Endodontic Practice US Summer 2019 Vol 12 No 2 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Summer 2019 – Vol 12 No 2 • endopracticeus.com

PROMOTING

EXCELLENCE

Practice Profile Mark Anthony Limosani, DMD, MS, FRCD(c)

ENDODONTICS

Efficacy of smear layer removal from root canals using three agitation devices Drs. Sandra Tipanta, Osvaldo Zmener, and Cornelis H. Pameijer

The cortical window — part 2 Drs. Naheed Mohamed, Yosi Nahmias, and Ken Serota

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Estimated provider map as of December 2018. 1 Molina B et al. (2015) J Endod. 41:1701-5 2 Sigurdsson A et al. (2016) J Endod. 42:1040-48 3 Vandrangi P et al. (2015) Oral Health 72-86 © 2019 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo, SAVING TEETH THROUGH SOUND SCIENCE and WE LIVE ENDO are trademarks of Sonendo, Inc. Patented: www.sonendo.com/intellectualproperty. MM-0785 Rev 01

ASSOCIATE EDITORS Julian Webber, BDS, MS, DGDP, FICD Pierre Machtou, DDS, FICD Richard Mounce, DDS Clifford J Ruddle, DDS John West, DDS, MSD EDITORIAL ADVISORS Paul Abbott, BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A. Baumann Dennis G. Brave, DDS David C. Brown, BDS, MDS, MSD L. Stephen Buchanan, DDS, FICD, FACD Gary B. Carr, DDS Arnaldo Castellucci, MD, DDS Gordon J. Christensen, DDS, MSD, PhD B. David Cohen, PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen, MS, DDS, FACD, FICD Simon Cunnington, BDS, LDS RCS, MS Samuel O. Dorn, DDS Josef Dovgan, DDS, MS Tony Druttman, MSc, BSc, BChD Chris Emery, BDS, MSc. MRD, MDGDS Luiz R. Fava, DDS Robert Fleisher, DMD Stephen Frais, BDS, MSc Marcela Fridland, DDS Gerald N. Glickman, DDS, MS Kishor Gulabivala, BDS, MSc, FDS, PhD Anthony E. Hoskinson BDS, MSc Jeffrey W Hutter, DMD, MEd Syngcuk Kim, DDS, PhD Kenneth A. Koch, DMD Peter F. Kurer, LDS, MGDS, RCS Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd, BDS, MSc, FDS RCS, MRD RCS Stephen Manning, BDS, MDSc, FRACDS Joshua Moshonov, DMD Carlos Murgel, CD Yosef Nahmias, DDS, MS Garry Nervo, BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot, DCSD, DEA, PhD David L. Pitts, DDS, MDSD Alison Qualtrough, BChD, MSc, PhD, FDS, MRD RCS John Regan, BDentSc, MSC, DGDP Jeremy Rees, BDS, MScD, FDS RCS, PhD Louis E. Rossman, DMD Stephen F. Schwartz, DDS, MS Ken Serota, DDS, MMSc E Steve Senia, DDS, MS, BS Michael Tagger, DMD, MS Martin Trope, BDS, DMD Peter Velvart, DMD Rick Walton, DMD, MS John Whitworth, BchD, PhD, FDS RCS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts, BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers, BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon © FMC 2019. 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.

Simplify and systemize — keys to a great endodontic practice

aparoscopic cholecystectomy is the eighth-most performed surgery in the United States. Until 1987, these were completed through an open technique. Around 1987, surgeons started to use a laparoscope and trocars to remove the gallbladder. U.S. Surgical and a few key clinicians developed specialized instruments, the most important of which was the Automatic Clip Applier. Over the next 5-7 years, an entire industry was born. Hundreds of products were developed. However, in 2018, the procedure was back to 10-12 basic steps with the Automatic Clip Applier being the only advanced tool used 80% of the time, Hamid Abedi, DDS, MS, MBA while clinical outcomes are at an all-time high. Cataract surgery, among others, followed this exact same trajectory. I tell you this story because it is my belief, we as clinicians, need to think about how we can simplify and create systems that address 80% of the pathology that is diagnosed. In our group, my colleagues and I perform approximately 40,000 RCTs a year, and we are growing to 50,000-60,000 by 2020. With the increased use of cone beam technology and strong oral-systemic health correlations, we firmly believe that pathology diagnosis will only increase. Schools are not going to keep up with that demand, so we as clinicians need to get better results, faster than before. Technology is fantastic, and I love to play with new devices. However, what is going to take the profession to the next level is not a new NiTi file design, or other gadgets designed to do something we already do but add time or massive cost. The change must be due to our collective approach to treatment. At Cornerstone Dental Products, our focus is on innovations that simplify the RCT process and remove steps and time, not add to them. The AccuFile is a perfect example: Clip the apex locator on the handle, not the file shaft, and produce this file at the same cost as traditional hand files. Because we are a company owned by practicing endodontists, and our vision is to simplify and create defined systems, anything we make has these goals in mind. Beyond products, which may come or may not, my sincere message to my fellow clinicians is to really think about how we collaborate on simplifying the art and the science of root canal therapy and apical surgery. What can we do to remove unnecessary steps? What can we do to standardize the approach like our General Surgeon colleagues have done with the laparoscopic cholecystectomy? How can we be proactive in doing this before the insurance reimbursements force us to do this? Or the demand of more and more pathology diagnosed with less clinical bandwidth forces us? In our group, we actively discuss this on a regular basis. However, we know that if we can engage the collective power of the endodontic community, we will arrive at a more optimal solution, which will drive the right innovations that simplify and reduce the time to treat endodontic disease. Hamid Abedi, DDS, MS, MBA

Hamid R. Abedi, DDS, MS, MBA, earned his dental degree from The Royal London Hospital, London, England in 1991; his MS in the Endodontic Specialty at Loma Linda University in Loma Linda, California in 1995; and his MBA at University of California, Irvine. Dr. Abedi is an Assistant Professor at Loma Linda University, Department of Endodontics. He enjoys teaching endodontics and has lectured extensively in his specialty field both in the United States and abroad. He has served on the Professional Standards, Peer Review, and Ethics Committees for the American Association of Endodontics 2005-2006, and is an active member of the AAE, ADA, CDA, and the Tri-County Dental Society. Dr. Abedi enjoys cycling, reading, and spending time traveling with his two children.

