionary new product as a part of its strategic alliance with Electro Medical Systems (EMS). AIR-FLOW Plus powder, designed for use with the AIRFLOW Therapy system, is the first air-polishing powder in dentistry that can gently and effectively remove biofilm from delicate surfaces while also efficiently eliminating light to moderate stains. The release of AIR-FLOW Plus powder gives the AIR-FLOW Therapy system an even broader range of applications for dental professionals to provide better care to their patients. This is because of the unique makeup of the powder. Made from erythritol, a harder material that ensures more efficient stain removal, AIR-FLOW Plus is the first high-tech powder in the market that removes biofilm in a minimally invasive way. The small 14-micron particle size also makes it suitable for all types of surfaces, including enamel, dentin, soft tissue, restorations, orthodontic appliances, and implant surfaces. The new AIR-FLOW Plus powder is a significant advancement that allows dentists to provide fast and efficient care to patients. This delivers a more pleasant experience, which with staying patient retention, Being an expert in saving teethhelps requires on top of the whilelatest also giving dental professionals extra time to educate patients, advances to ensure you’re giving your patients the best discuss treatment plans, and provide additional billable services. care—and better outcomes. The GentleWave® System delivers the To learn more, visit www.hu-friedy.com/BIOFILM. unprecedented cleaning and disinfection you need to do just that.

Improve patient outcomes by improving your technology.

• The entire procedure from access opening to obturation can typically be completed in just one visit 1

® ® Sonendo GentleWave • Cleansannounces the deepest, most complex anatomiessystem of the root canal ® integration with TDO endodontic software system2,3 to remove bacteria, debris tissue3 and biofilm4 ® save the structure and integrity of teeth • Helps by preserving Sonendo , Inc., announced that its GentleWave® System is 1 ® more dentin now designed to integrate with TDO endodontic software. TDO® Software is the only Practice Management Software that integrates with the GentleWave® System. This integration will allow endodontists who use the TDO endodontic software to more efficiently ® record and retrieve important procedure information directly from the GentleWave System’s console; the result is an improvement in chairside treatment efficiency.

For more information, visit https://sonendo.com/.

Discover the GentleWave difference today.

Learn more at sonendo.com/change.

© 2018. All rights reserved. SONENDO, the SONENDO logo GENTLEWAVE logo and SAVING TEETH THROUGH SOUND Sonendo, Inc. Patented: www.sonendo.com/intellectualpro

SON-152 Endo Practice Summer Full Page - Nothing Changes v1 Female.indd 1

Volume 11 Number 3

Simply illuminating.

ZEISS EXTARO 300 Fluorescence Mode

// INNOVATION MADE BY ZEISS

As the first device combining caries detection technology1 with optical magnification, the Fluorescence Mode in EXTARO® 300 from ZEISS expands the scope of microdentistry and elevates your ability to provide patients with premium dental care. The Fluorescence Mode helps you repair caries-infected fillings efficiently and more clearly identify the border between natural and artificial tooth material.

• Quickly target affected areas • Preserve healthy tooth substance • Save valuable chair time www.zeiss.com/us/extaro300 1

Jahrbuch der Endodontie 2017, Marktübersicht Mikroskope, OEMUS Verlag

SUR.10247 © Carl Zeiss Meditec, Inc., 2018. All rights 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. 17448 EN CS 8100 3D Family AD 0718 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