Endodontic Practice US Winter 2018 Vol 11 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Winter 2018 – Vol 11 No 4 • endopracticeus.com

PROMOTING

EXCELLENCE

Innovative Practice Management

ENDODONTICS Sometimes, everything lines up just perfectly: treating a permanent maxillary first molar with five canals Dr. José Francisco Gaviño Orduña

Practice profile S. Ryan Facer, DDS Greater Endodontics™

Thermafil® versus GuttaCore®: part 1 Drs. Giuseppe Cantatore, Katia Greco, and Lajos Palffi

Clinical application of WaveOne® Gold reciprocating instruments: part 1 Drs. Peet van der Vyver and Martin Vorster

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DR. ACE GOERIG

Years of intensive post-doctoral training

Extensive expertise in one concentration

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

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.

Take the lead, and create your dream practice

n a May 2017 interview with Charlie Rose, Warren Buffett was asked what gave him his greatest joy. “That I love going to the office,” said Buffett. “It has been my painting for over 50 years. I get to paint what I want, and I own the brush, and I own the canvas, and the canvas is unlimited. And that is a pretty nice game, and I get to do it every day with people I like. I don’t have to associate with anyone that causes my stomach to turn. If I were in politics, I’d have to smile at a lot of people I want to hit. I’ve got a really good deal, and I am hanging on to it.” Most dentist-owners forget that they have the brush and the Dr. Albert (Ace) Goerig canvas, and that they can create their story any way they want. Sometimes it takes the insight of a coach to help them through the process. One client, with whom I have been working for years, ran a very profitable office. However, over the past year or so, there was a lot of drama building up in the practice, particularly between the front and back office. He realized that three of his employees were causing the problem. He became very clear as to what he needed to do and fired one of them to see if the others would change. As often happens in these cases, the other two quit. It was perfect. As a result, there were only two employees at the front and two brand-new assistants. The atmosphere and mood of the office changed immediately, and even though he was understaffed, his production jumped up two cases per day as the black cloud of drama disappeared. He was a quiet doctor who liked to make everyone happy and tried to avoid conflict. But when we talked afterwards, he realized that, over the past year, he had given up his leadership role to those demanding employees. When you are not leading and paying attention, there is likely to be much more drama within the team since a few employees may lose respect for you and control the narrative on how the practice should be run. When you begin to have drama in your office, you must become clear about your vision and step back into the leadership role. Great leaders must always be vigilant of not giving up their leadership role. When there is strong leadership in the office, all employees know that the vision and direction of the practice is coming from the doctor, even though they have been empowered with responsibility and the ability to manage their area. When the person who is causing the drama in the office is identified, you and your office manager must sit down with him/her and let he/she know that, if this issue is not resolved, he/she will no longer be in the practice. Be sure to document all issues with this employee. Many doctors hate confrontation, but it is the only way to create the life and practice that you want, surrounded by the people you enjoy working with. I worked with another doctor who told me about an employee who was always causing him stress and a lot drama in the office. He had tolerated this employee for over a year. I told him to go back to the office and tell the owner of the practice to fire the employee that day. Then I reminded him that he was the owner. When you face your fears of confrontation and conflict, you can have the practice that you want now. Go for it. It’s not about making a living. It is about making a life worth living. Dr. Albert (Ace) Goerig

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

ISSN number 2372-6245

Volume 11 Number 4

Endodontic practice 1

INTRODUCTION

Winter 2018 - Volume 11 Number 4

TABLE OF CONTENTS

Practice profile S. Ryan Facer, DDS, Greater Endodontics™

For the Greater good of endodontics

Endodontic perspective Restraint: the lost art of endodontics Dr. John West discusses how to increase the awareness of the value that restraint plays in the mechanics of “Finding, Following, and Finishing” .......................................................16

Case study

Clinical 12 Introduction to vital pulp cryotherapy Drs. James Bahcall, Bradford Johnson, Qian Xie, Mark Baker, and Steve Weeks explore a new application for pulpal tissue

2 Endodontic practice

Sometimes, everything lines up just perfectly: treating a permanent maxillary first molar with five canals Dr. José Francisco Gaviño Orduña illustrates how 3D imaging helped during treatment of a complex tooth anatomy..........................................20

Volume 11 Number 4

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

TABLE OF CONTENTS

Continuing education Continuing education Thermafil versus GuttaCore : part 1 ®

Clinical application of WaveOne Gold reciprocating instruments: part 1 ®

Drs. Peet van der Vyver and Martin Vorster discuss the clinical applications and guidelines of WaveOne® Gold reciprocating instruments

Drs. Giuseppe Cantatore, Katia Greco, and Lajos Palffi discuss the features, differences, and protocols of use with Thermafil compared to GuttaCore ....................................................... 30

Practice management Practice management Freedom now: learn how to retire in practice Dr. Albert (Ace) Goerig discusses the “Ace Process”................................. 38

Step-by-step MTAFlow hydraulic repair cement for direct pulp-capping application ™

Dr. Carlos A. Spironelli Ramos discusses a second-generation MTA with improved mixing/delivering properties ....................................... 42

What do gossip and gum disease have in common? Cynthia Goerig discusses achieving an office environment based on teamwork ....................................................... 44

Industry news ....................................................... 47

Small talk Transformational leadership Dr. Joel C. Small discusses purposeful leadership for establishing a beneficial working relationship staff................48

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PRACTICE PROFILE

S. Ryan Facer, DDS, Greater Endodontics™ For the Greater good of endodontics What can you tell us about your background? I grew up in Bountiful, Utah, where I thoroughly enjoyed roaming around the Wasatch Front, especially when it came to mountain biking, snowboarding, wakeboarding, and rock climbing. But as it goes, I eventually had to grow up and decide upon a profession. At that time, I had no interest in dentistry, but I had an interest in an Italian girl whose dad was a dentist. So, needless to say, I earned my dental degree. I went on to graduate from the University of Utah with a degree in medical biology and attended the University of Iowa College of Dentistry. I graduated with high distinction and continued on thereafter, specializing in endodontics. I have been published in peer-reviewed journals such as the Journal of Endodontics and the Journal of Dental Research. My research interests range from sealer coverage, bacteriophage therapy, roentgen therapy, and adult stem cells with an emphasis on bone biology and dental trauma. I have been passionate in my pursuit to find new and innovative ways of treating and curing dental caries, pulpal diseases, apical periodontitis, and bone regeneration. I continue to teach locally and nationally and have actively maintained private practice since 2005. I’m known for bringing discovery and innovative ideas to industries to better treat patients and mentor colleagues.

When did you become a specialist, and why? While in dental school, I was on a scholarship that required me to participate in a research project. I quickly aligned myself with Dr. Richard Walton, who eventually became my reasoning and inspiration to become an endodontist. I had a natural affinity and attraction to microbiology, anatomy, and physiology. Endodontics offered me a unique understanding and perspective that incorporates these sciences, which is somewhat unique to endodontics and pulp tissue. For me, the prospect of restoring a tooth back to health or giving a tooth a second chance is very appealing and pure. I needed to find a way to incorporate basic sciences into dentistry, and I needed to find a way to use 6 Endodontic practice

State of the art: High-tech imaging guides Dr. S. Ryan Facer’s treatment

these skills in the way I practice dentistry. I have always looked at teeth differently, as plants not rocks. Rocks can be chipped away and ground down with little consequences. Yet teeth behave differently, or rather, they misbehave. The pulp requires much more attention to detail — attention that I was willing to give. The idea of future possibilities, possibilities pulps may offer us, possibilities of doing dentistry differently, gave me the desire to specialize. I was willing to do the research work, and I was willing to go beyond benchtop research. I wanted to innovate toward better patient care, better clinically techniques, and better root canal outcomes. I believe endodontics begins upon bacteria entering the pulp, and would that not be wonderful if a clinician could eradicate the bacteria without harming the pulp or living tissue?

Is your practice limited solely to endodontics, or do you practice other types of dentistry? While my practice is limited to endodontics, it includes removal and replacement of a tooth when it is determined to be nonrestorable or when the tooth is given a hopeless prognosis. When I was in my residency, I began to chase the dreams and possibilities of using stem cells to further our great profession. I proposed a crazy idea that involved

S. Ryan Facer, DDS

the Dows Institute and the department of medicine at the University of Iowa. There I had two fantastic mentors who became engaged in taking palatal stem cells and growing those cells into three-dimensional bone, using a rotary cell culture devices made popular by NASA. Their interests were in studying cells and their behaviors in a microgravity environment. For me, the translational applications seemed wondrous. That project drew me into the fascination of bone biology and the similitude to pulp biology. It drew me into the innate curiosities of vitality and eradication of infection in living and nonliving tissues. Ironically, this led me into the wonderful world of bone regeneration, bone grafting for dental implants, Volume 11 Number 4

PRACTICE PROFILE

and for apical pathosis concurrently. Consequently, my practice today is split between practicing endodontics and dental implants, having done so since 2005.

Why did you decide to focus on endodontics? The reason I jumped right into endodontics after dental school was because I was missing the biological component of my background. The regenerative potentials and treatment modalities of the pulp captivated me. The regenerative potential and treatment possibilities of bone interested me. Eradication of bacteria from living and nonliving tissues excited me. I believed that the future would hold more possibilities within the realm of endodontics than restorative and material sciences of teeth. We have done so much with burs, files, and materials. In fact, Arthur Barton Crane in 1920 made this published statement: “The upward progress of dentistry has been marked from the beginning by a tendency to perfect the purely mechanical and compromise with the therapeutical.” So yes, historically dentistry has largely focused on the mechanical and little on the biological, but endodontics has insight and offerings into future courses of action unique to the dental pulp and potentially can make a giant step forward toward the therapeutic and biologic.

Do your patients come through referrals? We see about two-thirds of our patients from referrals by general dentists and about one-third from word-of-mouth referrals, specifically from patients we have treated. Social media and millennials have really changed the game when considering the importance of patient education and expectations. Patients have become more selfeducated, self-aware, and self-conscious about what treatment we are performing,

Each operatory incorporates landscape views and all forms of technology possible to make our patients comfortable

even how it should be done. Stated simply, patients want better root canals. Subsequently, I am about to launch a marketing campaign that will target the general public with this message, aligning the interests of top endodontists across the United States. We will be reaching out to align our interests with other endodontists in their respective areas Q1 2019.

How long have you been practicing endodontics, and what systems do you use? I have been practicing endodontics since 2005. Like other endodontists and dentists, I have a tendency to learn about almost every endodontic approach and system on the market. I love to learn what works best in my hands and what doesn’t, and to verify what manufacture claims are, and take the bestin-class products and apply it to the right circumstances. Like my grandpa always said, “If you don’t have time to do it right the first time, when will you have time to do it right the

second time? Always trust, but verify.” I like to look at the anatomy of the tooth and resolve what is the most efficient way to get the job done. I have always practiced A-Z endodontics behind the microscope and have used CBCT ever since it was made available to me. Good information makes for good decisions. I don’t regret incorporating either one of those technologies and would not even think about not using it during a root canal treatment. Then came the GentleWave® Procedure, brought to us by Sonendo®. This has been the most interesting system and the most interesting approach to come my way in a long time. This technology is not based upon advance metallurgy; this technology is based upon advanced fluid dynamics cleaning and shaping root canal complexities as a procedural event. This technology is more closely aligned to my fundamental reasoning in becoming an endodontist and the dreams I was chasing during my residency. The emphasis toward changing the way root canals are performed

The contemporary office design bridges the Utah landscape with the interior through the use of large windows, soft-lit, polished-stone countertops, and a gallery of inspirational artwork Volume 11 Number 4

Endodontic practice 7

PRACTICE PROFILE has really shaken the industry up for good and the good of the profession. It offers us new skills; it provides new possibilities; it can give our patients better outcomes. But the thing I like the most is its emphasis on the therapeutic, the biological, in both the living and nonliving tissues of pulp and the spaces it occupies.

What training you have undertaken? Training never stops; residency, membership in AAE, and the associated gatherings our dental professions offer, not only are mandatory but rewarding. I make conscious attempts to be progressive and forwardthinking. I enjoy following the brightest minds in any discipline; certainly, I don’t just limit myself to endodontics or even dentistry for that matter. I often find my greatest inspirations from past history and from other sciences. Learning how to apply what you find and translate it to dentistry is easier said than done, yet it is so important to keep a thumb on the pulse of breakthroughs in any and all disciplines that may shed light on problems we face. I have also found a treasure trove of insight following the tech sector, particularly Silicon Slopes trends here in Utah.

Who has inspired you? Like any and all of us, we all have a list of individuals who have helped shape who we are today. As I state earlier mine begins with Dr. Richard Walton at University of Iowa, followed by Drs. Eric Rivera, Bill Johnson, James Jostes, Lynne Baldassari-Cruz, Anne Williamson, Bruce Justman, and Ali Fakhry, a periodontist who has done more to inspire me toward greatness in dental surgery more than words can describe. But I cannot fail to mention Dr. Galen Schneider, PhD, cell biology and Prosthodontics and Dr. Stephen Hunter, PhD, MD, who both believe enough in me to support my research and interests in stem cells. My list is plentiful and impressionable. They are great men and women who have directly inspired me and shaped me and continue to inspire me. I am indeed grateful to each and every one of them and the University of Iowa. I will always be open to newer and better ways to look at treatment methodologies because of these great people. I also admire many other historical dental figures and scientists in disciplines outside of dentistry. I’m always looking for other translational applications in their stories and hope to do more with my profession by way of innovation and development than 8 Endodontic practice

Greater Endodontics™ — a dental practice with curb appeal

traditional mainstream practices of patient care in endodontic practice.

What is the most satisfying aspect of your practice? People are not excited to visit the endodontist, yet it’s extremely satisfying to see people shocked at how easy and even pleasant a treatment can be. Usually, patients have had a previously negative experience, a failed attempt, or have anticipated the root canal treatment as being extremely painful. I suppose, in a way, we are lucky to be in a discipline where patients are buckled up for a painful operation. You can take that opportunity, turn it on its head, and make the experience a positive one. We call it “creating wows.” My favorite compliment is when people sincerely thank you or give you a hug. Another compliment I love is when someone says “that was way easier than the crown prep.”

Professionally, what are you most proud of? Professionally, I’m proud of becoming an expert, and using my expertise in many diverse ways. Outside the walls of treating patients, I’ve been involved in software and app developments as well as product development and education. Currently, I have built my fourth endodontic practice and have incorporated a novel approach to train and educate my dental colleagues, with live learning and giving live mentoring experiences. Despite what I have done professionally, my greatest achievements are my five kids.

What do you think is unique about your practice? Sometimes it just easier to see it to believe it. Greater Endodontics™ (in Murray, Utah) is all about what make us great. I believe our surroundings should reflect this. I was on a mission to create an environment that

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The GentleWave® System Microscope CBCT Bioceramics Fifth-generation rotary files 3% saline 70/30 corticocancellous bone graft ParaCore® build-up NOMAD™ 2AS rubber dam clamp

inspires me, my colleagues, and my patients. I aligned myself with others who foresaw its potential. We used the great landscape of Utah and the Wasatch Front to build our practice with iconic views of the mountains. With help from others, we made the hallmark feature around illuminating, soft-lit countertops made from real stone, which we often utilize as the sole light source in the operatory. The result is a soft, comfortable light that puts a patient at ease and promotes an experience with less anxiety. We have used and incorporated all form of technologies possible to make our patients comfortable. This ranges from noise-cancelling headphones to visual experiences. We also have incorporated local artists to create a gallery of inspirational artwork from the diverse landscapes of Utah. My favorite piece was one painted by my mother. We also have built dental learning live and have incorporated it into our operatories. We have a lot going on behind the scenes. We have multiple cameras capturing the ongoings of any given operation, the footage being stored and filed for easy access. Our hybrid software/hardware systems will be available for other doctors to take advantage of in 2019. We have six GentleWave systems that, as of the current date, are the most available anywhere in my state. We are happy to be able to provide the GentleWave procedure to any patient and accommodate their schedule. Volume 11 Number 4

Reid Pullen, DDS

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PRACTICE PROFILE

The wakesurfing dentist glides with ease

The name, Greater Endodontics, continues to push us to be captains of industry in both the endodontic and implant disciplines. If there is a better way to provide healing to a patient, you can bet we will be testing and evaluating.

What has been your biggest challenge? Challenges come to us all when we feel we can’t escape our hardships. Yet that experience can be one of the most refining things in our lives. Without these to reference, it would be much harder to realize what is really important and what is not. My biggest challenges are probably best left unsaid, but know the depth to which they have shaped me. Consequently, I am passionate toward cancer research and charity events aimed at helping those who are suffering.

What would you have been if you didn’t become a dentist? I would have been a medical doctor most likely, specializing in a research or in an engineering capacity. I have a love for biology, physiology, and discovery of applications that can make a difference in a patient’s life. I love looking into the past to gain insight into solving problems of the future. I’m more interested in what can be done than what is being done. It is hard to be satisfied with this mindset, but it certainly gives you a drive to push the boundaries. The only alternative career I may have chosen would have been in the tech sector, likely in software development.