ISSN number 2372-6245

Volume 12 Number 2

Endodontic practice 1

INTRODUCTION

Summer 2019 - Volume 12 Number 2

TABLE OF CONTENTS

Practice profile Mark Anthony Limosani, DMD, MS, FRCD(c)

Mastering his skill set at Weston Endodontic Care

Publisher’s perspective Taking a stand for success ......................................................... 6

Continuing education The cortical window — part 2

Case report

Drs. Naheed Mohamed, Yosi Nahmias, and Ken Serota discuss computerguided endodontic surgery (CGES) in the last of this 2-part series.............. 20

ON THE COVER Cover image courtesy of Dr. Mark Anthony Limosani. See article on page 8.

2 Endodontic practice

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TABLE OF CONTENTS

Technology profile The CS 9600 CBCT System: Five advanced features you didnâ&#x20AC;&#x2122;t know you needed, and how they benefit your patients Dr. John Khademi illustrates the benefits of CBCT imaging for diagnosing and treating endodontic patients........................................... 30

Product profile The elementsâ&#x201E;˘ e-motion Dr. Gary Glassman describes a product that improves the ease and effectiveness of root canal treatment ....................................................... 34

Continuing education Efficacy of smear layer removal from root canals using three agitation devices

Drs. Sandra Tipanta, Osvaldo Zmener, and Cornelis H. Pameijer investigate the effectiveness of three different irrigation/agitation techniques at removing debris and the smear layer from root canal systems

Practice management Shift your practice into high gear by turning your endo marketing upside-down!

Product profile

Small talk

XLDent Endo Suite

Think to Succeed

Dr. Mark Reber discusses reaching out to GPs each month and sharing practice-building information............ 36

A software solution made for you and your patients ....................................................... 38

Dr. Joel C. Small discusses skills that can positively impact the trajectory of your practice................................. 40

www.endopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

4 Endodontic practice

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PUBLISHER’S PERSPECTIVE

Taking a stand for success

t a recent seminar on growing business practices, one particularly meaningful session started with the speaker asking people to stand if their business has lasted 1 to 5 years. After that group sat down, next, the 5- to 10-year group was asked to rise. When recognizing people in the 10- to 15-year category, I looked around to see very few in that category standing in this large room. I was surprised and humbled, and also very proud that after 1½ decades, I was still standing — both literally and figuratively. With the ever-changing business climate we are currently living in, it is often difficult to keep track of all of the details needed to keep your business in the public eye while staying laser-focused on expansion and growth. While general dentists Lisa Moler Founder/Publisher, MedMark Media and specialists alike need to concentrate on all of the technology and techniques that lead to better patient care, you also must remember, and already may be painfully aware of, the vital importance of understanding how to keep your business side booming. From social media to networking with colleagues, to methods for hiring and retaining employees who will have your back and your practice’s best interests in their minds, both entrepreneurs and dentists have to find a work-life balance between our personal and business lives. In our upcoming issues, my column will offer tips on how to be a successful entrepreneur while being a caring business owner and running a profitable business! As a woman entrepreneur, I understand the frustrations and triumphs of tackling the world of business with all of its complexities and the competition of others who are also chasing success. It’s a massively competitive world we are living in! As always, this issue’s articles discuss topics to help your endodontic practice expand both clinically and professionally. The CE by Dr. Sandra Tipanta, et al., compares the efficacy of three agitation devices for removal of debris and smear layer from the root canal system — an essential part of endodontic treatment. Dr. Naheed Mohamed, et al.’s CE on the cortical window, part 2, discusses the role of computer-guided endodontic surgery and how surgical templates printed from three-dimensional imaging allow for greater efficiency and accuracy for creation of the access window, resulting in less trauma than alternative techniques. Drs. Trent Lally and Kent Sabey’s interesting case study shows how creativity in unusual situations can result in “the patient being distinctly grateful at being able to retain her tooth, to have resolution of her discomfort, and to enjoy a return of normal dental function.” Dr. John Khademi also focuses on 3D-imaging technology that has changed the way he diagnoses and treats patients, as well as his relationship to referrals. We hope that reading all of these articles helps endodontists take their practices to the next level of patient care and reach their fullest potential. Through my future columns, I hope to connect with you not just as dental specialists, but business people and entrepreneurs. At Endoodontic Practice US, we care about your stress AND success, and the often challenging and even painful journey to achieving your goals. After 15 years, I’m still standing — proud of the hard work that it took to get here, proud of my amazing, unwavering team that constantly has my back, and looking forward to all of the exhilaration of embracing and conquering business speed bumps and hurdles, while still learning with every step. I’m still standing. My goal is for you all to stand with me in the coming years, with our fierce entrepreneurial spirits — tackling life, propelling us upward, and pushing us forward to unlimited success in both your business and personal aspirations! To your best success! Lisa Moler Founder/Publisher MedMark Media

6 Endodontic practice

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com VP, SALES & BUSINESS DEVELOPMENT Mark Finkelstein mark@medmarkmedia.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING STRATEGIST Matt Simpson emedia@medmarkmedia.com SOCIAL & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com CONTENT MARKETING Lauren Nash emedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 | Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.endopracticeus.com www.medmarkmedia.com

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PRACTICE PROFILE

Mark Anthony Limosani, DMD, MS, FRCD(c) Mastering his skill set at Weston Endodontic Care

Dr. Mark Limosani at his practice, Weston Endodontic Care (www.westonendocare.com), which opened in 2014

What can you tell us about your background? Iâ&#x20AC;&#x2122;m originally from Montreal, Canada, where I spent the first 26 years of my life. Iâ&#x20AC;&#x2122;m of Italian descent; however, both of my parents were born and raised in Canada. I attended one of the two French dental schools in Quebec, the University of MontrĂŠal. Interestingly enough, my hometown is where the American Association of Endodontists (AAE) 2019 Annual Meeting was held.

When and why did you become a specialist? I was fortunate enough to have a wonderful mentor, Dr. Raphael Garofalo, who showed me just how high of a standard one can strive for in any discipline in dentistry. I really got 8 Endodontic practice

hooked on the level of precision necessary to perform endodontics at the highest level.