What is the future of endodontics and dentistry? The future of endodontics to me, falls within the realm of reversible pulpitis in teeth. 10 Endodontic practice

Work hard — play hard: Dr. Facer’s catch of the day

with regard to microbe hunting and preventive care yet to be discovered and has been so ever since Dr. Mayo made that statement to dental thought leaders in Chicago in 1913. Dr. Facer enjoys his family time

To chase down a microbe with a bur and file only to remove the pulp and kill bacteria is like playing horseshoes and hand grenades — where close enough is good enough. Rather than allowing bacteria to cause irreversible damage or necrosis to the pulp, the future of endodontics lies in the eradication of the causative insults, namely bacteria, while maintaining pulp vitality and pulp tissue health. This would necessitate and incorporate novel diagnosis, early microbial detection, and novel strategies to eradicate bacteria from the pulp tissue. The future would have to continue working backwards from pulp involvement toward the structural involvements of the enamel and dentin. Until we have novel ways of controlling bacteria, dental caries will also continue to be treated in a fashion similar to root canal treatments, through gross destruction of tooth structures by a bur. But why is that so? If a bacteria can get inside the tooth, why can’t we? Why can’t we hunt bacteria down through the same pathways upon which they encroached the tooth and pulp? The future should turn preventive maintenance inside out. Current preventive efforts include fluoride, floss, and a toothbrush, yet these should never be considered good enough. In fact, the great Dr. Charles Horace Mayo, founder of the Mayo Clinic made this profound statement: “The next great step in medical progress in the line of preventive medicine should be made by dentists. The question is will they do it?” There is, without a doubt, a new frontier

What are your tips for maintaining a successful specialty practice? Good communication! We have countless bosses. Every referring doctor is a boss, and every patient is a boss. Our staff and partners are bosses. Everyone has an agenda and a point of view, as do I. The key is to always over-communicate and set your colleagues up for success. Understand where you fit into the treatment plan and be part of the diagnostic loop. Help the patient understand the value of complete care and think bigger than yourself.

What advice would you give to budding endodontists? 1. Come work with our team. 2. Look at teeth as people and not people as teeth. 3. Treat needs and not benefits; you never know what innovations the future holds.

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

Spending time with my kids Training and exercise Pilates and yoga Running, biking, snowboarding, boating, and wakesurfing Traveling and exploring wondrous destinations Humanitarian service missions Fly-fishing and losing myself to river time Reading biographies, non-fiction, and history books Attending Utah Jazz games EP Volume 11 Number 4

Donâ&#x20AC;&#x2122;t Miss the Endodontic Practice US Digital Only Supplement Be sure to sign up for an Endodontic Practice US digital subscription or our e-newsletter to gain access to our special edition Digital Only Supplement which features an informative Q&A on CBCT with Dr. Emily Tyler, a technology article by Dr.

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John West, and a CE article on successful treatment of a maxillary central incisor diagnosed with infected dens invaginatus and associated apical periodontitis.

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CLINICAL

Introduction to vital pulp cryotherapy Drs. James Bahcall, Bradford Johnson, Qian Xie, Mark Baker, and Steve Weeks explore a new application for pulpal tissue Introduction The term cryotherapy is derived from the Greek word cryos, meaning “cold.”1 The goal of cryotherapy is to remove the heat by lowering the temperature of the tissue.2 Through the application of cold to human tissue, it has been shown to decrease nerve conduction velocity, reduce hemorrhage and edema, along with inflammation.3 Cryotherapy has also been shown to reduce the number of leukocytes adhering to the endothelial wall of capillaries, thus having fewer of these types of cells migrating to the affected tissue, reducing endothelial dysfunction and providing a further reduction in inflammation.4 The use of cryotherapy has been common practice in medicine and other fields of dentistry.5 In medicine, cryotherapy, sometimes referred to as cryosurgery, is a procedure used to destroy tissue of both benign and malignant lesions by the freezing and re-thawing process. Examples of the uses of cryotherapy in medicine are the treatment (removal) of various types of skin lesions, the treatment of dysplastic (precancerous) tissue of the uterine cervix, and the treatment of some prostate cancers. Cryotherapy can also refer to the use of ice or cold packs applied to a part of the body after an injury to reduce inflammation.6 Within the field of endodontics, although there are no previous vital pulp cryotherapy

James Bahcall, DMD, MS, is a Clinical Associate Professor, Department of Endodontics, University of Illinois at Chicago College of Dentistry. He can be reached at jbahcall@uic.edu. Bradford Johnson, DDS, MHPE, is a Professor, Department of Endodontics, University of Illinois at Chicago College of Dentistry. Qian Xie, DDS, PHD, is an Assistant Professor, Department of Endodontics, University of Illinois at Chicago College of Dentistry. Mark Baker, DDS, is a Clinical Associate Professor, Department of Endodontics, University of Illinois at Chicago College of Dentistry. Steve Weeks, DDS, is a Clinical Assistant Professor, Department of Endodontics, University of Illinois at Chicago College of Dentistry. Disclosures: Drs. Bahcall, Johnson, Xie, Baker, and Weeks have no financial interest in any of the products mentioned in this article and received no compensation for writing this article.

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cases reported in the endodontic literature, there has been recent reports of the success in using cold saline (2°C) irrigation in a root canal prior to canal obturation in order to reduce postoperative pain.7,8 The application of cryotherapy on pulpal tissue that has been exposed or indirectly exposed due to carious lesion excavation in conjunction with ethylenediaminetetraacetic acid (EDTA) irrigation, bioceramics, and a permanent restorative material (composite or amalgam) has shown to reduce post-operative pain after vital pulp cryoFigure 1: Preoperative bitewing radiograph of tooth No. 30 with arrow demarcating radiolucent appearance of decay therapy. This article will discuss clinical case selection and treatment technique when performing In regard to the pretreatment periradicthis new vital pulp cryotherapy procedure. ular diagnosis, normal or symptomatic apical Vital pulp cryotherapy technique periodontitis (percussion and/or palpationPrior to initiating vital pulp cryotherapy, a sensitive without radiographic evidence from pretreatment pulpal and periradicular diaga periapical radiograph and/or a CBCT, of a nosis needs to be obtained. The pretreatperiradicular radiolucency [lesion]) are not ment pulpal and periradicular diagnosis of a contraindicated for vital pulp cryotherapy tooth begins by first reviewing the patient’s treatment. Asymptomatic apical periodonmedical and dental history. This also should titis or chronic/acute apical abscesses are include taking a patient’s blood pressure, contraindicated for vital pulp cryotherapy pulse, and temperature (if indicated). Next, treatment because these are radiographic current preoperative radiographs: periapical, and clinical signs the pulpal tissue could be either necrotic or partially necrotic. bitewing, and cone beam computed tomography (CBCT) (as indicated) should be taken Lastly, prior to performing vital pulp cryo(Figure 1). therapy, the treatment tooth must be deemed After obtaining current radiographs, restorable with a permanent restoration of a composite or amalgam. Restoring the tooth objective pulpal and periradicular clinical posttreatment with a fabricated crown or a sensibility testing should be performed. temporary filling and then placing a permaPatients that present with a pretreatment nent filling at a subsequent appointment is pulpal diagnosis of a normal pulp, reversible pulpitis, or irreversible pulpitis, along with the contraindicated. The reason a permanent possibility of a direct or indirect pulp exporestoration is placed is twofold: First, it is sure as a result from caries excavation, are important to maintain a proper seal in order good candidates for a pulp-capping or a to prevent penetration related to salivary partial pulpectomy procedure.9,10 Pulps that (microbial) leakage from causing the reoccurhave a pretreatment diagnosis of necrosis or rence of pulpal inflammation. Second, if the upon pulp chamber access are observed to tooth remains asymptomatic posttreatment, have partial pulpal necrosis; vital pulp cryoyou do not risk the chance of causing further therapy treatment is contraindicated. inflammation of the pulpal and periradicular Volume 11 Number 4

Volume 11 Number 4

CLINICAL

tissue by performing a crown preparation or replacing the temporary filling with a permanent filling at a subsequent appointment.11 In addition, there is always the chance of a patient developing or maintaining the pretreatment pulpal diagnosis of symptomatic irreversible pulpitis after the vital pulp cryotherapy procedure and hence requiring a full pulpectomy. If this does occur, having a permanent restoration (composite or amalgam) in place will allow for a better conventional endodontic treatment access seal as compared to a temporary filling. After obtaining the proper pretreatment pulpal and periradicular diagnosis for vital pulp cryotherapy, along with the tooth’s restorability meeting the above criterion for a permanent restoration, the clinician can proceed with providing local anesthesia. After local anesthesia is given, and objective testing (no response to cold and/or electric pulp testing) is performed on the treatment tooth to confirm pulpal anesthesia,12 a rubber dam is placed, and the carious lesion is removed with a high-speed bur. If the pulp is exposed or indirectly exposed as a result of removing all the caries, vital pulp cryotherapy is indicated. Shaved sterile water ice (0°C) is then placed over the direct or the indirect exposure of the pulpal tissue along with the entire tooth (Figure 2). The shaved sterile water ice is produced by the freezing of sterile water and then placing it in an ice shaving device. After approximately 1 minute, the ice melts and should be removed with a highspeed suction. Following the removal of the melted sterile ice, the exposed or indirect exposed pulp should be irrigated with 17% EDTA solution for 1 minute.13,14 Although it has been stated in the literature to use sodium hypochlorite to control pulpal hemorrhage,15 it is important to note that sodium hypochlorite should not be applied to a direct or indirect pulp exposure when performing a vital pulp cryotherapy procedure. The reason for this is that sodium hypochlorite can kill the dental pulpal stem cells.14 EDTA solution should be used in place of sodium hypochlorite because it has been shown to release bioactive growth factors from the dentin, thus stimulating matrix secretion, odontoblast differentiation, and tertiary dentin formation. The conditioning of the dentin with EDTA will also promote the adhesion, migration, and differentiation of dental pulp stem cells.13,14,16 In a report by Finnegan, et al.,17 EDTA was shown to have antimicrobial effects on gramnegative and gram-positive bacteria, yeasts,

Figure 2: Packing shaved sterile water ice (0°C) over a direct pulp exposure on tooth No.19

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Endodontic practice 13

CLINICAL and fungi. EDTA also has been shown to induce antioxidants and anti-inflammatory activities.18 A recent study by Ricucci, et al.,19 found that a clinical pulpal diagnosis of a normal pulp or reversible pulpitis had a 96.6% histological match to the actual pulp tissue in a tooth, whereas in pulp diagnosis of symptomatic irreversible pulpitis, it only had an 84.4% histological correlation to the actual pulp tissue. This study noted that bacterial invasion of the pulp tissue was common in teeth diagnosed with irreversible pulpitis, but was absent in teeth diagnosed with a normal pulp or reversible pulpitis. This research also demonstrated that when a carious lesion encroaches the pulp that is diagnosed as normal or reversible pulpitis, that only the coronal portion of the pulpal tissue immediately adjacent to the caries showed signs of inflammation and not the entire pulp tissue as previously thought.19 Therefore, the clinician can treat the carious exposed or indirect pulp tissue with a pulp cap procedure and does not need to perform a partial or full pulpectomy. It is important to note that pulpal bleeding can be a clinical marker for the extent of the pulpal inflammation.20 In pulps that have a pretreatment diagnosis of normal or reversible pulpitis, the hemorrhaging tends to be stagnated and easily controlled with the application of ice. In clinical cases that have a pretreatment pulpal diagnosis of symptomatic irreversible pulpitis and, clinically, the caries has entered the pulp chamber on a treatment tooth, the hemorrhaging tends to be greater due to an increase in pulpal inflammation. According to the Ricucci, et al.,19 they found that unlike a clinical pulpal diagnosis of normal or reversible pulpitis, pulps with a pretreatment symptomatic irreversible pulpitis diagnosis, the coronal portion under the decay can demonstrate necrosis, bacterial infection, and increased signs of inflammation. Therefore, if the bleeding is profuse, the clinician needs to perform a partial pulpectomy to remove the inflamed pulp tissue immediately under the carious dentinal exposure. This can be accomplished with a spoon excavator in order to remove the pulpal tissue while minimizing the tissue trauma that can occur with the use of a high-speed bur. After the partial pulpectomy is performed, the shaved sterile water ice should be placed over the direct pulp exposure until the bleeding is controlled. If the pulp continues to bleed, it means one of two things: First, the practitioner needs to remove more coronal 14 Endodontic practice

Figure 3: Placement of a bioceramic material (EndoSequence BC RRM, Brassler USA, Savannah, Georgia) over a carious pulp exposure

pulpal tissue because the inflammation of the pulp has spread more apically; or second, the sterile water ice needs to be placed for a longer period of time for hemostasis to occur due to the advancement of the inflammation of the pulpal tissue. The clinician can also use epinephrine-soaked cotton pellets to assist in the pulpal hemostasis. If upon access of a tooth having a pretreatment pulpal diagnosis of symptomatic irreversible pulpitis, the bleeding is stagnated, the pulpal diagnosis is considered clinically reversible pulpitis, and the pulp should be treated the same as if the pretreatment diagnosis is normal or reversible. This correlates with the Ricucci, et al., study19 that reported there is a 15.6% chance a tooth with a pretreatment pulpal diagnosis of symptomatic irreversible pulpitis is clinically a reversible pulpitis. After the exposed or indirect exposed pulp has been treated with shaved sterile ice and EDTA, it is then covered with a bioceramic material: EndoSequence® BC RRM (Root Repair Material) (Brassler USA,

Savannah, Georgia) or Biodentine® (BD; Septodont, Saint-Maurdes-Fossés, France) (Figure 3). In a study by Miller, et al.,21 they reported that EndoSequence BC Root Repair Material-Putty (ES; Brasseler, Savannah, Georgia) and Biodentine (BD; Septodont, Saint-Maurdes-Fossés, France) are a better coronal barrier material for vital pulp therapy due to their excellent biocompatibility with stem cells and significantly greater odontoblastic potential than MTA (mineral trioxide aggregate). They state a possible reason for this is that MTA has a high calcium ion release and sustained high pH. Bioceramics (BC) or calcium silicatebased materials are biocompatible, nontoxic, and non-shrinking and are usually stable within a biological environment. Further advantages of these BC materials are their ability to form calcium hydroxide and hydroxyapatite.22 After performing a BC pulp cap or partial pulpectomy, a light-cured glass ionomer material (Vitrebond™, 3M ESPE, Saint Paul, Minnesota) or non-light-cured glass Volume 11 Number 4

Summary A new vital pulp cryotherapy technique that incorporates the use of cryotherapy, EDTA, bioceramics, and a composite or amalgam permanent restoration on an exposed or indirect exposed pulp tissue was demonstrated in this article. After performing a vital pulp cryotherapy procedure, the patient should be placed on 2-week recall to evaluate postoperative pain. If the patient presents within the first 2 weeks or any time after the 2-week period in which a vital pulp cryotherapy treatment has been performed with either no change in preoperative pain, the development of postoperative pain, or the pulp has become necrotic, the treatment tooth should be re-evaluated for conventional endodontic treatment. Further clinical studies need to be conducted to observe the longterm prognosis of a pulp after undergoing vital pulp cryotherapy.

Acknowledgments The authors would like to thank Drs. Doris Basali, Vikash Hullyar, and Gail Tischke, second-year endodontic residents at the University of Illinois at Chicago College of Dentistry, for the clinical treatment and documentation of vital pulp cryotherapy procedures. EP Volume 11 Number 4

CLINICAL

ionomer material (Ketac™, 3M ESPE, Saint Paul, Minnesota) should be placed directly over the BC pulp cap or partial pulpectomy.23 After this step, a permanent restoration (a composite or amalgam) is placed. A final periapical and bitewing radiograph is then taken after the permanent restoration is in place and the rubber dam has been removed (Figure 4). The patient should then be placed on 2-week recall. In a study by Linu, et al.,24 they reported that all vital pulp therapy failure occurred in the first 2 weeks after treatment. They also noted that the teeth that remained asymptomatic at the 2-week failure point remained asymptomatic, vital, and functional over the follow-up period of 12 to 18 months. Early clinical failures (within 2-weeks) are multifactorial but certainly can be related to an improper pretreatment pulpal diagnosis.23 If the patient presents within the first 2 weeks or any time after the 2-week period in which a vital pulp cryotherapy treatment has been performed with a symptomatic irreversible pulpitis, which has either not resolved or arose as a result of treatment, a necrotic pulp, asymptomatic apical periodontitis, or chronic/acute apical abscesses, it is recommended to re-evaluate the tooth for conventional endodontic treatment.

Figure 4: Postoperative periapical radiograph of tooth No.19 after a permanent restoration is placed and the rubber dam has been removed

REFERENCES 1. Vera J, Ochoa-Rivera J, Vazquez-Carcaño M, Romero M, Arias A, Sleiman P. Effect of intracanal cryotherapy on reducing root surface temperature. J Endod. 2015;41(11):1884-1887. 2. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury? J Athl Train. 2004;39(3): 278-279. 3. Modabber A, Rana M, Ghassemi A, Gerressen M, Gellrich NC, Hölzle F, Rana M. Three-dimensional evaluation of postoperative swelling in treatment of zygomatic bone fractures using two different cooling therapy methods: a randomized, observer-blind, prospective study. Trials. 2013;14:238.

13. Casagrande L, Demarco FF, Zhang Z, Araujo FB, Shi S, Nör JE. Dentin-derived BMP-2 and odontoblast differentiation. J Dent Res. 2010;89(6): 603-608. 14. Galler KM, Buchalla W, Hiller KA, Federlin M, Eidt A, Schiefersteiner M, Schmalz G. Influence of root canal disinfectants on growth factor release from dentin. J Endod. 2015;41(3):363-368. 15. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives—permanent teeth. J Endod. 2008; Jul; 34(7 Suppl):S25-28. 16. Cao Y, Song M, Kim E, Shon W, Chugal N, Bogen G, Lin L, Kim RH, Park NH, Kang MK. Pulp-dentin regeneration: current state and future prospects. J Dent Res. 2015;94(11):1544-1551.

4. Laureano Filho JR, de Oliveira e Silva ED, Batista CI, Gouveia FM. The influence of cryotherapy on reduction of swelling, pain and trismus after third-molar extraction: a preliminary study. J Am dent Assoc. 2005;136(6): 774-778.

17. Finnegan S, Percival S. EDTA: An antimicrobial and antibiofilm agent for use in wound care. Adv in Wound Care. 2015;4(7):415-421.

5. Gundogdu EC, Arslan H. Effects of various cryotherapy applications on postoperative pain in molar teeth with symptomatic apical periodontitis: a preliminary randomized prospective clinical trial. J Endod. 2018;44(3):349-354.

18. González-Cuevas J, Navarro-Partida J, Marquez-Aguirre AL, Bueno-Topete MR, Beas-Zarate C, ArmendárizBorunda J. Ethylenediaminetetraacetic acid induces antioxidant and anti-inflammatory activities in experimental liver fibrosis. Redox Rep. 2011;16(2): 62-70.

6. Shiel W, Helm S. Cryotherapy in pain management. MedicineNet. https://www.medicinenet.com/cryotherapy/ article.htm. Accessed November 11, 2018. 7. Vera J, Ochoa J, Romero M, Vazquez-Carcaño M, RamosGregorio CO, Aguilar RR, Cruz A, Sleiman P, Arias A. Intracanal cryotherapy reduces postoperative pain in teeth with symptomatic apical periodontitis: a randomized multicenter clinical trial. J Endod. 2018;44(1):4-8. 8. Keskin C, Özdemir Ö, Uzun İ, Güler B. Effect of intracanal cryotherapy on pain after single-visit root canal treatment. Aust Endod J. 2017;43(2):83-88. 9. Taha NA, Ahmad MB, Ghanim A. Assessment of Mineral Trioxide Aggregate pulpotomy in mature permanent teeth with carious exposures. Int Endod J. 2017; 50(2):117-125. 10. Taha NA, Khazali MA. Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial. J Endod. 2017; 43(9):1417-1421. 11. Kim S. Neurovascular interaction in the dental pulp in health and inflammation. J Endod. 1990;16(2):48-53. 12. Bahcall J, Xie Q. Clinically Enhancing Local Anesthesia Techniques For Endodontic Treatment. Compend Contin Educ Dent. 2017;38(2):80-84.

19. Ricucci D, Loghin S, Siqueira JF Jr. Correlation between clinical and histological diagnoses. J Endod. 2014;40(12):1932-1939. 20. Matsuo T, Nakanishi T, Shimizu H, Ebisu S. A clinical study of direct pulp capping applied to carious-exposed pulps. J Endod. 1996;22(10):551-556. 21. Miller AA, Takimoto K, Wealleans J, Diogenes A. Effect of 3 bioceramic materials on stem cells of the apical papilla proliferation and differentiation using a dentin disk model. J Endod. 2018;44(4):599-603. 22. Brizuela C, Ormeño A, Cabrera C, Cabezas R, Silva CI, Ramírez V, Mercade M. Direct pulp capping with calcium hydroxide, mineral trioxide aggregate, and biodentine in permanent young teeth with caries: a randomized clinical trial. J Endod. 2017;43(11):1776-1780. 23. Wang Z. Bioceramic materials in endodontics. Endodontic Topics 2015;32(1): 3- 30. 24. Linu S, Lekshmi MS, Varunkumar VS, Sam Joseph VG. Treatment outcome following direct pulp capping using bioceramic materials in mature permanent teeth with carious exposure: a pilot retrospective study. J Endod. 2017;43(10):1635-1639.

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ENDODONTIC PERSPECTIVE

Restraint: the lost art of endodontics Dr. John West discusses how to increase the awareness of the value that restraint plays in the mechanics of “Finding, Following, and Finishing”

have a confession. I am a dreamer! And, as such, I have always been obsessed by the power of ideas. It is that inward focus that has helped give me the confidence to share this overdue article about the forgotten endodontic word: Restraint. Simply being aware of it can change how we see and perform in the world of endodontics. My idea is that you will be a measurably better endodontic clinician if you embrace the fundamental component of this article: Restraint as an essential ingredient for Mastering Endodontics. For some, this article may be a hard read because it is not about a scientific endodontic technique, genius breakthrough, or products. For others, it has the capacity to change their experience of endodontics forever and transcend today’s newest technologies. The key operating word is R-E-S-T-R-A-I-N-T. The word restraint has not existed anywhere in the Journal of Endodontics (JOE) over the last 43 years (since the first JOE issue in 1975). A search on PubMed on April 12, 2018, returned zero results for the words restraint and endodontics. In addition, a similar lack of any “restraint” references exist for Dentistry Today (also searched on April 12, 2018), with only one relevant result for the words restraint and root canal.1 Two other clinical vocabulary words will facilitate readers’ lasting impact of this article: Follow and Envelope. First, Follow is the perfect word to describe manually following a curved file down an existing patent canal or

John West, DDS, MSD, received his dental degree from the University of Washington, where he is an affiliate professor. He is the founder and director of the Center for Endodontics in Tacoma, Washington, and a clinical instructor at Boston University, where he earned his MSD and was honored with the Distinguished Alumni Award. Dr. West and his two sons, Drs. Jason and Jordan West, are in private endodontic practice in Tacoma, Washington. He can be reached via email at johnwest@centerforendodontics.com. Disclosure: Dr. West is co-inventor of ProTaper® Gold, WaveOne® Gold, and Calamus Technologies.

16 Endodontic practice

patent part of a canal versus directing the file using manual motions, such as Watch Wind. In classic Watch Wind, the clinician attempts to direct the path of the file. “Following” instead allows the canal to direct the file, as if a child is sliding down a curved slide at the park. The slide’s walls direct, not the child! Second, “Envelope” is a unique manual motion where the canal shaping occurs on the outstroke. A curved file is simultaneously withdrawn in a clockwise motion, which then randomly sculpts the canal prep using the shaft of the file. The envelope is the only dental motion that is achieved moving away from the patient versus going toward them.

What is Restraint? Google defines Restraint as “a measure or condition that keeps someone or something under control or within limits” and “unemotional, dispassionate, or moderate behavior; self-control.” Restraint comes from the 15th-century, Old French word restreinte, meaning “a sense of reserve.” What do we know about the word “restraint,” and how can it make us better at doing endodontics? During the human species’ 300 million years of evolution, the act of restraint was not a useful word for Mother Nature’s survival of the fittest.2 Restraint could get you killed, and that would be the end of your genetic flow. However, 300 million years later, fight or flight often prevents masterful endodontics. Restraint is not a question of willpower. It is biology. Restraint is best measured in the endodontic clinician by something that is familiar to us: tactile sense. How do we know we are practicing at the highest tactile sense possible? How do we know where our “Restraint Threshold” is? For some insight into your own perception of “restraint,” I invite you to take the following self-awareness test.

Restraint: a self-awareness test Take a pen or pencil and hold it vertically between your thumb and index finger. Hold it as lightly as you can without dropping it. Now hold with 5% less squeeze. If it did

not fall from your fingers yet, hold with 10% less squeeze. Most dentists do not drop the pen at 5% less squeeze and some go up to 20% or 25% less squeeze before the pen or pencil falls out of their fingers. Some dentists hold on even longer. To start with, for most of you in the test, restraint was somewhere between your light grip of pen holding and your feather grip, where you ultimately lost control and dropped it. What’s the endodontic point? Every one of us has the capacity to be more delicate, gentle, and nimble in “Following” a canal to its terminus. The benefit of increased restraint for the dentist and the patient is to have more precision, be less invasive (only removing enough and the correct dentin for the radicular prep), and flawless (fewer mistakes such as blocks and ledges), and to make the procedure more enjoyable since Glidepath mechanics approach effortlessness. The skill of increasing restraint is available to all of us, and, once the awareness is raised, then “Finding,” “Following,” and “Finishing” endodontic treatment and thinking is automatically changed to something like, “The more restraint I own, the more delicate I am, and the easier my endodontics becomes. I am actually feeling guilty that my endo is going so easily.”3

Relationship between Restraint and “Finding” all canals Applying the benefit of restraint in “Finding” all canals (i.e., not being in a hurry, learning local knowledge, slowing down), all contribute to making endodontic accessing successful. Restraint allows us to savor the singularity of each access. Every access cavity is the only endodontic “cave” of its kind. Of the 7-plus billion humans on this planet, you are the one privileged to design this one-of-a-kind anatomical search. A Restraint in “Finding” the canal orifice is encouraged by accurate bite-wings, 3D CBCT, toothatlas.com, and cementoenamel junction (CEJ), landmarks for optimum root canal system access. Do not simply start drilling and expect to find the chamber. Intentionally design the access cavity, and take Volume 11 Number 4

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Figures 1A-1L: The relationship between the manual skills of “Follow” and “Envelope” past the first canal restrictive dentin. A. The selected first manual file. B. The gradual curve is placed with cotton pliers in the apical half of the manual file shaft. C. A slightly more abrupt, second curve, placed with cotton pliers in an apical fourth of the file shaft and at a different plane than in Figure 1B. D. Multiple curves randomize the angle of file access and incidence into the canal, allowing the natural virgin dentin walls to guide the file effortlessly in the apical direction. E.The multiple-curved file, manually approaching the canal orifice. F. The balls of the fingers are stroking the file and “Following” apically. Note the very little finger contact with the end of file handle so that the canal directs file advancement, not the clinician. G. An animation of an apically advancing file. H. Fingers slide down the shaft of the file with light pressure, “Following” the canal. I. Stopping short of maximum resistance. J. Gently squeeze the file handle. K. Rotate the file handle clockwise while simultaneously withdrawing the file. The “Envelope” motion results in the file shaft carving restrictive dentin, if present. L. An animation of clockwise envelope-of-motion dentin carving

your time to get it right! In a nutshell, treat these tissues with restraint. Remember the pen or pencil dropping. In the test, most of us had more restraint to give or, better yet, give away. Many dentists still miss the mark with access cavities. No plan is made, and a patient’s tooth is accessed with hope being their guide. So slow down, plan, and display a little restraint. The rewards are big: You “Find” the canal(s) — the important retentive ferrule is not affected or destroyed — and you do not perforate! All these results are produced by slowing down and practicing restraint. Most dentists show too little restraint, go too fast, and sabotage their ability to “Find” canals from the very beginning. Volume 11 Number 4

Relationship between Restraint and “Following” canals No aspect of endodontic mechanical skills benefits more from restraint than “Following” canals to their termini and maintaining or confirming the produced, smooth Glidepath tunnel. Regardless of disruptive technologies to improve the classic Clean, Shape, and Pack trifecta, the manual ability to “Find” and “Follow” canals emerges as Restraint: The Lost Art of Endodontics. The GentleWave System® (Sonendo®) promises disinfection, ProTaper® Gold™ (Dentsply Sirona Endodontics) promises minimally invasive precision shaping, and EndoSequence® BC Sealer (Brasseler USA®) promises a monoblock-type 3D sealer obturation, but

unless the dentist can “Follow” the canal’s orifi to their termini, none of these clean, shape, and pack innovations have any real value. Restraint, however, transforms and transcends today’s emerging technologies. So how do we use restraint to help us win the endodontic game? During canal “Following,” Restraint is a way of Doing and a way of Thinking. Let’s examine and learn from each. Restraint and Doing First, know the canal is there. You do not have to find it. Slipping and sliding down the canal is easy if we do it right. Start with a 21.0-mm .06 file or a .08 file with a double curved shaft (Figures 1A to 1D). Multiple Endodontic practice 17

ENDODONTIC PERSPECTIVE

ENDODONTIC PERSPECTIVE subtle curves enable the file to “Follow” randomly down Nature’s canal by careening off curving walls (Figures 1E to 1H). Irrigate with Chlor-XTRA™ (Vista Dental Products); this solution contains a surfactant to help penetrate and more rapidly dissolve any remaining pulpal tissue. Once the tip of the file is directed into the canal orifice, stop directing it. “Follow” the existing path by apically stroking and sliding down the handle of the file with index finger and thumb until it is short of maximum resistance. A light glove coating of baby powder facilitates the light-pressure finger sliding. The reason to stop attempting to “Follow” down the canal is because of possible danger deeper. The actual resistance is due to four possibilities: (1) dentin mud or collagen, (2) the access

Restraint is intentional by deciding before and literally at every second during the “Following” skill to relax — to be gentle, patient, thoughtful, present, and nimble — and to have positive expectations. and incidence of file curvature and the canal itself do not mimic each other, (3) the tip of the file is wider than the width of the canal, or (4) the shaft of the file is starting to bind in its body somewhere short of the tip.4 Situations 1 to 3 require file removal and a change in curvature or size. However, if the shaft is preventing navigating farther down the canal,

then the “Envelope of Motion” will solve the situation and allow the file to “Follow” farther toward the chosen length (Figures 1I to 1L). A good word to describe the envelope of motion, the ultimate Lost Art of Endodontics, is the word carve. “Following” is distinguished from the Watch Wind manual technique that most

Figures 2A-2L: Continue “Follow” and “Envelope” manual motions past remaining regions of restrictive dentin until the desired length is reached. A and B. Animation close-ups of Figure 1L. C. The “Follow” motion continued short of the next maximum dentin resistance. D. The “Envelope” outstroke clockwise motion removes the next restrictive dentin. E. Use the “Follow” motion apically until short of the next maximum dentin resistance. F. The “Envelope” outstroke clockwise motion removes the next restrictive dentin. G. Use the “Follow” motion apically until short of the next maximum dentin resistance. H. The “Envelope” outstroke clockwise motion removes the next restrictive dentin. I. Use the “Follow” motion apically until short of the next maximum dentin resistance. J. The “Envelope” outstroke clockwise motion removes the next restrictive dentin. K. Use the “Follow” motion apically to the desired length. L. An animation of the Before Glidepath, with areas of restrictive dentin present, and of the resulting smooth-walled “Follow and Envelope” After Glidepath, ready for safe mechanical shaping 18 Endodontic practice

Volume 11 Number 4

Restraint and Way of Thinking Restraint is intentional by deciding before and literally at every second during the “Following” skill to relax — to be gentle, patient, thoughtful, present, and nimble — and to have positive expectations. Remember, we have to overcome 300 million years of evolution insisting on fight or flight for the survival of the fittest. We are genetically programmed to move into flight or fight whenever something resists us, is in our way, or prevents us from getting what we want. Don’t feel bad that you pushed the file and blocked or ledged. We are built that way. All you have to do is be aware of restraint, and your canal “Following” success will follow. We want to reach the Volume 11 Number 4

end of the canal. The only problem is that fighting the canal back in by “trying” to go deeper becomes counterproductive and eventually results in a dentin mud/collagen block or a canal wall ledge that is difficult or impossible to bypass. If nothing else, think: What do I want to do with this file, how will I know I have achieved my goal, and what do I need to do differently if I don’t? Restraint is usually the missing component. Some clinicians just start filing for a while and hope something good will happen. It rarely does!

Closing comments The purpose of this article is to increase the awareness of the value that restraint plays in the endodontic mechanics of “Finding, Following, and Finishing.” The more mature I have become in my own personal practice of endodontics, the more I experience that restraint allows me to prepare a successful Glidepath in extremely narrow and apically curved canals. The transforming magic of restraint is available to all clinicians. Now it’s your turn! EP

REFERENCES 1. West JD. Manual versus mechanical endodontic glidepath. Dent Today. 2011 Jan;30(1):136, 138, 140. 2. Harari YN. Sapiens: A Brief History of Humankind. New York: Harper; 2015. 3. West JD. The Three Fs of Predictable Endodontics: “Finding, Following, and Finishing.” Dent Today. 2016;35(3):90, 92-96. 4. West JD. The endodontic Glidepath: “Secret to rotary safety.” Dent Today. 2010;29(9):86, 88, 90-93.

This article was previously published in Dentistry Today.

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ENDODONTIC PERSPECTIVE

dental students have learned. In Watch Wind, the clinician is directing. This can cause the failure of the file to easily proceed apically. For example, if the clinician Watch Winds to the right, and the canal actually goes to the left, the beginning of a shelf can begin. While the manual motion of Balanced Force is useful in expanding an existing smooth-walled Glidepath, it can be a dangerous way to slide down a canal tunnel with walls that are not pristinely smooth.4 The walls of the canal coronal and short of the point of maximum resistance are shaved by simultaneously withdrawing and clockwise carving with the “Following” file. This skill is called the “Envelope of Motion.” After one or several Envelopes, the same file is once again “Followed” as deep into the canal as it can easily “Follow” until it is again short of maximum resistance, and then the “Envelope of Motion” is repeated one or several times. This sequence continues until the desired length is achieved (Figures 2A to 2K). If, after any given Envelope, the file does not “Follow” deeper, do not push or “try” to go deeper because restrictive dentin is not the situation any longer. The situation is, as noted above, either dentin mud/collagen, the file curve is wrong or lost, or the file is too large at the tip. In order to solve these three situations, remove the file and place the new curve and also perhaps choose a smaller diameter file. If no force has been used, it is unlikely dentin mud or collagen is piled up ahead of the file. Slide the now differently curved file down the canal, and repeat the above sequence until length is achieved. Then proceed as desired toward the Finishing Glidepath (Figure 2L).

CASE STUDY

ndodontists are privy to the intricate beauty that is the internal anatomy of a tooth. However, after performing hundreds of routine root canals, we may forget the surprises that can be hidden within the enamel and dentin. Such is the circumstance for one once-in-a-lifetime case that started out as “just another root canal” but ultimately reminded me of the complexities of the human body.

Patient history A woman presented for an emergency appointment. She complained of continuous pain in the posterior upper right quadrant that was severe enough to keep her awake at night. She also experienced lingering pain, lasting more than 30 seconds, after hot or cold foods.

Figure 1: Preoperative 2D panoramic radiograph (CS 8100 3D)

Exam and diagnosis Suspecting decay, a panoramic radiograph was captured using the CS 8100 3D system (Carestream Dental) (Figure 1).

Figure 2: Operating microscope intraoral photographs of the partially debrided tooth No. 3 with the finding of mid-mesial canal José Francisco Gaviño Orduña, DDS, earned his degree in dentistry from the University of Barcelona in 2005 and is currently studying for his PhD. He also serves as an associate professor of conservative dentistry at the University of Barcelona. Dr. Gaviño’s practice focuses on endodontics, conservative dentistry, and surgery.