Is your practice limited solely to endodontics, or do you practice other types of dentistry? I am a believer that saving the natural dentition is a very intricate art to master both from an endodontic and a restorative perspective. For the time being, I am focusing on mastering this skill set prior to integrating any other procedures to my armamentarium. I have, however, added various levels of sedation to my practice. I provide moderate IV sedation to patients who request this service. For pediatrics or patients requiring deep sedation, we work with a dental anesthesiologist.

Dr. Limosani reviewing images from the Carestream Dental CS 8100 3D Scanner Volume 12 Number 2

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PRACTICE PROFILE

Dr. Limosani and assistant Maria Cristina treat a patient with the GentleWave® Procedure

Why did you decide to focus on endodontics? I believe saving the natural dentition is a noble art, and I have a passion to continually refine my skill set to provide the best care to my patients.

Do your patients come through referrals? Primarily, yes; however, I have seen an increase in patients who have been referred to us by other patients or choose our practice because of our online presence.

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

The GentleWave System from Sonendo®

X-Guide Dynamic 3D Navigation from X-NAV Technologies

What training have you undertaken?

I graduated from Nova Southeastern University’s specialty program in 2011 and have been practicing with microscopes and CBCT technology ever since. I have recently integrated the GentleWave® System to my practice, and I am very pleased with the procedural as well as the patient-centered results I’ve seen thus far.

In order to have a better understanding of treatment planning, I’ve engaged in both Spear’s and Dawson’s curricula. I have also completed my IV sedation training at Georgia Regents University. I have also completed more advanced training in sedation through Dr. Bill Gottschalk’s Alpha Anesthesia Seminars.

What is the most satisfying aspect of your practice?

10 Endodontic practice

The impact that I feel I can provide to my team and my community by striving to set the standard for excellence in my profession.

Who has inspired you? My parents have inspired me because of their resilience and passion. My wife Volume 12 Number 2

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PRACTICE PROFILE

The Weston Endodontic Care administration team: Doug, office manager (left), and Valentina, billing and collections (right)

The Weston Endodontic Care team: Kavita, lead front desk (left); Dr. Limosani (center); and Maria Cristina, lead assistant (right)

Top 10 favorites 1. Global Surgical microscopes with assistant oculars 2. ASI carts with NSK electric motors 3. Carestream 8100 CBCT 4. Munce Bur® 5. SS White® V-Taper™ files 6. The GentleWave® System 7. SoundSeal™ Block-out resin 8. Silker-Glickman Clamp 9. X-NAV dynamic navigation device 10. Atwood crown remover

continues to show me how much one must enjoy life and just how precious it is. My two boys’ thirst for exploration and learning never ceases to amaze me. Last but not least, the late Dr. Leon Lemian taught me to embrace the life lessons that can gleaned from our beautiful profession.

Professionally, what are you most proud of? The first answer that comes to mind would be becoming a Diplomate of the American Board of Endodontics as well as a Fellow of the Royal College of Dentists of Canada. However, upon deeper reflection, I would argue that professional growth is a lifelong process, and I’m proud just to be on the journey.

What do you think is unique about your practice? I constantly strive to instill a growth mindset within my team members. I believe this creates a sense of serenity and comfort within my practice that puts patients at ease. This is something that is difficult to achieve with degrees and qualifications alone, in my opinion.

What has been your biggest challenge?

I believe saving the natural dentition is a noble art. is clinical decision-making and therapy that is very patient-specific. In endodontics, this would involve making recommendations based on host response and possibly creating an environment within the root canal system that is well tolerated by that specific individual.

What are your top tips for maintaining a successful specialty practice? Set a high standard and communicate it effectively.

What advice would you give to a budding endodontist? Fear is only a precursor to growth. Growth is an integral part to fulfillment. Don’t let anyone stifle your dreams of practice ownership if you have them. The only regret you will have is not having done it sooner.

What would you have been if you didn’t become a dentist? Good question! I’m fascinated with anesthesiology; I believe that could have been another calling.

Creating a sense of work-life balance.

What is the future of endodontics and dentistry? One of two operatories at Weston Endodontic Care 12 Endodontic practice

I believe the next step toward achieving more predictable, patient-centered outcomes

What are your hobbies, and what do you do in your spare time? • Triathlon • Nonfiction audiobooks • Spending time with the family EP Volume 12 Number 2

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CASE REPORT

Emergency treatment by intentional replantation using Pedialyte® as a medium Drs. Trent Lally and Kent Sabey discuss an unusual treatment for an urgent procedure, while using a nontraditional storage medium Abstract Background Unusual cases occasionally present where there may be several suitable treatment options. In this case, a 38-year-old female developed significant periapical disease, either persistent or secondary to previous endodontic treatment, where a considerable amount of obturation material had been extruded well beyond the root confines. Case report Intentional replantation was selected as a treatment option and carried out in traditional fashion, albeit with a few departures. Those included the choice of this procedure as an urgent treatment modality, use of an easy-to-obtain Pedialyte® solution as a PDL cell preservation medium, the use of sutures alone to support the tooth after replantation, and the removal of an existing crown to accommodate significant occlusal interferences and masticatory discomfort several days after the procedure. Other aspects of the treatment were typical of an intentional replantation case, including root resections, root-end preparations, and root-end fillings with mineral trioxide aggregate. Trent Lally, DDS, MSD, following graduation from the University of Detroit Mercy School of Dentistry in 2012, attended the endodontic post-graduate residency at Louisiana State University Health Sciences Center. He received his certificate and his Masters of Science in Dentistry degree in 2014. He is a Diplomate of the American Board of Endodontics. Dr. Lally is currently practicing in Phoenix, Arizona. Kent Sabey, DDS, following 8 years in an Arizona general dentistry practice, enjoyed a full career in the U.S. Air Force, retiring in January 2011. While in the military, he attended two postgraduate dental training programs — a 2-year AEGD and an endodontics residency, achieving board certification for both areas. Dr. Sabey’s current pursuit is that of a full-time educator, and he serves as the Program Director for the LSU Advanced Education in Endodontics. Disclosure: Both authors deny any conflicts of interest.

14 Endodontic practice

Clinical implications The outcome of the case was the retention of an asymptomatic, fully functional, properly restored molar, with evidence of periradicular tissue healing, and having met the patient’s expectations.