Figure 3: 3D Rendering of isolated root canal anatomy 20 Endodontic practice

Volume 11 Number 4

CASE STUDY

A periapical lesion was present on tooth No. 30 (FDI No. 46), and nonsurgical retreatment was offered to the patient. However, since the patient was asymptomatic, she declined treatment. Routine diagnostic tests (percussion, apical palpation, mobility, and periodontal probing) were performed and recorded for all teeth. Pulp vitality tests using thermal stimulation (cold and hot) were also performed in the upper right quadrant (area of discomfort). The patient experienced continuous pain identifying the symptomatic tooth as tooth No. 3 (FDI No. 16), describing the pain as spontaneous and lingering after the stimulus was removed. Final diagnosis was determined to be irreversible pulpitis of tooth No. 3 (FDI No. 16).

Treatment The patient then agreed to undergo root canal therapy for tooth No. 3 during the initial visit. An access cavity on tooth No. 3 was prepared with the aid of a microscope. Afterwards, using ultrasonic tips, complete root canal access was established, and five root canal orifices were discovered: three in the mesiobuccal (Figure 2), the distobuccal, and the palatal canals. A 5 cm x 5 cm limited field of view CBCT scan was also acquired with the CS 8100 3D to gain a three-dimensional view of the tooth’s unique anatomy (Figure 3). The oblique view of the scan confirmed the confluence of canals and allowed for better instrumentation: The mesiobuccal and mesiomiddle canals aligned perfectly with each other (Figure 4). In dealing with this unusual situation, it was decided that the best course of action would be to treat each canal independently before they converged (Figure 5). Following RTC, the patient returned for a third appointment for a direct overlay. The patient is now asymptomatic and may choose to return at a later date to treat the lesion found on tooth No. 30 (FDI No. 46).

Discussion The chances of a maxillary first molar having a fifth canal is about 2%.1 However, to encounter not only a fifth canal but to see four of those canals in a perfectly straight line was a once-in-a-lifetime experience. Even as an associate professor at the University of Barcelona, who teaches students about such rare clinical situations, to encounter it in my practice was amazing. Fortunately, the use of cone beam computed tomography allowed me to examine the unusual anatomy of the tooth in minute detail and adjust the treatment plan Volume 11 Number 4

Figure 4: Oblique axial and sagittal views of tooth No.3 from CS 3D Imaging software

accordingly. The use of CBCT in endodontics in Spain is growing each year; currently, it’s more popular among oral surgeons, but there’s no doubt of its benefits to the endodontic field. The fact that treatment during the first appointment had to be stopped to take the scan highlights CBCT’s important role in treatment planning. It provides insight that microscopes and ultrasonic tips can’t the day of treatment. However, taking a CBCT scan allowed me to reevaluate treatment and move forward with confidence of greater success; since being treated in the spring of 2018, the patient has not returned complaining of pain. This case could have gone much differently without the use of CBCT. However, much like this patient’s mesiobuccal and mesiomiddle canals, sometimes, everything lines up just perfectly for successful treatment and pain-free patients. EP

REFERENCE 1. Anand P, Mahalaxmi S. Maxillary first molar with five canals. SRM J Res Dent Sci. 2016;7(1):45-47.

Figure 5: 2D periapical radiograph of postoperative RCT on tooth No. 3 Endodontic practice 21

CONTINUING EDUCATION

Clinical application of WaveOne® Gold reciprocating instruments: part 1 Drs. Peet van der Vyver and Martin Vorster discuss the clinical applications and guidelines of WaveOne® Gold reciprocating instruments

he WaveOne® nickel-titanium file system was introduced to the dental market in 2011. It was a pre-packaged, pre-sterilized, single-use system that was designed to shape root canal systems to a continuously tapering morphology (Webber, et al., 2011; van der Vyver, 2011). Recently, WaveOne® Gold, a new generation of reciprocating files, was launched. According to Webber (2015), these single-use shaping files offer the clinician more simplicity, safety, improved cutting efficiency, and mechanical properties compared to the previous generation of reciprocating instruments. In this article, the authors will discuss the design features of the instruments and focus on the WaveOne Gold primary file. This primary file can be used in approximately 80%-85% of cases as a single file technique for root canal preparation. In part 2 of this series, we will discuss the management of larger diameter root canals systems, more challenging and curved root canal systems, and provide the reader with examples on when to use more than one WaveOne Gold file for canal preparation.

Why reciprocation? When conventional nickel-titanium instruments are rotated in root canals, they are subjected to structural fatigue that, if continued, will eventually lead to fracture (Sotokawa, 1988; Pruett, Clement, Carnes, 1997). Torsion and fatigue through flexure are the two main reasons for this failure (Serene, Adams, Saxena, 1995). Torsional fractures occur when the tip or any other part of the rotating instrument binds to the root canal walls, while the rest of the file keeps turning. Fracture due to flexural fatigue (bending stress) occurs when an instrument that has Peet van der Vyver, ChD, MSc Odont, Dip Odont (Pret), is a professor at the Department of Odontology, School of Dentistry, University of Pretoria. He is in private practice limited to endodontics in Sandton, South Africa. (Visit www. studio4endocom for more details.) Martin Vorster, BChD (Pret), PG Dip Dent (Endo)(Pret), MSc (Odont) (Pret), is a lecturer at the Department of Odontology, School of Dentistry, University of Pretoria, Pretoria, South Africa.

22 Endodontic practice

Educational aims and objectives

This clinical article aims to present the clinical applications of WaveOne® Gold reciprocating instruments.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 29 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the design features of WaveOne Gold reciprocating instruments, particularly the primary file, for use in root canal preparation.

•

Realize the benefits of reciprocating motion.

•

Realize some characteristics of M-Wire technology.

•

See clinical guidelines for the use of WaveOne Gold instruments.

•

See a clinical protocol for canal preparation with the primary WaveOne Gold.

Figure 1: WaveOne Gold files may appear slightly curved when they are removed from a curved root canal because the metal demonstrates less memory compared to conventional nickel-titanium or M-Wire

already been weakened by metal fatigue is placed under further stress. The instrument does not bind to the root canal walls but rotates freely until fracture of the instrument occurs at the point of maximum flexure (Gabel, et al., 1999; Sattapan, Palamara, Messer, 2000). The amount of bending stress imposed on an instrument depends on the anatomy of the root canal and is obviously greater in curved root canals (Pruett, Clement, Carnes, 1997). The first study experimenting with an alternating movement was that of Yared in 2008, which used the ProTaper® F2 instrument (Dentsply Sirona) in a reciprocating movement (Yared, 2008). The alternating changes in direction of rotation would, in theory, reduce the number of cycles of the instrument and, therefore, reduce the cyclic fatigue on the instrument compared with that imposed when instruments are used in a consistent rotating motion (You, et al., 2010; Varela-Patiño, et al., 2010). The study showed great promise for the reduction of the number of instruments required in the cleaning and shaping sequence; in

minimizing possible contamination; and alleviating operator anxiety of the possibility of instrument failure (Yared, 2008). Apart from these benefits, preparation time was shown to be faster than when using the same instrument in full rotation (You, et al., 2010). These findings were confirmed by Bürklein and Schäfer in 2012 when they compared Reciproc® (VDW) and WaveOne (Dentsply Sirona) functioning in reciprocating motion to Mtwo® (VDW) and ProTaper in conventional use (Bürklein, Schäfer, 2012).

Reciprocation motion Instead of a rotary motion, the files work in a reverse “balanced force” cutting motion (Sotokawa, 1988) and are driven by a preprogrammed motor (X-Smart™ Plus motor fitted with 6:1 reducing handpiece) (Dentsply Sirona) or the new X-Smart™ IQ (Dentsply Sirona) endodontic motor fitted with a 8:1 reducing handpiece (paired to an iPad® mini) that is capable of turning the files in a back and forth “reciprocating” motion. The counterclockwise (CCW) movement of 150 degrees is capable of advancing the Volume 11 Number 4

Figure 3: WaveOne Gold primary file (25/07)

Figure 4: WaveOne Gold medium file (35/06)

Figure 5: WaveOne Gold large file (45/05)

Figure 6: The handles of the WaveOne Gold files (bottom) are 2 mm shorter compared to previous generation (top)

instrument apically as the dentin on the root canal wall is engaged and cut. This movement is followed by a 30-degree clockwise (CW) movement, which ensures that the instrument disengages before excessive torsional stress is transferred onto the metal alloy and before the instrument can bind (taper lock) into the root canal. Three sequential reciprocating cycles will complete one whole reverse CCW rotation, and the repeated cutting and release process allows the instrument to advance apically into the root canal (Webber et al, 2011). This unequal CW/CCW reciprocating motion of the WaveOne Gold system has the following advantages over continuous rotation systems: • Binding of the instruments into the root canal dentin walls is less frequent, reducing torsional stress (Varela-Patiño, et al., 2008). • The reduction of the number of cycles within the root canal during preparation results in less flexural stress on the instrument (Sattapan, Palamara, Messer, 2000). • Improved safety, as the CCW disengaging angle is designed to be less than the elastic limit of the instrument (Ruddle, 2016). • There is decreased risk of instrument fracture (Yared, 2008; Varela-Patiño, et al., 2008). • It allows the file to easily progress toward working length without using potentially dangerous inward pressure (Yared, 2008; Ruddle, 2016). • It enhances the augering of cutting debris out of the canal during canal preparation (Ruddle, 2016; De-Deus, et al., 2010).

process, claimed to increase flexibility and resistance to cyclic fatigue (Gambarini, et al., 2008; Shen, et al., 2013). WaveOne Gold instruments are manufactured using a post-manufacturing thermal process whereby a new phase-transition point between martensite and austenite is identified to produce a file with superelastic nickeltitanium metal properties. This process gives the file a gold finish with improved mechanical characteristics. The WaveOne Gold primary file (Dentsply Sirona) is 50% more resistant to cyclic fatigue, 80% more flexible, and 23% more efficient than the conventional WaveOne primary instrument (Ruddle, 2016; Webber, 2015). Due to the superelastic properties of the new gold wire, the file may appear slightly curved when it is removed from a curved root canal because the metal demonstrates less memory compared to conventional nickeltitanium or M-Wire (Figure 1). The file can either be straightened out, or if it is placed back into a root canal, it will follow the natural shape of that canal (Webber, 2015). Another advantage of this reduced memory of the file is that in cases with difficult straight-line access, it is possible to slightly precurve the file, to allow easy placement into the canal orifices. Conventional WaveOne instruments were characterized by different cross-sectional designs over the entire length of the working part of the instruments. In the tip region, the cross section presented radial lands, while in the middle part and near the shaft, the crosssectional diameter changed from a modified triangular/convex cross section with radial lands to a neutral rake angle with a triangular/ convex cross section (Bürklein, et al., 2012). WaveOne Gold files are characterized with a parallelogram (with two 85-degree cutting edges) off-centered, cross section (Webber, 2015). According to Ruddle, this design limits the engagement between the file and the dentin to only one or two contact points at any given cross section. This will

Metallurgy and design features The conventional WaveOne system was manufactured from M-Wire technology. M-Wire is prepared by a special thermal Volume 11 Number 4

Figure 7: Postoperative radiograph of a root canal treatment on a maxillary left first molar where the root canal preparation was done with a single WaveOne Gold primary file (Dentsply Sirona). Irrigation solutions were activated in the shaped canals using an air scaler (NSK) and EDDY (VDW) irrigation device. Note the obturation of the apical bifurcation in the palatal root canal system demonstrating effective irrigation exchange achieved by the 25/07 tapered shape of the WaveOne Gold primary file

subsequently reduce taper lock and the screw-effect, improve safety and cutting efficiency, and provide more space around the instrument to remove debris coronally during canal preparation (Ruddle, 2016). The newly designed files are also manufactured with an ogival, roundly tapered, and semi-active guiding tip to ensure that the file progresses safely along canals with a secured and confirmed reproducible glide path (Webber, 2015; Ruddle, 2016). The WaveOne Gold single-file reciprocating system is available in four different file tip sizes in lengths of 21 mm, 25 mm, and 31 mm: 1. WaveOne Gold small file (yellow ring) (Figure 2) — tip of the file is size ISO Endodontic practice 23

CONTINUING EDUCATION

Figure 2: WaveOne Gold small file (20/07)

CONTINUING EDUCATION 20, and the first 3 mm of the file (D1D3) has a continuous taper of 7%. 2. WaveOne Gold primary file (red ring) (Figure 3) — tip of the file is size ISO 25, and the first 3 mm of the file (D1D3) has a continuous taper of 7%. 3. WaveOne Gold medium file (green ring) (Figure 4) — tip of the file is ISO 35, and the first 3 mm of the file (D1-D3) has a continuous taper of 6%. 4. WaveOne Gold large file (white ring) (Figure 5) — tip of the file is ISO 45, and the first 3 mm of the file (D1-D3) has a continuous taper of 5%. From D4-D16, each file demonstrates a progressively decreasing percentage tapered design to ensure more flexibility and to preserve more dentin in the body of the prepared root canal to ensure more conservative root canal preparations (Ruddle, 2016; Webber, 2015). The WaveOne Gold files also have shortened 11-mm handles (Figure 6) that improve straight-line access into the posterior region of the mouth. It is color-coded (according to ISO size) with an expanding ABS ring after autoclaving to promote the philosophy of single use (Webber, 2015). All of the previously mentioned product features produce a file system with improved mechanical and clinical benefits to ensure predictable root canal preparation. In the majority of cases, a single file can be used to complete root canal preparation with adequate resistance form to ensure exchange of irrigation solutions for adequate disinfection prior to root canal obturation in single or multiple root canal systems (Figure 7).

Clinical guidelines for the use of WaveOne Gold instruments 1. Create adequate access It is always important to prepare an adequate access cavity that will ensure straight-line access into each root canal

Figure 8: Preoperative periapical radiograph of a nonvital right maxillary first premolar with decay under a previously placed composite restoration 24 Endodontic practice

system after removal of all the pulp chamber contents. Ultrasonic instruments — e.g., Start-X ultrasonic instruments (Dentsply Sirona) — are very useful instruments to remove any pulp calcification and to refine the access cavity walls to improve straight-line access. However, another characteristic of the new WaveOne Gold instruments are that the metal has less memory compared to conventional nickel-titanium or M-Wire instruments. It is therefore possible to slightly prebend the tip of the file to allow easy insertion into a secured canal orifice that fails to have complete straight-line access or in cases where patients present with a limited amount of mouth opening. 2. Select the correct WaveOne Gold file The following guidelines can be used for WaveOne Gold file selection. a. WaveOne Gold primary file (25/07) (Figure 3) Any canal where a size 08 and 10 K-file has to be negotiated to working length, followed by preparation of a glide path or where a size 15 K-file fits loose in the canal to working length. This will usually include the majority of root canal systems with average length with moderate curvatures in mid-root and apical regions. b. WaveOne Gold medium file (35/06) (Figure 4) Any canal where a size 20 or 25 K-file fits loose in the canal and is not necessary to negotiate and prepare a glide path with smaller instruments. This will usually include larger diameter, relatively straight root canals. This file can also be used after the primary file if more shape is desired, or if it is felt that not enough infected dentin was removed from the canal. c. WaveOne Gold large file (45/05) (Figure 5) Any canal where a size 30 or 35 K-file fits loose in the canal and is not necessary to

Figure 9: Buccal root canal negotiated to patency (arrow) with a size 10 K-file

Figure 10: Periapical radiograph showing the position of the files during length determination — two size 10 K-files in buccal and palatal root canals

negotiate and prepare a glide path with smaller instruments. This will usually include larger diameter, relatively straight root canals. This file can also be used after the medium file if more shape is desired, or if it is felt that not enough infected dentin was removed from the canal. d. WaveOne Gold small file (20/07) (Figure 2) The small WaveOne Gold file is mainly used when the primary 25/07 file does not passively progress apically, or when the operator feels insecure with the primary file, after the canal was negotiated to patency and a glide path prepared. When this small file reaches working length, the clinician may accept the canal preparation or, alternatively, if more shape is required, to further enlarge the canal with the primary 25/07 file. The small file is then considered as a “bridge file” between the small and primary file (Ruddle, 2016). However, in canals with severe apical curvatures, very long root canals or in canals where the glide path preparation was very challenging, the WaveOne Gold small file can be used to start root canal preparation with more safety. When this file reaches working length, the clinician may again accept the canal preparation or, alternatively, if more shape is required, further enlarge the canal with the primary 25/07 file.