Background Endodontics plays a crucial role in maintaining good oral health by eliminating both infection and pain, ultimately preserving the patient’s natural dentition. Resolution of endodontic disease and the resultant pain relief may contribute to an improved quality of life. Though modern tooth replacement procedures such as implants can be very effective, it is very difficult to truly “replace” a patient’s own natural tooth. Additionally, costs associated with dental implants and their restoration may be prohibitive to those with limited financial resources. Modern endodontics enjoys high success rates. Root canal therapy, root canal retreatment, and periradicular surgery have shown success rates ranging from 86% to 96%.1,2,3,4 Unfortunately, even for the most experienced and skilled clinician, there are times when root canal therapy, root canal retreatment, or endodontic surgery has failed and is not feasible or even predictable, and other options must be considered. One such is intentional replantation. Intentional replantation is defined as the removal of a tooth and its almost immediate replacement, with the object of preparing and obturating the canals apically while the tooth is out of the socket.5 Though many consider intentional replantation as a procedure of last resort, others have argued that it should be considered equally along with periapical surgery and retreatment. Success rates have been reported in the ranges of 81% and 95%.6,7 Indications for intentional replantation follow: • intracanal obstructions that cannot be bypassed • anatomical factors that contraindicate root-end surgery

• resorption present in an anatomical area not amenable to surgical access • aberrant, unnegotiable root canal anatomy • overextension of an excess amount of root canal filling material • situations where apical surgery would lead to damage to adjacent roots or unacceptable periodontal defects • a patient who will not consent to potential complications associated with traditional root-end surgery such as persistent paresthesia. Contraindications to intentional replantation follow: • a medical history that precludes a surgical procedure • a non-restorable tooth • advanced periodontal disease • missing septal bone • extremely divergent or curved roots that predispose the tooth to fracture during extraction • a patient who is unwilling to consent to a guarded prognosis • a patient who is not likely to comply with requirements associated with the procedure8 When intentional replantation is selected as the treatment of choice for a tooth, it is imperative the procedure be completed while minimizing extra-alveolar time. A successful outcome is heavily dependent on the maintenance of the vitality of the periodontal membrane tissues.5 Mechanisms to achieve this include avoiding or minimizing trauma to the cemental covering of the root; maintaining a moist and physiologically compatible environment during the extraoral period; minimizing extra-oral time of the tooth; proper splint rigidity; and appropriate splinting duration.8 The purpose of this report is to share details of a case where intentional replantation was undertaken as an urgent procedure, due to acute pain. The unusual presenting nature of this case and the selected treatment option led to some variance from Volume 12 Number 2

Case report A 38-year-old Caucasian female patient had root canal therapy completed on the maxillary right second molar tooth (tooth No. 2) 6 years prior to our involvement with the case. Following that, the crown had been adjusted several times to relieve persistent discomfort. Two months prior to her visit to our office, the pain had become intolerable, and she was referred to an oral and maxillofacial surgeon for extraction of the tooth. During evaluation by the surgeon, the patient expressed a desire to save her tooth, and she was subsequently referred to our endodontic practice for evaluation. Both medical and dental histories were reviewed. Significant medical history included hypertension, which was managed with 12.5 mg of hydrochlorothiazide taken once daily. The patient reported a Type I penicillin allergy. The extraoral and intraoral examinations, including oral cancer screening, were unremarkable. There was no evidence of any swelling or sinus tracts. Pulp testing showed normal responses to cold by teeth Nos. 3 and 4, with no response by tooth No. 2. Tooth No. 2 was moderately tender to both percussion and palpation, while others in the sextant were non-tender. All teeth in the sextant exhibited physiologic mobility. Probing depths ranged from 3 mm-4 mm with slight bleeding on probing. Clinically, there were no caries or defective restorations apparent. Radiographically, a well-circumscribed, 5 mm-diameter periapical radiolucency was present. Obturation material was extended beyond the apex of both mesial and distal roots. The distal-buccal root obturation appeared to extend well into the region of the image interpreted as the right maxillary sinus (Figure 1). A CBCT scan was considered. After discussing that the amount of helpful information likely to be attained from the image was minimal and that additional images would not appreciably alter the intentional replantation procedure, coupled with the patientâ&#x20AC;&#x2122;s financial concerns, that option was deferred. It was determined that orthograde endodontic retreatment would not be adequate to address the extruded obturation material. Extraction, root-end surgery, Volume 12 Number 2

CASE REPORT

traditional methods. One clear example was the utilization of unflavored Pedialyte electrolyte solution, in maintaining the viability of the periodontal membrane. Specifics of the case management and outcome will be presented.

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Endodontic practice 15

CASE REPORT and intentional replantation were discussed with the patient as treatment options. Due to the restrictive nature of the patient’s masticatory muscles and vestibular height, it was determined that inadequate access to the operative site would make a root-end procedure unfavorable. Intentional replantation was recommended to the patient. As part of the informed consent process, benefits and risks of the intentional replantation procedure were discussed with the patient. The patient was made aware that the tooth may have already been fractured, which might be visualized once extracted. This would render the tooth unsuitable for replantation. The patient selected intentional replantation as the choice for treatment, with acknowledged understanding that the prognosis for the ultimate retention of tooth No. 2 was “questionable” due to the possibility of either an existing root fracture or a fracture occurring during the treatment. The patient was scheduled for the procedure 2 weeks following that evaluation appointment. Ten days later, the patient presented to our office for an unscheduled visit, complaining of severe, constant pain associated with the tooth. The tooth exhibited increased mobility and was now depressible in the socket. Due to the degree of acute discomfort, 3.4 ml of 0.5% bupivacaine with 1:200,000 epinephrine were administered via PSA block and infiltration injections to provide the patient pain relief for the evening. The patient was given the following prescriptions: 600 mg ibuprofen (1 tab every 6 hours); 5/325 mg hydrocodone/acetaminophen (1-2 tabs every 6 hours, as needed); 300 mg clindamycin (1 tab every 6 hours for 7 days); and 0.12% chlorhexidine mouth rinse (twice daily intraoral rinse and expectoration of 5 ml, starting morning of procedure until 1 week after suture removal). An appointment time was given to accomplish the intentional replantation the next day. The patient presented the following day for the procedure. Local anesthesia was obtained via 1.7 ml 4% articaine with 1:100,000 epinephrine (buccal infiltration), 1.7 ml 2% lidocaine with 1:100,000 epinephrine (palatal infiltration), and 1.7 ml 0.5% bupivacaine with 1:200,000 epinephrine (PSA block). The periodontal attachment for tooth No. 2 was released using a No. 12 scalpel blade. The tooth was cautiously (as atraumatically as possible) extracted using a No. 150 forceps and immediately placed into gauze soaked with unflavored Pedialyte oral electrolyte solution in order to maximize maintenance of PDL cell viability. 16 Endodontic practice