Figure 11: Clinical confirmation of reproducible glide path: a super “loose” 10 K-file must able to travel 4 mm-5 mm to and from working length without any obstruction Volume 11 Number 4

CONTINUING EDUCATION

Figure 12: ProGlider instrument (Dentsply Sirona) is used to expand the reproducible micro glide path

Figure 13: (left) WaveOne primary file is inserted into the root canal, and the initial depth of file penetration is recorded by adjusting the rubber stop to a reference point on the cusp tip of the tooth. (middle) The rubber stop is adjusted to a working length of 4 mm-6 mm longer than the initial recorded length. (right) The reciprocating file is then activated and allowed to prepare the root canal until the rubber stop reaches the cusp reference point

Clinical protocol for canal preparation with the primary WaveOne Gold file When we select the primary file for canal preparation, it is generally a canal where a size 08 and 10 K-file has to be negotiated to working length, followed by preparation of a glide path or where a size 15 K-file fits loose in the canal to working length. If we need to negotiate the canal and prepare a glide path, the authors would recommend the following protocol as outlined in the following example. The patient, a 40-year-old female presented with a nonvital right maxillary first premolar with decay under a previously placed composite restoration (Figure 8). With an estimated working length obtained from a preoperative radiograph, a size 08 or 10 K-file is negotiated to patency in the presence of a viscous chelator. After the establishment of patency (Figure 9), a working length is determined (Figure 10), and the canal is ready for the preparation of a reproducible manual glide path (RMG), using manual stainless-steel instruments (van der Vyver, 2011). It is recommended to use size 08 or 10 K-files in a vertical in-andout motion with an amplitude of 1 mm from working length, gradually increasing the amplitude to approximately 4 mm, as the irregularities are removed from the dentin wall (van der Vyver, 2011). A â&#x20AC;&#x153;super looseâ&#x20AC;? size 10 Volume 11 Number 4

Figure 14: WaveOne Gold primary after the first cutting cycle. Note the flutes are filled with cutting debris

Figure 15: Cutting flutes of two WaveOne Gold primary files. The first file show normal cutting flutes compared to the unwound cutting flutes in the apical 3 mm of the second file. Fortunately, this is a very uncommon finding when clinicians prepare a glide path before canal preparation with the WaveOne Gold instruments

K-file is the minimum requirement (BĂźrklein, et al., 2012; van der Vyver, 2011). To confirm that a reproducible glide path is present, a size 10 K-file is taken to full working length. The file is withdrawn 1 mm and should be able to slide back to working length by using only light finger pressure. Thereafter, the file is withdrawn 2 mm and

should be able to go to working length, using the same protocol. When the file can be withdrawn 4 mm-5 mm and slides back to working length, an RMG is confirmed (Figure 11). After the establishment of an RMG, it is recommended to enlarge the glide path further to create a macro glide path. The micro glide path can be expanded by Endodontic practice 25

CONTINUING EDUCATION

Figure 16: (left) Irrigation solution (sodium hypochlorite) is dispensed into the root canal. (middle) A 08 or 10 K-file is taken to full working length, using a watch-wind motion (recapitulation) in order to loosen up cutting debris inside the root canal. (right) Final irrigation step is to flush out dislodged debris

using either the ProGliderÂŽ (Dentsply Sirona) (Figure 12) or WaveOne Gold Glider (Dentsply Sirona). Both are single file glide path instruments. The ProGlider is a rotating instrument with an ISO size 16 tip and 2% taper manufactured from M-Wire. The taper then progressively increases to 8.5% over the 18 mm of active cutting flutes. The WaveOne Gold Glider operates in a reciprocating motion with an ISO size 15 tip and 2% taper manufactured from gold wire. The taper then increases to 6% over the length of the active cutting flutes.

Canal preparation with the primary WaveOne Gold file The authors suggest a controlled and disciplined way to ensure predictably cutting cycles without the risk of overstressing the file, reducing cutting efficiency, and reducing the risk of debris extrusion is to control the length of each cutting cycle. After glide path preparation (of all the canals), insert the primary file into the buccal or palatal root canal and record the initial depth of the file penetration by adjusting the rubber stop to a reference point on the cusp tip of the tooth (Figure 13 left). Remove the instrument from the root canal and record the length. Repeat the same procedure for the other canal and take an average of the measured length between the two canals. Move the rubber stop to a working length of 4 mm6 mm (depending on your level of expertise) longer than the initial recorded length (Figure 13 middle). The primary file in the presence of an irrigation solution (sodium hypochlorite, NaOCl), is allowed to passively advance inwards and to progress down the canal upon activation 26 Endodontic practice

of the reciprocating motor. A brushing motion is only utilized in canals with irregular cross sections or to remove coronal interferences when necessary. The objective with the first cutting cycle will be only to cut with the instrument until the rubber stop reaches the cusp reference point (Figure 13 right), thereby ensuring that the operator knows that it is time to remove the instrument and clean the cutting debris from the flutes (Figure 14). After cleaning of the cutting flutes, it is advisable to inspect the cutting flutes for any visible distortion or unwinding of the flutes (Figure 15) before using the instrument again. After cleaning the flutes of the file, the first cutting cycle can be preformed in the buccal canal using the same protocol. Before the next cutting cycle, it is recommended to also remove any loose and compacted debris from the root canal and that the glide path is still reproducible, and the canal is patent. This is achieved by dispensing an irrigation solution (NaOCl) into the root canal (Figure 16A), followed by inserting a 08 or 10 K-file, using a watchwind motion (recapitulation) in the canal (Figure 16B), followed by a final irrigation step (irrigation-recapitulation-re-irrigation, IRR) (Figure 16C). The objective of recapitulation is to loosen up any compacted debris and move it back into solution before it is flushed out of the canal. The root canal and the instrument are now ready for the next cutting cycle. The rubber stop on the instrument is again adjusted to a further 4 mm-6 mm longer or up to the point of the predetermined working length (Figure 17A). Again, the objective of the second cutting cycle will be to only cut with the instrument until

Figure 17: 17A.The rubber stop is again adjusted to a further 4 mm-6 mm length or up to the point of the predetermined working length. 17B. The file is again activated and allowed to prepare the root canal until the rubber stop reaches the reference point

the rubber stop reaches the cusp reference point. The same protocol is followed after each cutting cycle as outlined previously until predetermined working length of the root canal is reached (Figure 17B). When the primary file tip reaches full working length, the file is withdrawn from the canal and inspected. Some articles recommend that if the apical 2 mm-3 mm of the flutes are filled with cutting debris, it would indicate that shaping in the apical part of the canal is adequate. If the flutes have no Volume 11 Number 4

Case report 1 The patient, a 31-year-old female, presented with a nonvital mandibular left first molar. Figure 22A shows the preoperative periapical radiograph, and Figure 22B the postoperative result after root canal preparation, irrigation, and obturation of the two mesial and one distal root canals, using a single WaveOne Gold 25/07 file. Volume 11 Number 4

Figure 18: A size 25/02 nickel-titanium hand file that fitted snug at working length confirmed the final shape in the buccal canal

Figure 19: Radiographic confirmation of gutta-percha points

Case report 2 The patient, a 52-year-old female, presented with irreversible pulpitis on her maxillary right first premolar. A preoperative periapical radiograph revealed a very deep, previously placed Class II composite restoration (Figure 23A). After access cavity preparation, three root canal systems were detected (two buccal and one palatal). All three root canals were prepared with a WaveOne Gold primary 25/07 file after glide path preparation using stainless steel K-files and a ProGlider. Figure 23B depicts the postoperative result after obturation of the root canals and placement of fiber post and composite core.

Figure 20: EDDY Endo Irrigation Tip (VDW) driven by an airscaler (Soniflex LUX 2000L, KaVo)

Case report 3 The patient, a 51-year-old female, presented with a nonvital maxillary left first molar restored with a porcelain-veneered crown. A preoperative periapical radiograph (Figure 24A) and CBCT scan revealed a conical root configuration. After access cavity preparation, mesiobuccal, distobuccal, and palatal root canals were located, and a glide path preparation was done with stainless steel K-files and a ProGlider. Figure 24B illustrates the postoperative radiograph after the canals were prepared with a single WaveOne Gold primary file and the canals obturated.

Case report 4 The patient, a 51-year-old male, presented with a nonvital mandibular right canine. A preoperative periapical radiograph revealed a large root canal system in the coronal aspect of the tooth before the canal bifurcates

Figure 21: Final radiographic result after root canal obturation

(Figure 25A). A CBCT scan confirmed that there were two separate roots. Also visible on the radiograph is a plate from a previous osteotomy procedure 11 years ago, and at that time, the surgeon damaged the root of the mandibular second premolar. MTA was packed as an obturation material. An access cavity was prepared on the labial aspect of Endodontic practice 27

CONTINUING EDUCATION

evidence of dentinal debris, it is advisable to continue shaping with the WaveOne gold medium and or WaveOne gold large file. Gauging the apical foramen with a corresponding nickel-titanium hand file is another alternative (Ruddle, 2016). For example, if the final canal preparation was done with a primary 25/07 instrument, a size 25/02 nickel-titanium hand file (Dentsply Sirona) is fitted into the prepared root canal. If the tip of the file is snug at length, the final shape is confirmed, and a matching WaveOne Gold primary guttapercha point (Dentsply Sirona), or a size 25 GuttaCore® Obturator (Dentsply Sirona) is used for cone fit or verification radiograph, prior to obturation. If the 25/02 nickeltitanium hand file is loose at length, or if it can be pushed past working length, it means that the apical foramen is larger than 0.25 mm. In these cases, it is recommended to gauge the apical foramen with a size 30/02 nickeltitanium hand file. If this instrument is snug at working length, the shape is confirmed to an ISO size 30. If the size 30/02 file is loose at length, then proceed to the medium WaveOne Gold instrument, or if necessary the large WaveOne Gold instrument using the same protocol as described previously. In this clinical case, the tip of a size 25/02 nickel-titanium hand file fitted snug at working length in the buccal and palatal (Figure 18) canals, and matching WaveOne Gold primary gutta-percha points were placed and verified radiographically (Figure 19). The prepared canals filled with 17% EDTA and the solution activated for 1 minute with the EDDY™ Endo Irrigation Tip (VDW) driven by an airscaler (SONICflex™ LUX 2000L, KaVo) (Figure 20). Thereafter, final disinfection was achieved by activating 3.5% heated sodium hypochlorite for 3 minutes, again activated with the EDDY Endo Irrigation Tip. The canals were dried with paper points and obturated using the gutta-percha points, Pulp Canal Sealer (Kerr) and the Calamus® Dual Obturation Unit (Dentsply Sirona). Figure 21 shows the final result after obturation. The following case reports were all done using a single primary WaveOne Gold file for the root canal preparation to illustrate the simplicity, speed and superior results of the system.

CONTINUING EDUCATION

Figure 22: (left) Preoperative periapical radiograph. (right) Postoperative result after root canal preparation, irrigation, and obturation

Figure 23: (left) Preoperative periapical radiograph. (right) Postoperative result after root canal preparation, irrigation, and obturation Figure 24: (left) Preoperative periapical radiograph. (right) Postoperative radiograph after the canals were prepared with a single WaveOne Gold primary file and the canals obturated

Figure 25: (left) A preoperative periapical radiograph. Note the canal bifurcation in the mid-root area of the canine. Also visible on the radiograph is the resected root of the first premolar as a result of a previous osteotomy. MTA was packed as an obturation material. (middle) Two Primary WaveOne Gold gutta-percha points fitted through the labial access cavity after root canal preparation. (right) Final result after root canal obturation and the access cavity closed with SDR and capped with a final layer of ceram.x® Sphere TEC™ one composite resin

the tooth to provide straight-line access into the two root canal systems. After glide path preparation, the two root canals were prepared with the primary 25/07 WaveOne Gold file. After irrigation, two primary WaveOne Gold gutta-percha points were fitted (Figure 25B) and verified radiographically. Figure 15C shows the final result after root canal obturation and the access cavity closed with SDR® posterior bulk fill flowable base (Dentsply Sirona) and capped with a final layer of ceram.x® Sphere TEC™ one composite resin (Dentsply Sirona).

Case report 5 The patient, a 46-year-old female, presented with a nonvital maxillary left first molar. A preoperative periapical radiograph revealed that the tooth was treated previously with an emergency root canal treatment (Figure 26A). Four root canal systems, a mesiobuccal, a second mesiobuccal, distobuccal, and palatal root canals were located, and glide path preparation was done with stainless steel K-files and a ProGlider instrument. Figure 26B illustrates the postoperative radiograph after the four canals were prepared with a single WaveOne Gold primary file and the canals obturated. The palatal and distobuccal root canals were obturated with WaveOne Gold primary gutta-percha points 28 Endodontic practice

and the two mesiobuccal root canals using two size 25 GuttaCore obturators.

Conclusions 1. The design and metallurgy of the WaveOne Gold instruments provides the operator with improved cutting efficiency, flexibility, and nearly complete elimination of file fracture if the instruments are used single use 2. In approximately 80%-85% of clinical cases, the clinician will need only the single primary WaveOne Gold file to complete canal instrumentation 3. The single file shaping technique with the WaveOne Gold primary file, as illustrated in this article, provide clinicians with three distinct advantages: safety, simplicity, and superior results. EP

REFERENCES 1. Bürklein S, Hinschitza K, Dammaschke T, Schäfer E. Shaping ability and cleaning effectiveness of two singlefile systems in severely curved root canals of extracted teeth: Reciproc and WaveOne versus Mtwo and ProTaper. Int Endod J. 2012;45(5):449-461. 2. Bürklein S, Schäfer E. Apically extruded debris with reciprocating single-file and full-sequence rotary instrumentation systems. J Endod. 2012;38(6):850-852. 3. De-Deus G, Brandão MC, Barino B, et al. Assessment of apically extruded debris produced by the single-file ProTaper F2 technique under reciprocating movement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110(3):390-394. 4. Gabel WP, Hoen M, Steiman HR, Pink FE, Dietz R. Effect of

Figure 26: 26A. Preoperative periapical radiograph revealed that the tooth was treated previously with an emergency root canal treatmen. 26B. Postoperative radiograph after the four canals were prepared with a single WaveOne Gold primary file and canals obturated rotational speed on nickel-titanium file distortion. J Endod. 1999;25(11):752-754. 5. Gambarini G, Grande NM, Plotino G, et al. Fatigue resistance of engine-driven rotary nickel-titanium instruments produced by new manufacturing methods. J Endod. 2008;34(8):1003-1005. 6. Pruett JP, Clement DJ, Carnes DL. Cyclic fatigue testing of nickel-titanium endodontic instruments. J Endod. 1997;23(2):77-85. 7. Ruddle CJ. Single-file shaping technique: achieving a gold medal result. Dent Today. 2016;35(1):98, 100, 102-103. 8. Sattapan B, Palamara JE, Messer HH. Torque during canal instrumentation using rotary nickel-titanium files. J Endod. 2000;26(3):156-160. 9. Serene TP, Adams JD, Saxena A. Nickel-titanium instruments: applications in endodontics. St. Louis, MO: Ishiyaku EuroAmerica; 1995. 10. Shen Y, Zhou HM, Zheng YF, Peng B, Haapasalo M. Current challenges and concepts of the thermomechanical treatment of nickel-titanium instruments. J Endod. 2013;39(2):163-172. 11. Sotokawa T. An analysis of clinical breakage of root canal instruments. J Endod. 1988;14(2):75-82. 12. Van der Vyver PJ. WaveOne instruments: clinical application guidelines. Endodontic Practice. 2011; 45-54. 13. Varela-Patiño P, Ibañez-Párraga A, Rivas-Mundiña B, et al. Alternating versus continuous rotation: a comparative study of the effect on instrument life. J Endod. 2010;36(1):157-159. 14. Varela-Patiño P, Martín-Biedma B, Rodriguez-Nogueira J, et al. Fracture rate of nickel-titanium instruments using continuous versus alternating rotation. Endod Prac Today. 2008;2:193-197. 15. Webber J. Shaping canals with confidence: WaveOne GOLD single-file reciprocating system. International Dentistry. 2015;6(3)6-17. 16. Webber J, Machtou P, Pertot W, et al. The WaveOne singlefile reciprocating system. Roots. 2011;1:28-33. 17. Yared G. Canal preparation using only one Ni-Ti rotary instrument: preliminary observations. Int Endod J. 2008; 41(4):339-344. 18. You SY, Bae KS, Baek SH, et al. Lifespan of one nickeltitanium rotary file with reciprocating motion in curved root canals. J Endod. 2010;36(12):1991-1994.

Volume 11 Number 4

REF: EP V11.4 VAN DER VYVER/VORSTER

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Clinical application of WaveOne® Gold reciprocating instruments: part 1 VAN DER VYVER/VORSTER

1. Torsional fractures occur when _________. a. the tip or any other part of the rotating instrument binds to the root canal walls, while the rest of the file keeps turning b. an instrument that has already been weakened by metal fatigue is placed under further stress. c. the instrument rotates freely until fracture of the instrument occurs at the point of minimum flexure. d. an instrument works in reverse “balanced force” 2.

The amount of bending stress imposed on an instrument depends on the anatomy of the root canal and is obviously greater in _________ root canals. a. straight b. curved c. wide d. ogival

advancing the instrument apically as the dentin on the root canal wall is engaged and cut. a. 30 degrees b. 45 degrees c. 100 degrees d. 150 degrees

that the file progresses safely along canals with a secured and confirmed reproducible glide path. a. ogival b. roundly tapered c. semi-active d. all of the above

5. This movement (counterclockwise) is followed by a __________ clockwise (CW) movement, which ensures that the instrument disengages before excessive torsional stress is transferred onto the metal alloy and before the instrument can bind (taper lock) into the root canal. a. 30-degree b. 45-degree c. 60-degree d. 150-degree

8. The authors suggest a controlled and disciplined way to ensure predictably cutting cycles without the risk of ______ is to control the length of each cutting cycle. a. overstressing the file b. reducing cutting efficiency c. reducing the risk of debris extrusion d. all of the above

3. The (Yared 2008) study showed great promise for _________. a. the reduction of the number of instruments required in the cleaning and shaping sequence b. minimizing possible contamination c. alleviating operator anxiety of the possibility of instrument failure d. all of the above

6. (In reciprocation motion) _________ reciprocating cycles will complete one whole reverse CCW rotation, and the repeated cutting and release process allows the instrument to advance apically into the root canal. a. Two alternating b. Three sequential c. Four sequential d. Four alternating

4. (For reciprocation motion) The counterclockwise (CCW) movement of ___________ is capable of

7. The newly designed files (WaveOne Gold) are also manufactured with a/an ______ guiding tip to ensure

Volume 11 Number 4

9. After cleaning of the cutting flutes, it is advisable to inspect the cutting flutes for _________ before using the instrument again. a. secondary adjustment b. any visible distortion c. unwinding of the flutes d. both b and c 10. The objective of _________ is to loosen up any compacted debris and move it back into solution before it is flushed out of the canal. a. using larger files b. re-inspecting the cutting flutes c. recapitulation d. none of the above

Endodontic practice 29

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Thermafil® versus GuttaCore®: part 1 Drs. Giuseppe Cantatore, Katia Greco, and Lajos Palffi discuss the features, differences, and protocols of use with Thermafil compared to GuttaCore

he carrier-based obturation concept was initially described by Dr. W.B. Johnson in 1978. However, the first carrierbased obturator (Thermafil) with a metal carrier was only commercialized in 1991. First-generation Thermafil had a metal carrier, and the final obturation was characterized by a steel core in the middle of a layer of sealer and gutta percha. This design led to difficulties when post space or pretreatment was needed (Cantatore, Goracci, Maviglia, 1992; Cantatore, Goracci, Maviglia, 1993). As a result of these problems, later versions were redesigned as Thermafil® Plus (Dentsply Sirona) — an obturator with plastic carriers — was introduced (Figure 1). In the last 20 years, carrier-based obturation techniques have become very popular with the introduction of many different types of obturators including ProTaper® Obturators, ProTaper® Next™ Obturators, WaveOne® Gold Obturators, GT Obturators (all Dentsply Sirona) and so on (Figure 2). These obturators differ from the original Thermafil due to the taper and diameter of the carrier that is optimized for the corresponding endodontic instruments. However, when the clinician uses a precise protocol, the use of these “dedicated” obturators is not mandatory since the original Thermafil Plus, with its high flow and good adaptation of its gutta percha, can be used after preparation with any file system. The most recent major design change in carrier-based obturation (2012-2013) has led to cross-linked gutta-percha carriers from Dentsply Sirona (USA) and VDW (Germany) and the introduction of GuttaCore® and

Educational aims and objectives

This clinical article aims to discuss the features, differences, and use of carrier-based obturation techniques Thermafil and GuttaCore.