Figure 1: Preoperative radiographs: (A) straight-on and (B) angled

Figure 2: Intraoperative radiographs: (A) post-extraction and (B) immediately after replantation

Slight purulent drainage was noted within the extraction socket. The two roots were fused into one S-shaped oval root mesial-distally, and what appeared to be gutta percha extended beyond the mesial canal terminus. While holding only the clinical crown, the tooth was inspected under the microscope at high magnification. No fractures were visualized. The root resection was completed using a tapered diamond bur, and 3 mm-deep root-end preparations were completed in both roots using a No. 245 carbide bur. Throughout both these procedures, the entire root surface was constantly bathed and irrigated with the Pedialyte solution by a dental assistant. ProRoot® Gray MTA (Dentsply Sirona) was placed as a root-end filling material in all root-end preparations. During the extraoral procedure time, the socket was continually irrigated by another dental assistant with a gentle flow of sterile saline, to prevent formation of an organized blood clot. All apparent granulomatous, inflamed tissue, and most of the overextended obturation material were removed from the apical portion of the extraction socket with several of the small fragments unable to be visualized or retrieved. There was no apparent exposure of the sinus during the procedure. After a total “out-of-socket” time of 13 minutes, tooth No. 2 was reinserted with slow, minimal pressure into the socket

and secured into place with a 5-0 chromic gut “figure-eight” continuous sling suture, extended over the occlusal aspect of the crown. A postoperative periapical radiograph revealed adequate root-end fillings. An ice bag was immediately applied to the area, and both verbal and written postoperative instructions were provided to the patient. She was instructed to comply with the previously prescribed medication regimens. She was to return to the office 3 days later for a followup evaluation. The patient was called the evening of the procedure and the following morning. She reported that she was having only minimal discomfort with a very slight puffy feeling, but that she felt “much better.” She returned 3 days later, with no reported changes with her medical status. She indicated she had been compliant with the prescribed medications and that her discomfort was adequately controlled with the ibuprofen. She reported that her severe, constant pain had resolved but had been replaced by a moderate pain when biting. She described tooth No. 2 as occluding in the arch first, causing her discomfort. The suture was removed. To alleviate the occlusal interference and associated discomfort, occlusal adjustment was performed. Ultimately, due to the extent of interference, the existing PFM crown on tooth No. 2 was sectioned and removed, rendering the tooth free from occlusal Volume 12 Number 2

Figure 4: Follow-up radiographs: (A) and (B) 6-months postoperatively

Following the intentional replantation procedure, the patient reported complete resolution of her pain that occurred in a reasonably short span of time.

Discussion

Figure 5: Follow-up radiographs: (A) and (B) 1-year postoperatively

Figure 6: Follow-up radiographs: (A) and (B) 18-months postoperatively. Tooth No. 1 exhibited severe vertical bone loss, and extraction was recommended Volume 12 Number 2

The case presented above demonstrates intentional replantation truly as a procedure of last resort, meaning that no other endodontic treatment options were feasible to maintain the tooth and that loss of the tooth was the only other alternative. The patient had limited financial resources, yet she wanted to save her tooth, if possible. The oral surgeon recognized the patientâ&#x20AC;&#x2122;s desire and referred the patient to determine if any other treatment possibility was feasible. Ultimately, several aspects of the case deviated from typical treatment, the most extreme of which was the use of a nontraditional storage medium. The initial plan was to use Hanks Balanced Salt Solution (HBSS). However, when the patient returned 10 days later in severe pain, the office had not yet received the solution that had been ordered. Though HBSS is commonly recommended, several other solutions have been advocated for encouraging the preservation Endodontic practice 17

CASE REPORT

Figure 3: Follow-up radiographs: (A) 1-month postoperatively and (B) 2 months postoperatively

contact in maximum intercuspation, as well as during any excursive movements. One week later the patient was seen again for a follow-up evaluation and expressed considerably reduced tenderness to biting. The patient returned for additional evaluations at the 4- and 8-week postoperative intervals. At those appointments, the tooth exhibited acceptable mobility and was nontender to both percussion and palpation; the patient reported being comfortable during function. There was no sinus tract or swelling present. Radiographic imaging revealed that the periapical radiolucency was diminished in size (Figure 3). At that time, the patient was referred to her general dentist for placement of a new full-coverage restoration. At the 6-month follow-up visit, a new fullcoverage gold crown on tooth No. 2 was in place. The tooth remained non-tender to percussion and palpation. The marginal gingiva appeared pink and healthy, with normal probing depths and no bleeding. The tooth exhibited acceptable mobility. Considerable radiographic healing was observed on the radiograph (Figure 4). The patient indicated all associated discomfort had resolved, and the tooth had full normal function. At the 1-year and 18-month followup visit, the tooth remained asymptomatic and functional, and complete radiographic healing was present (Figures 5 and 6). Final recall was at 34 months, at which time the tooth remained asymptomatic, functional, and with no abnormal radiographic findings (Figure 7).

CASE REPORT of PDL cell viability. Most associated studies look at tooth avulsion, though can be applied to intentional replantation (with the goal of maintaining PDL cell viability). Though early studies used sterile or physiologic saline as a medium with high success,5,6 many studies have identified solutions that are less damaging to PDL cells and thus more suitable during intentional replantation.9,10,11 These solutions include skim milk, HBSS, Propolis, and ViaSpan. A more recent study concluded that Pedialyte can also be considered a potential viable alternative as a storage solution for avulsed teeth.12 Aware of these findings, Pedialyte could be quickly acquired at a nearby store, and thus was selected for the procedure. Though more studies are necessary, its use may have elevated the likelihood of a successful outcome. The procedure was also undertaken during a time of acute inflammation and infection. When the patient initially presented to the office for evaluation, the tooth was much less symptomatic, and we would have preferred to complete treatment under those conditions. However, she returned in severe pain, and clinical findings indicated that she was undergoing an acute exacerbation of symptoms related to the existing periapical disease. No evidence of a fluctuant swelling was noted or other indication of a systemic involvement; thus, an incision for drainage was not performed. Following the intentional replantation procedure, the patient reported complete resolution of her pain that occurred in a reasonably short span of time. This rapid resolution more typically appears following emergency treatment such as an incision for drainage, or cortical trephination. Removal of the tooth as part of the intentional replantation procedure likely served as an avenue to allow adequate drainage. Stabilization following replantation is recommended to eliminate excess mobility and help with initial PDL healing.13 Physiologic mobility affords the best periodontal healing, and therefore, non-rigid splinting is recommended.14 Postoperative stabilization with an Essix-type retainer was also considered and planned, and would have been the preferred method in this case; however, the general dentist had not yet fabricated the appliance at the time of the patient’s emergency visit. In this case, the tooth was secured into place using a “figure-8” suture across the occlusal surface. This limited degree of splinting likely permitted slight instability of the replanted tooth, resulting in excess mobility of the tooth and resultant premature occlusion for several days. Published 18 Endodontic practice

Figure 7: 34-months follow-up radiograph. Tooth No. 1 now missing

reports indicate that traumatic occlusion following surgery in the periodontal tissue may interfere with healing.17 The degree of occlusal interference in this case led to the decision to remove the entire existing crown restoration, as minor occlusal reduction would not have sufficiently relieved the interferences. Given the clinical presentation of this case, other splinting methods mentioned in the literature such as wire and composite, use of acrylic, or placing composite interproximally were not especially appropriate.13 Some even suggest that splinting is not mandatory in all situations.14,15,16 For intentionally replanted teeth, a common cause of failure is resorption, either inflammatory or replacement.17,18 These complications are directly related to the degree of PDL damage that may have occurred during the procedure.19,20 The process in this report was completed while limiting the extraoral dry time to only 13 minutes, lower than the favorable threshold of 20 minutes reported in the literature.21,22 Constant irrigation of the cells throughout the extraoral portion of the procedure with a high volume of favorable medium, such as Pedialyte, could account for adequate survival of these cells. Another aspect of the case that the patient considered was the cost of treatment. The intentional replantation, even with replacement of the full-coverage crown, was decidedly less expensive than extraction and replacement with a single implant and crown restoration. Potential additional costs were any necessary bone graft and sinus elevation procedures. Publications have inves-

tigated the cost-effectiveness of molar endodontic retreatment and root-end surgery as compared with single-tooth implants. They found that a single implantsupported restoration was the least costeffective option.24 In our endodontic practice, both endodontic retreatment as well as molar root-end surgery would have carried a higher fee than the intentional replantation. Several authors have proposed criteria to evaluate procedural outcomes. Some propose a 3-year survival interval as successful,25 and some believe that more than 4 years is necessary,23 while others require 5-10 years of follow-up.26,27 Some prefer extended evaluation times owing that posttreatment resorptive processes can occur up to 10 years after the procedure.28 However, other authors share another view,29 that if the tooth meets the typical radiographic and clinical criteria for success — absence of pain, normal function and mobility, healthy periodontium, a decreasing or resolved radiolucency, and absence of resorption — then the case can be considered a success. Interestingly, all these conditions are met in this presented case. The patient was distinctly grateful at being able to retain her tooth, to have resolution of her discomfort, and to enjoy a return of normal dental function.

Conclusion Despite departures from several traditional aspects of an intentional replantation protocol, biologic principles were creatively and adequately adhered to, allowing the retention of a tooth that had been recommended Volume 12 Number 2

REFERENCES 1. Sjogren UL, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498-504. 2. Gorni F, Gagliani MM. The outcome of endodontic re-treatment: a 2-yr follow-up. J Endod. 2004;30(1):1-4. 3. Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and Super-EBA as root-end filling material. J Endod. 1999;25(1):43-48. 4. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod. 1999;28(5):378-383.