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: •

Realize some history of carrier-based obturation techniques.

•

Identify some carrier features.

•

Identify some gutta-percha external layer characteristics.

•

Recognize some characteristics of verifiers.

•

Read about sealing ability of these materials.

•

Recognize some protocols of use and suggestions for obtaining better clinical results.

Figure 1: Features of a carrier-based obturator with plastic carrier. Note the measurement rings are located on the carrier at 18, 19, 20, 22, and 24 mm on the carrier and at 27 mm and 29 mm on the handle

GUTTAFUSION respectively. GuttaCore and GUTTAFUSION® are the same product with a few differences in the design of the handle (Figure 3) and manufactured by two different distributors. (Editor’s note: Currently, GUTTAFUSION is not available in the U.S.) In this two-part article, the authors will refer mainly to GuttaCore since it was first to the market and has been the object of a

Professor Giuseppe Cantatore, MD, DDS, graduated in medicine in 1980 at the University of Rome La Sapienza. From 2000 to 2013, he has been a professor of endodontics at the University of Verona, Italy. Since 2014, Professor Cantatore has been professor of endodontic and restorative dentistry at the University Vita-Salute S Raffaele of Milan, Italy. Professor Cantatore has authored a number of articles in national and international dental journals and co-authored various books on endodontics and post-endodontic restorations. He is past president of the European Federation Associations Microdentistry (EFAM), past President of the Italian Association of Dental Microscopy (AIOM), and past president of the Italian Society of Endodontics (SIE). Professor Cantatore lives and works in Rome with a clinical practice limited to endodontics. Katia Greco, DDS, graduated in Dentistry in 1998 at the University of Rome La Sapienza. From 2000 to 2013, she has been visiting professor of endodontics at the University of Catanzaro. Since 2015, Dr. Greco has been visiting professor in the Department of Endodontics at the University Vita-Salute S Raffaele of Milan, Italy. Lajos Palffi, DDS, graduated in Dentistry at the CEU Cardinal Herrera University in Valencia, Spain. Lajos finished his studies in 2017 with a thesis on root canal irrigation. He attended the endodontics departments at the University of Milan, Italy, and at the University of Turin, Italy, as part of the Erasmus program.

30 Endodontic practice

significantly higher number of studies than GUTTAFUSION. Since heated discussions continue to occur between supporters and detractors of the obturators with plastic and cross-linked gutta percha carriers, the authors will compare them according to the available literature and clinical experience. In this article, the following topics will be discussed: 1. Carrier features 2. Gutta-percha external layer characteristics 3. Verifiers 4. Sealing ability 5. Protocols of use and suggestions for obtaining better clinical results The second part of this article will be dedicated to the drawbacks of the carrierbased obturation technique, the possible complications, the protocol for preparation of the dowel space, and retreatments in easy and difficult cases. Volume 11 Number 4

Figure 2: Various types of carrier-based obturators with plastic carrier. They differ from the original Thermafil only for the taper and diameter of the carrier

Thermafil plastic carriers Thermafil plastic carriers (Figure 1) are made of a radiopaque polymer of polysulfone and are available with a tip diameter from 0.20 mm up to 1.40 mm. They show measurement rings located at 18 mm, 19 mm, 20 mm, 22 mm, 24 mm on the carrier, and at 27 mm and 29 mm on the obturator handle. Furthermore, they show a longitudinal groove to facilitate retreatments, creating a space between the plastic core and the canal walls (Cantatore, Johnson, 2009). Plastic carriers are very flexible and can even follow the more severe curvatures without breakage (Figure 4). They are sensitive to heat, thus can be melted using high-speed burs like the Thermacut® Prep burs (Dentsply Sirona), System B™ (Kerr) heated tip and ultrasonic tips. Conversely, however, they are resistant to the cutting action of both hand and rotary instruments and the action of most solvents. The taper of the plastic carrier in Thermafil is approximately 4%. Consequently, a minimum canal taper of 5% is required for an adequate flow of the warm gutta percha. The plastic carrier of Thermafil can be used as a verifier to select an obturator of the correct size. As there is no adhesion between the polymer and the plastic core, the external layer of gutta percha can be “stripped” away to leave a bare plastic carrier. A plastic carrier can then be selected, which binds 1 mm short of the working length, and its Volume 11 Number 4

Figure 4: (1) Endodontic treatment of UL6 with extremely curved canals; (2) root canal negotiation and working-length determination in the MB1 and distobuccal canals, and in the MB2 and palatal canals (3); (4) MB1 and MB2 canals show separated apical foramina; (5) immediate postoperative obturation with Thermafil obturator No. 30; (6) the 6-year follow-up confirmed a healthy periapical status not only for UL6 but also for UL5 and UL7 also filled with Thermafil obturators

Figure 5: (1) Endodontic treatment of UL6; (2) working-length determination. Radiopaque plastic carriers X-ray; (3) the correct plastic carrier should block 1 mm short of the working length; (4) postoperative X-ray. Gutta percha alone filled the apical foramina and lateral ramifications

adaptation is confirmed radiographically (Figure 5). An obturator of the same size as the plastic verifier can then be chosen with the rubber stop set at a working length of -1 mm. The relative resistance of the plastic carrier can be very useful in case of intracanal obstacles

like a broken instrument, which has been first bypassed by manual and/or rotary files (Figure 6). However, these situations do not lend themselves to GuttaCore or a gutta-percha point as they are too fragile to bypass the separated instrument and tend to “snag,” deform, and/ or break (Cantatore, Johnson, 2009). Endodontic practice 31

CONTINUING EDUCATION

Figure 3: GuttaCore and GUTTAFUSION obturators are identical, except for the design of the handle

CONTINUING EDUCATION

Figure 7: Example of a cross-linked molecule. The cross-linking reagents links the polymeric chains into a giant supermolecule through covalent bonds, dramatically modifying their physical properties

Figure 6: (1) Endodontic treatment of LR7 with a broken file inside one of the two mesial canals. The length, position, and low diameter of the root contraindicates the removal of the fragment because of a high risk of root perforation; (2) bypass of the fragment using hand files and then rotary files. The two mesial canals join in the apical third; (3) due to the relative resistance to pressure, it is possible to bypass the fragment also with the plastic carriers and Thermafil Obturators No. 25 (4). Note the minimal invasive approach of this technique (when it is applicable)

Figure 8: Gray (first generation) and pink (second generation) GuttaCore. The first has tungsten as the radiopacifier. Pink has bismuth oxide. The pink color is produced by the colorants. However, the substitution of tungsten with bismuth oxide significantly increased flexibility and resistance of the pink GuttaCore

GuttaCore carriers GuttaCore carriers have measurement rings identical to Thermafil but are available only up to size No. 90. They are made of a thermoset cross-linked gutta percha. A cross-link is an irreversible process that ties all the molecules of a polymer together with covalent bonds into a giant supermolecule (Figure 7) (Jenkins, et al., 1996). Cross-links can be formed by chemical reactions that are initiated by specific chemicals called crosslinking reagents. According to the number of cross-links, the physical property of the materials, like resistance to heat and flexibility, can change dramatically. The resulting material is called thermoset plastic material (Jenkins, et al., 1996; Alhashimi, et al., 2014). GuttaCore obturator cores are made from a cross-linked, thermoset elastomer of gutta percha that cannot be melted and that increases the bond strength between the carrier itself and the external layer of gutta percha (Alhashimi, et al., 2014). Alhashimi, et al. (2014), demonstrated a significantly higher push-out bond strength of the guttapercha coating in GuttaCore compared with Thermafil. Consequently, it is not possible to remove the external coating of gutta percha from the core and to utilize the GuttaCore carriers as a verifier. 32 Endodontic practice

Figure 9: (1) Endodontic treatment of LR8 with severely curved canals affected by a pulpitis due to a severe cervical erosion; (2) working-length determination using ProGliderÂŽ (Dentsply Sirona). Preparation with ProTaper Next (Dentsply Sirona); (3) root canal obturation with GuttaCore No. 20 (mesial canal) and No. 25 (distal canal)

Two types of GuttaCore are available in certain countries with gray (first generation) and pink (second generation) carriers (Figure 8). The composition of the two types of obturators is identical and includes polyisoprene and a tougher rubber called EPDM (ethylene propylene diene monomer). The cross-linking occurs via peroxide and a tri-functional cross-linking agent chosen to improve the physical properties. The remaining physical properties are developed through the addition of silica and fibers. Radiopacity is obtained by adding tungsten in gray GuttaCore and bismuth oxide in pink GuttaCore.

The pink color is produced by the colorants. Clinically, the substitution of tungsten with bismuth oxide increases the resistance to pressure and flexibility of the pink carriers (Figures 9 and 10). The GuttaCore carrier resists high temperature and can be heated in the ThermaPrepÂŽ Oven (Dentsply Sirona) without problems. The best way to sever the GuttaCore handle is to use a sharp spoon excavator at the canal orifice. This method allows precise cuts and leaves the pulp chamber floor relatively clean. It is also possible to bend the obturators to sever the handle as Volume 11 Number 4

Figure 11: (1) Endodontic treatment of LR6; (2) negotiation and working length determination with hand files. Note the lateral exit of the distal canal; (3) metal verifier X-ray obturation with GuttaCore No. 30; (4) note the complex root canal system in the distal root three-dimensionally filled thanks to the high flow of the GuttaCore gutta percha

suggested by the manufacturers, but this technique does not work well in small access cavities, since it can leave a portion of the carrier protruding into the pulp chamber. It is also possible to use long neck, high-speed cutting burs, but they create a lot of debris. Thermacut Prep burs or System B tips do not properly sever the thermoset guttapercha handle of the GuttaCore, so they are contraindicated.

Gutta percha According to the manufacturers, the gutta percha used for the external coating in GuttaCore and Thermafil is exactly the same: alpha phase gutta percha. Indeed, chemically pure gutta percha exists in two distinct, different crystalline forms: alpha and beta. The α phase gutta percha shows an ordered molecular arrangement and is brittle and fragile at room temperature, but becomes adhesive and highly flowable when heated. Furthermore, it is unstable and slightly compressible (Schilder, Goodman, Aldrich, 1985). The β phase gutta percha shows a disordered molecular arrangement, is stable, flexible, and compressible at room temperature, but becomes less adhesive and flowable when heated. The α and β phases are interchangeable depending on the temperature of the material (Schilder, Goodman, Aldrich, 1985). Whereas most commercially available forms are in the beta structure, newer products have adopted the alpha-crystalline structure for compatibility with the thermosoftening of the material during obturation. Volume 11 Number 4

Figure 12: SEM images at 1,000x and 5,000x, demonstrating the penetration of the gutta percha used for both Thermafil and GuttaCore into the dentinal tubules. Samples obtained by fracture using the critical point technique

Indeed, produced in the alpha phase, the gutta percha undergoes less shrinkage during cooling and needs less compaction pressure to compensate for any shrinkage that may occur (Cantatore, Johnson, 2009). It has been advocated (Cantatore, et al., 2004; Cantatore, Lupoli, Menghini, 1993; Cantatore, 1995) that the α phase gutta percha used for Thermafil and GuttaCore undergoes physical treatments able to degrade the long polycarbonate chains freeing low molecular weight fragments that are responsible for the low viscosity of the polymer, as well as for its capacity to penetrate the dentinal tubules and the lateral canals. Without a doubt, the gutta percha used for the carrier-based obturators show a high rate of filling of the lateral canals as demonstrated in an ex vivo study on 445 root canals filled with GT obturators (Ruiz Piñón, et al., 2004). Lateral ramifications were detected in 110 teeth with a total of 129 lateral canals

and a frequency of lateral ramifications/tooth (39.83%) (Ruiz Piñón, et al., 2004) (Figures 10 and 11). Thus, Thermafil and GuttaCore gutta percha can be defined as a modified α phase polymer with excellent flow and sealing ability depending mainly on its low viscosity and ability to penetrate lateral canals and dentinal tubules (Figure 12) (Cantatore, Johnson, 2009).

Thermafil verifiers For the root canal obturation with Thermafil or similar, two types of verifiers can be used: firstly, a plastic verifier, i.e., the obturators stripped of the gutta percha are used to stimulate the clinical condition that will occur when the complete obturator is moved into the root canal. The correct plastic verifiers should bind 1 mm short of the working length, and the position should be confirmed with an X-ray. An obturator of the same size is then chosen with the rubber Endodontic practice 33

CONTINUING EDUCATION

Figure 10: Endodontic treatment of LR7 with severely curved canals. (1) Working length determination; (2) obturation with GuttaCore No. 25 (mesial canals) and No. 30 (distal canal)

CONTINUING EDUCATION placed at the same length (-1 mm working length) and is used for the root canal filling. Keeping the plastic carrier at 1 mm from the working length will avoid the risk of having a rigid material at the apical foramen and reduce overfilling (Cantatore, Johnson, 2009) (Figure 15). Secondly, the metal verifier can be used for both Thermafil or GuttaCore. They are hand nickel-titanium instruments available with the same tip diameter as the obturators. They have a taper of 5% and cutting blades (radial lands like the old ProFiles®). The metal verifiers are used to check the size of the canal and the available space for the carrier and the plasticized gutta percha. They should be inserted to the working length, and their position should be confirmed with an apex locator and X-ray. Normally, the size of the correct metal verifier should correspond to that of the last apical file. Since the metal verifiers have a cutting action, they may be used for small adjustments of the canal shape until they can reach the working length without excessive friction. Finally, since they cut dentin and produce smear layer, their use should be followed with adequate root canal irrigation. After the selection of the metal verifier, a Thermafil or GuttaCore of the same size will be chosen with the rubber stop placed at the working length (-1 mm) for the same reasons explained before (Figure 10) (Cantatore, Johnson, 2009).

Figure 13: (1) Endodontic retreatment of LR6 with a large periapical radiolucency on the mesial root; (2) renegotiation of the two mesial canals that show curvatures with different direction; (3) postoperative radiograph after three-dimensional obturation with Thermafil No. 25 (mesial canals) and vertical condensation of warm gutta percha (distal canal); (4) 3-year follow-up that shows a very good healing of the apical infection

GuttaCore verifiers For the GuttaCore obturators, only the metal verifier can be used as previously described.

Sealing ability of carrier based obturators with plastic carrier The quality of the apical seal obtainable with plastic carrier obturation has been assessed in vitro using many research methods. From a review of the scientific literature (41 articles) published from 1991 to 2012 (Cantatore, Johnson, 2009) on the apical sealing ability of the most popular obturation techniques, it is clearly evident that the apical sealing capabilities of the carrier-based obturators did not differ significantly from that of System B and the vertical condensation of warm gutta-percha technique. Compared with cold lateral condensation, Thermafil gave better results in 17 of 30 studies (Cantatore, Johnson, 2009). The two techniques did not differ significantly in 10 of 30 studies. Lateral condensation gave better results than Thermafil in three of 30 studies (Cantatore, Johnson, 2009). If we consider the in vivo clinical studies published in the past 10 years, using Thermafil and 34 Endodontic practice

Figure 14: (1) Endodontic retreatment of a tooth LL6 with a large periapical radiolucency on the mesial root; (2) removal of the cast post and negotiation of the three canals; (3) 1-year follow-up and working length X-ray of the tooth LL6; (4) 3-year follow up that shows the healing of LL6 and the healthy conditions of LL7. Obturation in both teeth was carried out using GuttaCore obturators No. 25 and No. 30; (5A and 5B) axial view, cone-beam scans taken before the treatment and at the 2-year follow-up; (6A and 6B) coronal view; (7A and 7B) sagittal view

cold lateral condensation in the filling of root canals did not result in significant differences in the clinical treatment outcome (Chu, Lo, Cheung, 2005; Hale, et al., 2012; Demirci, Çalışkan, 2016) (Figure 13).

Sealing ability of GuttaCore obturators Considering the recent introduction of the GuttaCore obturators, the literature is scarce on their sealing ability and success rate. Li, et

al. (2014), examined the quality of obturation in oval-shaped canals obturated by GuttaCore by comparing the incidence of gaps and voids identified from similar canals obturated by cold lateral compaction or warm vertical compaction. Both micro-CT and SEM data indicated that canals obturated with GuttaCore had the lowest incidence of interfacial gaps and voids, although the results were not significantly different from canals obturated by warm vertical compaction. Volume 11 Number 4

Figure 16: Protocol for a correct use of the GuttaCore obturators. (1) Complete shaping with your preferred files; (2) irrigate with sodium hypochlorite and EDTA; (3) choose a metal verifier with the same tip diameter of the master apical file. The verifier should reach the working length without excessive friction against the canal walls; otherwise, it is possible to adjust the canal shape by rotating the verifier within the root canal. The metal verifiers have cutting blades and can be used to optimize the shape of the root canal to that of the GuttaCore; (4) irrigate again to remove debris produced by the metal verifier; (5) dry the root canal; (6) place a small amount of sealer by using three paper points as described in Figure 15; (7) using a scalpel, cut 1 mm of gutta percha from the tip of the obturator (optional and not advised by the manufacturers), then place the rubber stop 1 mm short of the working length, heat the obturator, and slowly insert it within the root canal in 3 to 4 seconds; (8) sever the handle of the obturator using a sharp spoon excavator, and condense the gutta percha at the canal orifice until it sets

In another study, Schafer, et al. (2016), compared GuttaCore and GUTTAFUSION obturation techniques with lateral condensation in terms of the percentage of guttapercha-filled areas (PGFA), sealer-filled areas (PSFA), and voids in straight root canals prepared with different instruments. The study authors concluded that GuttaCore and GUTTAFUSION, in comparison with lateral condensation, produced more homogenous root canal fillings with higher PGFA and a low incidence of voids independent of the instrument used for canal preparation (Schafer, et al., 2016). Finally, Thermafil and GuttaCore were compared in a recent study from Neuhaus, et al. (2016), who assessed filling characteristics (adaptation, homogeneity, sealer percentage, position of the carrier) of warm (Thermafil and GuttaCore) and cold obturation methods (single cone) in curved root canals. The proportion of sealer and of voids per area were significantly greater when roots were obturated with a single cone technique. No significant differences were reported between Thermafil and GuttaCore in curved root canals (Figure 14) (Neuhaus, Shick, Lussi, 2016).

Final considerations • Thermafil and GuttaCore offer good three-dimensional obturation. • Thermafil and GuttaCore require continuous tapered canals. • Thermafil and GuttaCore gave the best results in long and curved canals. • Thermafil and GuttaCore are not indicated in straight and short canals and teeth with open apices. • Thermafil and GuttaCore can cause extrusion of the obturation materials (the risk is slightly higher for GuttaCore). • The risk of extrusion can be minimized following a precise protocol (more on this in the second part of the article). • Thermafil is the best choice in case of intracanal impediments. • GuttaCore is the best choice in case of a post space preparation and in cases of retreatment (more in the second part in Endodontic Practice US). EP

4. Cantatore G, Goracci G, Maviglia P. Sistema Thermafil nelle otturazioni canalari: analisi sperimentale. Dental Cadmos. 1993;4:11-38. 5. Cantatore G, Johnson WB. The Thermafil System. In Castellucci A: Endodontics Vol 2. Milano, Italy: Martina Ed; 2009. 6. Cantatore G, Lupoli G, Menghini A. A SEM analysis of several dental gutta-perchas. Attualità dentale. 1993;26:8-28. 7. Cantatore G, Varela Patiño P, Biedma BM, Ruiz Piñón M. Frequenza e localizzazione dei canali laterali dopo otturazione canalare con GT Obturators: uno studio radiografico in vitro. G It Endo. 2004;18(4):185-191. 8. Chu CH, Lo EC, Cheung GS. Outcome of root canal treatment using Thermafil and cold lateral condensation filling techniques. Int Endod J. 2005;38(3):179-185. 9. Demirci GK, Çalışkan MK. A prospective randomized comparative study of cold lateral condensation versus core/gutta-percha in teeth with periapical lesions. J Endod. 2016;42(2):206-210. 10. Hale R, Gatti R, Glickman GN, Opperman LA. Comparative analysis of carrier-based obturation and lateral compaction: a retrospective clinical outcomes study. Int J Dent. 2012:954675. 11. Jenkins AD, Kratochvíl P, Stepto RFT, Suter UW. Glossary of basic terms in polymer science (IUPAC Recommendations 1996). Pure and Applied Chemistry. 1996;6(12):2287–2311. 12. Johnson W. A new gutta-percha technique. J Endod. 1978;4(6):184-88 13. Li GH, Niu LN, Selem LC, et al. Quality of obturation achieved by an endodontic core-carrier system with crosslinked gutta-percha carrier in single-rooted canals. J Dent. 2014;42(9):1124-1134. 14. Li GH, Niu LN, Selem LC, Eid AA, Bergeron BE, Chen JH, Pashley DH, Tay FR. characteristics of carrier-based techniques vs. single cone technique in curved root canals. Clin Oral Invest. 2016;20(7):1631-1637.

REFERENCES

15. Ruiz Piñón M, Cantatore G, Varela Patiño P, Biedma BM. Frequency and localization of lateral ramifications after root canal obturation with GT obturators [master’s thesis]. Compostela, Spain: University of Santiago; 2004.

1. Alhashimi RA, Foxton R, Romeed S, Deb S. An in vitro assessment of gutta-percha coating of new carrierbased root canal fillings. ScientificWorldJournal. 2014; 2014(239754):1-6.

16. Schafer E, Schrenker C, Zupanc J, Burklein S. Percentage of gutta-percha filled areas in canals obturated with crosslinked gutta-percha core-carrier systems, single-cone and lateral compaction technique. J Endod. 2016;42(2):294-298.

Protocols for use

2. Cantatore G. The sealing capabilities of Thermafil guttapercha. Dental Cadmos. 1995;11:38-47.

The protocols of use are summarized in Figures 15 and 16.

3. Cantatore G, Goracci G, Maviglia P. Thermafil, un nuovo sistema per l’otturazione canalare. Dental Cadmos Dossier. 1992;15:13-48.

17. Schilder H, Goodman A, Aldrich W. The thermomechanical properties of gutta-percha. Part V. Volume changes in bulk gutta-percha as a function of temperature and its relationship to molecular phase transformation. Oral Surg Oral Med Oral Pathol. 1985;59(3):285-296.

Volume 11 Number 4

Endodontic practice 35

CONTINUING EDUCATION

Figure 15: (1) Protocol for the correct use of the obturators with plastic carrier. Complete shaping with your preferred files; (2) irrigate with sodium hypochlorite and EDTA; (3) dry canal with paper point; (4) select the obturator of the correct size by using the plastic verifiers (bared obturators) starting with that with the same tip diameter of the master apical file. The correct verifier should stop 1 mm short of the working length; (5) place a small amount of sealer by using three paper points: introduce a drop of sealer with the first paper point in the canal coronal third; then insert a second paper point (dry) to the working length to distribute the sealer. Finally, remove any excess sealer until only a thin layer of sealer will cover the canal walls; (6) using a scalpel, cut 1 mm of gutta percha from the tip of the obturator; then place the rubber stop 1 mm short of the working length, heat the obturator and, slowly, in 3 to 4 seconds, insert it within the root canal; (7) sever the handle of the obturator using a ThermaPrep bur without spraying water, and condense the gutta percha at the canal orifice until it sets

REF: EP V11.4 CANTATORE, ET AL.

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

ThermafilÂŽ versus GuttaCoreÂŽ: part 1 CANTATORE, ET AL.

1. The carrier-based obturation concept was initially described by _______ in 1978. a. Dr. W.B. Johnson b. Dr. Edgar D. Coolidge c. Dr. Pierre Fauchard d. Dr. Louis Grossman 2. Thermafil plastic carriers are made of a radiopaque polymer of ________ and are available with a tip diameter from 0.20 mm up to 1.40 mm. a. barium sulfite b. bismuth c. polysulfone d. tungsten 3. Furthermore, they (Thermafil plastic carriers) show a longitudinal groove _____, creating a space between the plastic core and the canal walls (Cantatore, Johnson, 2009). a. to prevent retreatments b. to facilitate retreatments c. that creates challenges d. that causes inflexibility 4. The taper of the plastic carrier in Thermafil is approximately ______. a. 1 %

36 Endodontic practice

b. 2 % c. 3% d. 4% 5. A plastic carrier can then be selected, which binds ______ short of the working length, and its adaptation is confirmed radiographically. a. 1 mm b. 2 mm c. 3 mm d. 4 mm 6. An obturator of the same size as the plastic verifier can then be chosen with the rubber stop set at a working length of ______. a. -1 mm b. -2 mm c. -3 mm d. -4 mm 7. GuttaCore carriers have measurement rings identical to Thermafil but are available only up to size ______. a. No. 55 b. No. 60 c. No. 80 d. No. 90

8. A cross-link is a/an __________ process that ties all the molecules of a polymer together with covalent bonds into a giant supermolecule. a. reversible b. irreversible c. non-chemical d. unstable 9. GuttaCore obturator cores are made from a cross-linked, thermoset elastomer of gutta percha that _________. a. can be melted b. cannot be melted c. increases the bond strength between the carrier itself and the external layer of gutta percha d. both b and c 10. Thus, Thermafil and GuttaCore gutta percha can be defined as a modified phase polymer with excellent flow and sealing ability depending mainly on its _________. a. low viscosity b. ability to penetrate lateral canals and dentinal tubules c. high viscosity d. both a and b

Volume 11 Number 4

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PRACTICE MANAGEMENT

Freedom now: learn how to retire in practice

Dr. Albert (Ace) Goerig discusses the “Ace Process”

n our culture, retirement has acquired somewhat of a negative connotation, suggesting old age, “too old to work,” or a reward for working hard for 40 years. I do not buy into this old concept of retirement. By my definition, retirement is a time of many choices, opportunities, and excitement. We can always make more money, but we can never make more time in our life. Why work hard all your life and wait until you’re in your 60s before you have true

freedom and choices in your life? I believe you can begin your retirement when you’re young, using the concept of “retire in practice.” This happens when you become debtfree, which allows you to have unlimited choices in your life. It can begin in your 30s as an owner of an endodontic practice, or even as an associate. I have coached many endodontists who became debt-free within 2 to 3 years, and some became debt-free in their 30s.

38 Endodontic practice

They subsequently brought in an associate, allowing them to work 130 days a year. Now they have the time to spend with their family when they are young and can create real relationships with their children and spouse. They also have more time to travel, teach, learn or enjoy their hobbies, or work on their bucket list. What message are you sending to your children about how to live life? Give them the example of what real retirement (choices) looks like throughout life. Most dentists see vacation and time off as a reward for working hard, but I see vacations as a time of rejuvenation and creativity. It is amazing how creative you can be in developing new ideas to improve your relationships, your life, your practice and how to maximize your productivity when you are sitting on the beach in Maui. Volume 11 Number 4

COACHING PROGRAM OPPORTUNITIES For over 20 years Dr. Ace Goerig and Endo Mastery have helped coach some of the most successful endodontic practices in the country. Through his customized hands-on approach he and the Endo Mastery Team can help you I closely followed Dr. Ace Goerig’s coaching advice and have trimmed my work week to three days and was able to shed more than a million dollars’ worth of debt and heaviness in less than four years. I am completely debt free, growing my retirement and living more fully than ever.

increase your efficiency and profits along with creating a stress free working environment. We customize each plan for your individual practice to make your life goals a reality.

I know that Dr. Goerig’s insight and coaching program can be tailored to each person. – Dr. Brian Hornberger, D.D.S., M.S.

Innovative Practice Management for Today’s Successful Endodontic Team

NEW

Let us help! For more details on our services, resources and solutions call 1-800-482-7563 Visit our website to take advantage of our Free Practice Analysis.

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PRACTICE MANAGEMENT After graduating, most associates work in a corporate, or average, endodontic practice 4 to 5 days a week, with only a few weeks of vacation per year, and they only earn between $150k to $300k per year. In an Endo Mastery-coached practice, an associate usually starts off around $300,000 per year, and he/she learns to become very efficient in a fun, patient-oriented, dramafree environment. Many endodontists come to Endo Mastery asking for help to successfully integrate an associate into their practice. We implement systems to help increase the associate’s efficiency over time, so they can eventually earn $400k to $700k per year, while working 3 or 4 days a week, and while enjoying 8 to 10 vacation weeks off a year. This is how an associate can also “retire in practice.” In 1992, I created a practice model of working about 120 days a year and taking a week off each month. This was made possible by having an associate work with me in my practice. I initially called this the “retire in practice” model, but many of my clients started calling it the “Ace Process.” It begins with a beautiful vision, the right systems, scheduling, a good team, efficient techniques, and marketing. With the increased profitability, most endodontists can

Why work hard all your life and wait until you’re in your 60s before you have true freedom and choices in your life? be completely debt-free within 2 to 3 years, even if saddled with $2 million in debt. Once the practice reaches $1.4 million, you can bring in an associate. This allows you to work 3 days a week, with your associate working 3 or 4 days, thus making sure the office is always open 5 days a week. Most of my associates take home $600,000 to $750,000 per year working 3 to 4 days a week. The average endodontist collects around $750,000 a year and takes home $250,000 to $450,000 a year, working 4 to 5 days a week. The goal with our Endo Mastery clients is to have them reach $1.4 million in collections and find a long-term associate who is not interested in ownership. They must be compatible and have the same treatment philosophy.

Table 1: Retire in/out of practice models Working Practice type

Solo owner works 4-5 days/week (190 to 225 days/year)

40 Endodontic practice

Retire in practice 1

Retire in practice 2

Retire out of practice (remote-controlled practice)

Owner works 3 days/week with 1 associate (130 days per year)

Owner works 2 days/week with multiple associates (90 days per year)

Team managed with multiple associates and non-producing owner (0 days per year)

Earning less than $1.4 million causes a significant reduction in the owner’s income, resulting in inadequate revenue to pay an associate doctor. Many doctors can increase their collections to $1.4 million in 1 year but may require up to 2 to 4 years of coaching. When you work fewer days, you are more refreshed, perform higher quality treatment, and enjoy the practice more. You create an empowered team that runs the practice even when you’re not there, which still remains under your complete control. We also help reprogram negative beliefs, such as needing to work hard for a living or, in some way, having to take a difficult path to earn it. These are just negative imprints and encoding from your family and life history. As you grow into the “Ace Process,” you will understand the secret of happiness and loving life. If you only work 2 or 3 days a week, why completely retire at all? With an incredible, empowered team, the practice runs on its own and provides an ideal patient experience through loyal associateships and motivated team members. The question is, why ever sell your practice? Without needing to work in the practice, you will continue to have a constant source of income, which keeps up with inflation and gives you total freedom and plenty of abundance to share with people in need. Table 1 shows the “retire in and out practice” model. To fully embrace how to develop your “Freedom Now” plan, go to EndoMastery. com and check out Dr. Ace Goerig’s new book, Dr. Ace’s Financial Freedom Blueprint: 7 Secrets of Creating Personal and Financial Freedom for Endodontists. EP Volume 11 Number 4

Endodontic Practice US

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STEP-BY-STEP

MTAFlow™ hydraulic repair cement for direct pulp-capping application Dr. Carlos A. Spironelli Ramos discusses a second-generation MTA with improved mixing/delivering properties

ricalcium silicate hydraulic cement materials such as the well-known mineral trioxide aggregate (MTA) are biocompatible materials with high-sealing ability and have been used for various reparative purposes in dentistry, including root-end ﬁlling, sealing perforations, treating open apices, and direct pulp-capping.1 Primarily composed of tricalcium silicates, MTA cements are radiopaque materials that form a self-setting calcium silicate hydrate mix when manipulated with water.2 The first formulation of MTA (1995) was composed of gray Portland cement with the addition of bismuth oxide powder as a radiopacifier. MTA has been recognized as a bioactive material that is hard tissue conductive, hard tissue inductive, and biocompatible, so the applications of this material have been rapidly expanding in dentistry. Despite such good characteristics, the first generation of MTA repair material presented some drawbacks, including difficult handling properties, a long setting time, and an unfriendly delivery method. The multipurpose use of MTA demanded the development of improved formulations. A shorter setting time and better washout performance were desired, so the clinician could feel confident that the product had set before the procedure was finished and wouldn’t be flushed out by water or blood. Considering the importance of the ideal flowability that a repair material should have to reduce the difficulty of handling and delivering, a high-plasticity MTA cement was developed with the aim of improving these characteristics.

Released in 2015, MTAFlow™ cement (Ultradent Products Inc.; South Jordan, Utah, Figure 1) is a bioactive repair material that represents a second-generation MTA with improved mixing/delivering properties. Keeping the same biological characteristics of the original MTA, this product presents advantages in the plasticity during mixing and versatility in terms of syringe-cannula delivery. The main differences in the presentation of MTAFlow are the particle size of the di- and tricalcium silicate powder and the viscosity of the water-soluble siliconebased gel. The use of antiwashout gel aims to increase viscosity and the resistance of particles to external water solutions while enhancing physical properties such as compressive strength, reduced setting time, and porosity. According to studies,3,4 the water-based gel in conjunction with the small particles facilitates manipulation and insertion into the cavity when compared with first-generation MTA, while showing biocompatibility and the ability to form biomineralizated tissue, representing an alternative to the conventional MTA. Tricalcium silicate cements such as MTAFlow are now considered the materials of choice for vital pulp therapy. Histologic studies have demonstrated dentin-pulp regeneration without pulp inflammation in human teeth.5 The therapeutic use of these materials in direct pulp-capping implies their straight application on the underlying fibroblasts that have been reported to play a significant role in initiating pulp regeneration.6 A clinical direct pulp-capping application of MTAFlow is described in the numbered list.

Figure 1: MTAFlow repair cement

Direct pulp-capping 1. Assess the pulp vitality and pulp inflammatory stage (normal, reversible, or irreversible pulpitis) using an ice test before anesthesia. 2. Complete a cavity preparation outline under rubber dam isolation. 3. Excavate all carious tooth structure using a round bur at low speed or use hand instruments. 4. Gently rinse the exposed pulp with sterile saline solution. 5. Control hemorrhage with pressure on the exposed pulp using a cotton pellet moistened with saline (Figure 2). If the hemorrhage/bleeding is abundant and cannot be controlled, correlate with the initial ice test result. In cases of suspected irreversible pulpitis and uncontrolled bleeding, consider a pulpectomy rather than a conservative procedure. 6. Optionally, apply Consepsis® chlorhexidine 2% antibacterial solution (Figure 3) for 60 seconds. Do not rinse. Gently air-dry.