CASE REPORT

for removal, accompanied by resolution of significant periapical disease. EP

5. Grossman LI. Intentional replantation of teeth: a clinical evaluation. J Am Dent Assoc. 1982;104(5):633-639. 6. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral Surg Oral Med Oral Pathol. 1993;76(5):623-630. 7. Kingsbury BC Jr, Wiesenbaugh JM Jr. Intentional replantation of mandibular premolars and molars. J Am Dent Assoc. 1971;83(5):1053-1057. 8. Fegan S, Steiman HR. Intentional replantation. J Mich Dent Assoc. 1991;73(6):22-24. 9. de Souza BD, Bortoluzzi EA, da Silveira Teixeira C, et al. Effect of HBSS storage time on human periodontal ligament fibroblast viability. Dent Traumatol. 2010;26(6):481-483. 10. Hiltz J, Trope M. Vitality of human lip fibroblasts in milk, Hanks balanced salt solution, and Viaspan storage media. Endodo Traumatol. 1991;7(2):69-72. 11. Blomlรถf L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J. 1981;8(suppl 8):1-26. 12. Macway-Gomez S, Lallier TE. Pedialyte promotes periodontal ligament cell survival and motility. J Endod. 2013;39(2):202-207. 13. Rouhani A, Javidi B, Habibi M, Jafarzadeh H. Intentional replantation: a procedure as a last resort. J Contemp Dent Pract. 2011;12(6):486-492. 14. Kratchman S. Intentional replantation. Dent Clin North Am. 1997;41:603-617. 15. Morris ML, Moreinis A, Patel R, Prestup A. Factors affecting healing after experimentally delayed tooth transplantation. J Endod. 1981;7(2):80-84. 16. Koenig KH, Nguyen NT, Barkhordar RC. Intentional replantation: A report of 192 cases. Gen Dent. 1988;36(1):327-331. 17. Harn WM, Chen MC, Chen YHM, Liu JW, Chuyng CH. Effect of occlusal trauma on healing of periapical pathoses: report of two cases. Int Endod J. 2001;34(7):554-561. 18. Andreason JO, Hjorting-Hansen E. Radiographic and clinical study of 110 human teeth replanted after accidental loss. Act Odontol Scand. 1966;24(3):263-286. 19. Andersson L. Dentoalveolar ankyloses and associated root resorption in replanted teeth. Experimental and clinical studies in monkeys and man. Swed Dent J. 1988;56(suppl):1-75. 20. Dryden JA, Arens DE. Intentional replantation. A viable alternative for selected cases. Dental Clin North Am. 1994;38(2):325-353. 21. Messkoub M. Intentional replantation: A successful alternative for hopeless teeth. Oral Surg Oral Med Oral Pathol. 1991;71(6):743-747. 22. Caffesse RG, Nasjleti CE, Castelli WA. Long-term results after intentional tooth replantation in monkeys. Oral Surg Oral Med Oral Pathol. 1977;44(5):666-678. 23. Lu DP. Intentional replantation of periodontially involved and endodontically mistreated tooth. Oral Surg Oral Med Oral Pathol. 1986;61(5):707-709. 24. Kim SG, Soloman C. Cost-effectiveness of endodontic molar retreatment compared with fixed partial dentures and singletooth implant alternatives. J Endod. 2011;37(3):321-325. 25. Grossman L, Chacker F. Clinical evaluation and histologic study of intentionally replanted teeth. Transactions of the fourth international conference on endodontics. Philadelphia, University of Pennsylvania. 26. Gossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966;72(5):1111-1118. 27. Nosonowitz DM, Stanley HR. Intentional replantation to prevent predictable endodontic failures. Oral Surg Oral Med Oral Pathol. 1982;54:423-432. 28. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors, 4 Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995;11(2):76-89. 29. Emmertsen E. Replantation of extracted molars; preliminary report. Oral Surg Oral Med Oral Pathol. 1956;9(1):115-122.

Volume 12 Number 2

Endodontic practice 19

CONTINUING EDUCATION

The cortical window — part 2 Drs. Naheed Mohamed, Yosi Nahmias, and Ken Serota discuss computer-guided endodontic surgery (CGES) in the last of this 2-part series

echniques, materials, and innovations in the micro-armamentarium of endodontic microsurgery are seminal to enhanced predictable outcomes by comparison with historical microsurgical procedures. The superior magnification and illumination of surgical operating microscopes improves the identification of root peripheries, ensures a lesser degree of root reduction, and diminishes the size of osteotomies, thus retaining greater residual bone. Smaller resection angles (perpendicular to the long axis of the root) reduce the number of tubuli exposed. Lateral canals, canal deltas, isthmus connections, and microcracks can be identified prior to root resection, retro-preparation, and retro-sealing.1 Studies of positive treatment outcomes for conventional endodontic surgical therapy show a diverse range of success dependent upon an array of predictors.2,3 A study by Wang, et al., reported an overall healed rate of 74% of assessed teeth; root filling length and size of preoperative lesions proved to be important predictors of treatment outcomes.4 Positive treatment outcomes (94%) were demonstrated by microsurgical techniques.5 Retreatment of failing endodontic procedures demonstrate statistically less positive treatment outcomes than those done by microsurgical techniques (86%); fewer failures ensue.6 These conditions are more readily addressed with microsurgical techniques.7

The computer-guided cortical window approach A cortical window (bone lid) access to the apical region is less invasive, minimizes bone

Educational aims and objectives

The aim of this article is to discuss, with illustrations, the clinical reasons for the cortical window technique in endodontics.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 24 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize when and how to perform the cortical window technique.

•

Identify the computer-guided cortical window approach.

•

Identify the piezotome osteotomy.

•

Recognize the advantage of facilitating bone preservation by allowing replacement of the cortical plate.

•

Realize the advantage of the 3D-printed guide.

loss, and is less traumatic in comparison to alternative techniques. The perimeter of the window is determined from radiographs of the area. Radiographs are essential to all aspects of endodontics; however, flat films are two-dimensional images of three-dimensional structures, and so data interpretation is subjective. Cone beam computed technology (CBCT) enables the clinician to visualize structures in sagittal, axial, and coronal planes. Three-dimensional imaging provides more substantial data for diagnosis, pretreatment planning, posttreatment assessment, and reassessment evaluations.8,9 A printed stereolithographic surgical template can guide the osteotomies during the surgery, minimizing deviation from the digital surgical plan. Surgical templates printed from three-dimensional imaging optimize site preparation, the perimeter of the osteotomy, depth of cortical bone,

extent of pathology, and volume of bone graft required.10-13

Piezotome osteotomy Traditional osteotomies use large, round burs, which remove significant cortical bone. Delayed healing, increased postoperative pain, and other complications may ensue. With microscopes, piezotomes, and ultrasonic tips, a smaller osteotomy is created, thus minimizing the aforementioned sequelae. Piezo surgery enables micrometric saw cuts, which preserve cortical bone loss and facilitates preservation of root length by lower resection angles and enhanced visibility. In deep spaces, ultrasonic vibrations break down irrigants into small particles readily washed from the crypt. Less vascular presence in the crypt minimizes use of hemostatic agents (ViscoStat™, Ultradent Products, Inc.) and

Naheed Mohamed, DMD, MSD, Perio, FRCD(c), is a board-certified periodontist and Diplomate of the American Academy of Periodontology. He is a partner in a group periodontal practice in Mississauga, Ontario, and maintains his own private practice in Oakville, Ontario. He can be reached at naheedm@gmail.com. Yosi Nahmias, DDS, MSc, was born and raised in Mexico City. After he graduated from the Universidad Tecnologica de Mexico, School of Dentistry in 1980, he decided to advance his education and chose endodontics as his specialty. Dr. Nahmias earned his MSc degree in endodontics in 1983 at Marquette University in Milwaukee, Wisconsin. He has authored many articles and continues to lecture in Canada and internationally. Dr. Nahmias has been a practicing endodontist in Oakville, Ontario, since 1983. He can be reached at yosi@allianceds.com. Ken Serota, DDS, MMSc, graduated from the University of Toronto faculty of dentistry in 1973 and received his certificate in endodontics and Masters of Medical Sciences degree from the Harvard-Forsyth Dental Center in Boston, Massachusetts. Active in online education since 1998, he is the founder of the online forums Roots and Nexus. Dr. Serota is a clinical instructor in the University of Toronto postdoctoral endodontics department.