Carlos A. Spironelli Ramos, DDS, MS, PhD, graduated in dentistry in 1987 in Brazil, then soon after received a scholarship to study in Japan. He finished his residency in endodontics in Brazil in 1990. From 1991 to 1993, he attended the master’s program in endodontics, receiving a Master of Science degree. He then began the PhD program in endodontics, completing it in 1997, the same year he published his first book. From 1995 to 2012, Dr. Ramos worked as a professor of endodontics at the State University of Londrina, where he coordinated the endodontics sector. During this same time, he published three books and wrote more than a dozen chapters for various endodontics books. Dr. Ramos performs many lectures, hands-on workshops, and conferences worldwide each year and has visited over 40 countries. Disclosure: Dr. Ramos is currently the Senior Endodontic Advisor at Ultradent Products in South Jordan, Utah.

Figures 2A-2B: A. Pulp exposure after deep caries excavation. B. Pressure using a cotton pellet moistened with saline 42 Endodontic practice

Volume 11 Number 4

Figure 3: Chlorhexidine 2% antibacterial solution (Consepsis® solution) being applied using a Black Mini® brush tip

Figures 4A-4B: A. Mix two drops of gel with two big end spoons of powder using a metal spatula. B. A creamy mixed MTAFlow

Figures 5A-5B: A. Insert small amounts of the mixed MTAFlow inside the syringe. B. Replace the plunger

12. Apply Ultra-Etch® etchant with the Blue Micro® Tip to all surfaces of tooth preparation for 20 seconds (Figure 8). Rinse thoroughly for 5 seconds. Apply Consepsis with Black Mini Brush Tip to preparation with a scrubbing motion. Lightly dry, leaving preparation slightly damp. 13. Apply a puddle coat of Peak® Universal Bond light-cured adhesive with Inspiral® Brush Tip. Gently agitate for 10 seconds (Figure 9).

Thin/dry 10 seconds using ¼ to ½ air pressure. Light-cure for 10 seconds (20 seconds for lights with output < 600mW/cm2). 14. Proceed with the restoration. EP

REFERENCES 1. Akbari M, Rouhani A, Samiee S, Jafarzadeh H. Effect of dentin bonding agent on the prevention of tooth discoloration produced by mineral trioxide aggregate. Int J Dent. 2012;563203; Epub 2011. 2. Parirokh, M, Torabinejad, M. Mineral trioxide aggregate: a comprehensive literature review—part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27. 3. Guimarães BM, Vivan RR, Piazza B, Alcalde MP, Bramante CM, Duarte MAH. Chemical-physical properties and apatite-forming ability of mineral trioxide aggregate flow. J Endod. 2017;43(10):1692-1696. 4. Bueno CRE, Vasques AMV, Cury MTS, Sivieri-Araújo G, Jacinto RC, Gomes-Filho JE, Cintra LTA, Dezan-Júnior E. Biocompatibility and biomineralization assessment of mineral trioxide aggregate flow. Clin Oral Investig. 2018;Mar 23; ePub ahead of print. 5. Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, Kosierkiewicz A, Kaczmarek W, BuczkowskaRadlińska J. Response of human dental pulp capped with biodentine and mineral trioxide aggregate. J Endod. 2013;39(6):743-747.

Figures 6A-6B: A. Insertion of MTAFlow using a Micro 20 ga Tip on the exposure. B. After approximately 5 minutes, the material surface turns opaque, showing that it is ready to proceed

Figure 7: MTAFlow covered by a layer of Ultra-Blend Plus Volume 11 Number 4

Figure 8: Ultra-Etch etchant 35% phosphoric acid solution in place. Note how the Ultra-Etch stays in place without run off

6. Klos A, Tenner AJ, Johswich KO, Ager RR, Reis ES, Köhl J. The role of the anaphylatoxins in health and disease. Mol Immunol. 2009;46(14):2753-2766.

Figure 9: Peak® Universal Bond light-cured adhesive being applied with Inspiral® Brush Tip Endodontic practice 43

STEP-BY-STEP

7. Using a metal cement spatula, gradually mix the 2 drops of gel into 2 big measuring spoon ends (0.26g) of powder until the chosen consistency is obtained. Thoroughly mix with the spatula to ensure all the powder particles are hydrated. Add more powder or liquid during or right after mixing to achieve the desired consistency (Figure 4). 8. Remove the cap and plunger of the clear Skini syringe. Take small portions of the mixed MTAFlow with the mixing spatula, and insert the cement in the back part of the barrel. Replace the plunger back to the barrel (Figure 5). The mixed MTAFlow inside the syringe capped can be used for up to 15 minutes after mixing. Be sure there is no air inside the syringe 9. Attach the Micro 20 ga Tip securely onto Skini syringe. Gently move the plunger to remove the air inside the syringe. Verify flow of cement prior to applying intraorally 10. Gently insert MTAFlow cement on the pulp exposure without pressure (Figure 6). 11. Approximately 5 minutes after application, dry with a gentle blast of air (using ¼ to ½ air pressure). Note than now MTAFlow has an opaque surface. Place a light-activated liner (Ultra-Blend® Plus liner ) or a flowable composite (PermaFlo® composite) over the MTAFlow (Figure 7).

PRACTICE MANAGEMENT

What do gossip and gum disease have in common? Cynthia Goerig discusses achieving an office environment based on teamwork

entists want to look forward to going to the office. And although they wish they could just perform dentistry and not have to deal with all of the business aspects of running a practice, they realize that a typical day may include glitches that need their attention before the first patient arrives. When team member drama is involved, there may be tension and hushed whispers,

and the doctor may be visited by multiple team members who update him with the latest gossip, suggesting who is to blame and who did something wrong. Many times the practice owner knows he/she needs to address the situation but doesnâ&#x20AC;&#x2122;t, hoping it will go away. Throughout the day, similar distractions pop up, as well as scheduling and patient issues, and by the end of the

Cynthia Goerig, Master Teacher and Executive Coach, has been developing leaders and coaching dental executives for more than 15 years. She is the founder of Legacy Life Consulting and CEO of Endo Mastery. Legacy Life Consulting, Home of Inner Legacy Seminars, was created to bridge the gap between clinical mastery and leadership excellence for dental specialists. Personal Leadership is taught in seminars, executive coaching, and team programs. Legacyâ&#x20AC;&#x2122;s unique method is taught in small groups where doctors uncover patterns that prevent them from effectively leading their practice. For a consultation or program availability, please contact David Stamation, Chief Operating Officer, at 208-946-3894 or email: david@legacylifeconsulting.com

44 Endodontic practice

day, the dentist could feel drained and exhausted, privately wishing he/she could just do dentistry and feel the satisfaction of completing cases. What do gum disease and gossip have in common? It is an infection that can spread without being noticed, and when left to fester, puts the patient or practice at risk and is expensive to treat. Gossip is a very expensive production killer. The negative energy is off-putting to the rest of the staff and the patients, and creates unnecessary frustration and stress for the doctor. Gossip damages relationships, manipulates emotions, creates competition, causes drama in the workplace, and affects the bottom line. In one Volume 11 Number 4

WHERE CLINICAL MASTERS BECOME LEADERSHIP EXPERTS

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– Dr. Gerald Gray

– Dr. Ammon Anderson

Specializing in Endodontic Practices Legacy Life Consulting - Home of Inner Legacy Seminars SEMINARS | EXECUTIVE COACHING | TEAM PROGRAMS

PRACTICE MANAGEMENT

Envision an office environment based on teamwork with everyone working in the best interests of the patient — a team that looks forward to going to work; one with camaraderie, support, and problem solving.

case, an endodontic office was burdened with gossip and a team openly at war with each other. When this was addressed, production increased 36%, slightly better than the doctor’s prediction.

Gossip fosters an environment of blaming A little-known fact: people who gossip are terrified of conflict. When there is a culture of blaming, people do not take responsibility to solve problems. They would rather make someone

else wrong for fear they will get in trouble. People will look to find fault in why something doesn’t work and manipulate your time in convincing you who is to blame.

Now imagine … Envision an office environment based on teamwork with everyone working in the best interests of the patient — a team that looks forward to going to work; one with camaraderie, support, and problem solving. A culture of celebration is pronounced around the success of the day and a team that

Step One Answer the following questions: 1. What is your vision for how people treat each other in the office? 2. What is your vision for how the team will treat patients? 3. Pick three to five words to describe the daily environment or culture of the office. (examples — focused, supportive, fun, friendly, professional, caring, etc.) Step Two Call a team meeting, and schedule it for 30 minutes. Step Three At the meeting ... 1. Share your answers from questions 1-3. Explain why this is important to you, coming from an authentic and vulnerable place, and ask for their help in achieving it. People respond when they feel they are needed to help create the new vision. 2. Create a “no gossip” rule. Explain why there is no gossip, and how it will reinforce the culture you want. 3. In closing the meeting, ask if everyone can get behind this and agree by raising his/her hand. When people physically act, like raising their hand, in front of everyone, they feel like they have a choice and are more likely to follow through.

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rallied to close the office and prepare for the next day. Imagine not having to remind your team members what they are supposed to do that they already knew, and that it was taken care of. They know the objectives and goals, and are invested in the vision — not only sharing it, but also owning it. Envision that the team felt safe at work, knowing that if something goes wrong, the whole team will help.That they don’t criticize or judge each other; instead, they look for the strengths in each other and improve upon their weaknesses. Finally, imagine when leaving the office, the team thanks the doctor and each other, leaving everyone energized, proud of the team and the work they do. In short time, the practice becomes known as one of the best to work for. The good news is that you are a few steps away from this possibility. (See the steps in the red box.) The most effective way for a change in a practice to occur is for the leader to model it. I recommend printing out your three to five words that describe the environment you want to cultivate (from question 3) and review them daily. Inspire your team to make the change, model it, and become the office that everyone wants to work for. EP

Volume 11 Number 4

The Cellerant Best of Class Technology Award Winners for 2018 are: CELLERANT • 3D Systems NextDent 5100 BEST OF CLASS • 3Shape TRIOS® MOVE TECHNOLOGY AWARD • DEXIS and Simplifeye 2018 DEXvoice • AdDent Calset Composite Warmer and CoMax • LED Dental VELscope® Vx Composite Dispenser • MMG ChairFill by MMG • Bien-Air iOptima INT Fusion • Bien-Air TORNADO • Orascoptic EyeZoom™ • DDS Rescue • Orascoptic Spark™ • Dentrix G7 • Shofu EyeSpecial C-III • DEXIS FS Ergo by KaVo • Simplifeye Amplify • Digital Doc LUM G2 • Ultradent Gemini® 810 + • Garrison Dental Solutions 980 Diode Laser Composi-Tight® 3D Fusion™ • WEO Media The selection process relies on an expert panel of dentists recognized as thought leaders and educators. The panel includes Drs. Paul Feuerstein, John Flucke, Marty Jablow, Pamela Maragliano-Muniz, Chris Salierno, and Lou Shuman. Over the course of each year, the panel members seek out and conduct research on potentially practice-changing technologies, with deliberations on nominees and final voting taking place in February. Panelists are precluded from voting in any category where they have consulting relationships. The entire selection process is conducted and managed on a not-for-profit basis. For more information, visit cellerantconsulting.com/bestofclass.

Ultradent pledges $25,000 for Hurricane Florence and Hurricane Michael relief efforts In response to the catastrophic devastation caused by Hurricane Florence and the most recent damage caused by Hurricane Michael, Ultradent Products, Inc., has pledged $25,000 to All Hands and Hearts Smart Response. These funds will be used to aid in the rescue, relief, and rebuilding efforts of those affected by the storms. In addition to these donations, Ultradent is offering to help dentists whose practices have been damaged by these hurricanes. Ultradent has offered any dentist whose office has sustained substantial physical damage by Hurricanes Florence or Michael $500 worth of free consumable product, plus 40% off all consumable products, and 15% off all equipment purchases exceeding the initial $500 on that order. Through this offer, Ultradent hopes to provide some aid in the rebuilding efforts of the dental community. To find out more about Ultradent’s disaster relief efforts, please visit www.ultradent.com/relief.

Volume 11 Number 4

American Association of Endodontists announces award winners The AAE has announced the 2019 recipients of its most prestigious awards to be presented at the Association’s annual meeting in Montréal this April. “We are honored and thrilled to announce the winners of our top awards and to celebrate their achievements in the endodontic specialty,” said AAE President Dr. Patrick E. Taylor. “These five AAE members stood out as leaders within the research, education, and service communities, and we are incredibly proud to be presenting them with these awards.” The award winners will officially be recognized during the AAE Annual Meeting, known as AAE19, April 10-13, 2019. • Louis E. Rossman, DMD, will receive the Edgar D. Coolidge Award, AAE’s highest honor, in recognition of his extraordinary leadership and exemplary dedication to dentistry and endodontics. Dr. Rossman is a clinical professor of endodontics and overseer at the University of Pennsylvania School of Dental Medicine. • Markus Haapasalo, DDS, PhD, is the winner of the Louis I. Grossman Award for cumulative publication of significant research studies that have made an extraordinary contribution to endodontology. • Glenn R. Walters, DDS, BDS, is the winner of the Calvin D. Torneck Part-Time Educator Award, recognizing his contributions to endodontics through his dedication as a parttime educator. • James D. Johnson, DDS, MS, is the winner of the I.B. Bender Lifetime Educator Award, presented to an individual whose contributions to endodontics in the field of education have demonstrated excellence through selfless commitment to fulltime educational pursuits, and whose contributions have instilled in students the desire to pursue excellence in their career. • Avina K. Paranjpe, BDS, MS, PhD, MSD, is the winner of the Edward M. Osetek Award, which is presented to a full-time educator with less than 10 years of teaching experience, who has earned the esteem and respect of students and faculty associates. For more information on the AAE, visit aae.org.

3Shape TRIOS® MOVE wins Innovation of the Year Award in the UK 3Shape TRIOS® MOVE, the latest version of the award-winning 3Shape TRIOS® intraoral scanner, gained the new honor, “Innovation of the Year” at the UK’s FMC Dental Industry Awards. The award was presented by the FMC media company in conjunction with the British Dental Industry Association (BDIA). 3Shape TRIOS MOVE beat out seven other short-listed solutions to win the “Innovation of the Year” award. The FMC panel deemed the 3Shape solution the dental market’s most innovative product for the past 12 months. For information, visit https://www.3shape.com/en/triosmove.

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INDUSTRY NEWS

Cellerant announces the Best of Class Technology Award winners for 2018

SMALL TALK

Transformational leadership Dr. Joel C. Small discusses purposeful leadership for establishing a beneficial working relationship staff

’ve heard it said many times that the best team members are those who place the needs of their organization above their own personal needs. I understand this concept, but I fail to see this happening in the real world. Can we really expect our valued team members to subordinate their own needs to our organization’s needs? I find this to be wishful thinking. In fact, my experience leads me to believe that unfulfilled needs are a major cause of staff turnover. Perhaps a more realistic expectation would be for everyone to get what they need out of a long-term working relationship, thus creating the ultimate win-win scenario. This means the organization benefits from the hard work of loyal team members, and the team members have their needs met as well. Such a scenario does not occur without thoughtful and purposeful leadership.

There are two forms of leadership to consider when creating a win-win scenario between organizational and staff needs 1. Transactional leadership is ineffective. It is based on a quid pro quo between the leader and staff. In a transactional relationship, the leader and team limit their involvement to financial concerns. In other words, the staff works and, therefore, receives a salary. This arrangement works on a superficial level if the staff members’ only need is financial, and the leader expects nothing more than a warm body fulfilling daily obligations. Transactional leadership requires a “command and control” mentality, which demands mandatory compliance with numerous rules and regulations relating to staff behavior.

2. Transformational leadership is very effective. Transformational leaders develop teams that align their own individual needs with the needs of the organization so that fulfilling the needs of one fulfills the needs of the other. There are few rules and regulations because they are not necessary. The relationship between the leader and his/her team is synergistic in that both parties experience higher levels of performance, commitment, and fulfillment based on mutually shared values and purpose. Transformational leadership looks for the win-win scenario and is committed to the concepts of collaboration, inclusiveness, and staff empowerment. The difference between transactional and transformational leadership has been the subject of numerous intellectual discussions over the past 30 years. The consensus opinion is that people will commit to shared purpose and values. They will only comply with rules and regulations. As the concepts of effective leadership have developed over recent years, it has become apparent that the “command-andcontrol” style of leadership, which was once the norm during the industrial revolution, is no longer effective or advisable in today’s egalitarian society. Thus, leaders have had to learn new skills to accommodate the needs and expectations of a new kind of worker. Today’s workforce is looking for more than a paycheck. They reject a transactional workplace and seek opportunities where their need to feel valued, respected, and relevant is met. Numerous studies have shown that leadership matters. Well-led organizations consistently outperform their competition in

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.

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almost every significant metric. Corporate America has compiled an abundance of leadership data and currently spends billions of dollars each year training their best and brightest people to become transformational leaders. These are realities that are just now becoming obvious to the healthcare industry, and even though we lack the abundance of data, there is no reason to assume the benefits of transformational leadership will be any different in our industry. I equate transactional leadership with default leadership, which I believe to be healthcare’s biggest barrier for taking our practices from mediocre to exceptional. The very act of taking a clinical practice from mediocre to exceptional is a process of transformation. Transforming a practice requires transforming people, and like every good leader, we must lead the way. Becoming a transformational leader requires our personal transformation. This is a purposeful endeavor that takes time and unwavering commitment. There is a prevailing thought among leadership opinion leaders that our organizations will never exceed our ability to lead them. There is a direct cause-and-effect relationship between transformational leadership and organizational performance. Better leaders create win-win scenarios that meet the needs of both the staff and the practice. In doing so, they create a team that is committed to the practice’s growth and ultimate success. These practices consistently perform at the highest levels found in the healthcare industry. EP Volume 11 Number 4

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

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.

For more information, call 800.944.6365 or visit carestreamdental.com