20 Endodontic practice

Figure 1: A variety of piezotomes are commercially available; saw-toothed tips of 8 mm to 10 mm are essential. Piezotomes ensure precise and safe cutting of mineralized tissues and preserve soft tissues (blood vessels, nerves, and mucosa) Volume 12 Number 2

Figure 4: Eighteen months post-endodontic retreatment therapy — apical pathology appears to be present

Figure 2: The porcelain-fused-to-metal (PFM) crown appears to fit appropriately. The root filing demonstrates incomplete sealing, and there is no evidence of the expected MB2 canal

interference with retro-seal setting time. The use of a piezo surgical device (Figure 1) enables accurate shaping of the cortical window and diminished osseous removal, in contrast to traditional crypt creations that are freehand guided.14

Case report The patient presented to our surgery with a history of “sporadic discomfort in the gum” overlying tooth LR2. A two-dimensional intraoral radiograph revealed a prior history of root canal therapy and a porcelain-fused-tometal (PFM) crown (both completed approximately 10 years ago) (Figure 2). Swelling began the evening prior to the appointment; the patient reported that the throbbing necessitated analgesics for relief of the pain. No sensitivity to pressure or reaction to temperature was noted; the patient could not localize the tooth causing the distress. Treatment options were discussed with the patient; retreatment through the PFM crown was chosen. Anesthesia was administered (posterior superior alveolar nerve block — 2% xylocaine with epinephrine 1:100,00 and infiltration facially and palatally 2% xylocaine with epinephrine 1:50,000). A conservative access preparation was made; decay was identified proximal to the palatal canal, and no fractures or cracks were noted. Cavit™ (3M) was present beneath the composite core, and the untreated MB2 canal was discovered.15 A reservoir was made in the gutta percha (ProUltra®, Dentsply Sirona ultrasonic tip). Endosolv E (Septodont) was used to soften the gutta percha.16 After debridement and shaping, Ca(OH)2 (UltraCal™ XS, Ultradent) was placed in the root canal space to further enhance disinfection. Volume 12 Number 2

Figure 5: The cone beam computed tomography (CBCT) scan results show rarefying osteitis and sinus cortical floor elevation along the mesiobuccal and distobuccal roots

Prior to obturation, drainage was noted coming from the MB2 canal; drainage was arrested, and the canal’s root was filled with vertical condensation of warm gutta percha (VCWG) and AH-Plus® sealer (Figure 3). The patient returned in 6 months for reassessment. Tooth LR2 was within normal limits to percussion, bite, palpation, mobility, and probing. Eighteen months later, the patient returned for a second reassessment appointment (Figure 4). Tooth LR2 was slightly sensitive to percussion, and the overlying gingival tissues were inflamed. The patient was referred for a CBCT; the scan (Figure 5) revealed a common area of rarefying osteitis surrounding the mesial buccal and distal

buccal roots, which had caused elevation of the sinus floor. As the endodontic pathology had not resolved, treatment options were proposed. The patient chose to have microsurgical therapy performed. A 3D-printed stereolithographic template was created by combining the CBCT scan data with an intraoral scan’s (3Shape TRIOS® intraoral scanner) digital data. The data was then imported into coDiagnostix® (Dental Wings) software in order to plan our approach and design our cortical window dimensions for optimal access to the roots (Figure 6). The guided microsurgical approach would facilitate an osteotomy design to minimize the potential for sinus membrane Endodontic practice 21

CONTINUING EDUCATION

Figure 3: The postoperative radiograph shows four treated canals

CONTINUING EDUCATION

Figure 6: The digital rendering of the surgical stent used to guide the cortical bone window osteotomies

Figure 7: The 3D-printed model and surgical stent used to guide the cortical bone window access

Figure 9: The clinical view of the surgical site once the cortical window has been removed and the roots resected

Figure 11: Bosworth SuperEBA® is placed and the root end burnished with a multi-fluted carbide bur

perforation. The 3D-printed guide for the cortical window would guide the length and angle of the osteotomies using the piezosurgical saw (Figure 7). Cervical recession and decay were in evidence about teeth LL1 and LR1 in addition to exposure of the crown margin of tooth LR2. The cervical area of tooth LR3 was severely abraded. An intrasulcular fullthickness muco-periosteal flap was raised; a vertical releasing incision was positioned mesial to tooth LR1. The surgical stent was placed over the maxillary teeth (Figure 8), and a piezotomeguided surgical window was developed using the margins of the stent (Figure 9). 22 Endodontic practice

Figure 8: The surgical stent is put in place against the bone to guide the piezosurgical saw osteotomies

Figure 10: The microsurgical view of the root apical retro-preparation and apical seal

Figure 12: The defect is grafted with allograft cortical bone chips (Straumann® AlloGraft)

Figure 13: The cortical bone window is replaced and fixated in place with gentle pressure

A chisel was used to elevate the cortical plate, and root resection performed with Lindemann burs (Figure 10). The cortical window was placed in sterile saline while the endodontic microsurgery was completed. After resection using Lindemann burs, the root periphery was stained with methylene blue and examined for anomalies, and the root canal space was retro-prepared with ultrasonic tips to a depth of 3 mm, creating a reservoir for the retro-sealing materials. The retro-preparation was rinsed with ethylenediaminetetraacetic acid (EDTA) and dried with paper points. Bosworth SuperEBA® was placed (Figure 11) and the root end burnished with a multifluted carbide bur. Radiographs were taken

Figure 14: The flap is replaced and sutured with prolene monofilament sutures Volume 12 Number 2

CONTINUING EDUCATION

Figure 15: The immediate postoperative radiograph

Figure 17: The 1-year postoperative CBCT scan shows complete regeneration of the defect and buccal plate

Figure 16: The 9-month postoperative radiograph shows excellent bone regeneration

at the retro-preparation stage and the retrosealing stage to ensure accuracy of direction and material placement. The defect was thoroughly debrided and was grafted with allograft (Straumann® AlloGraft) (Figure 12). The cortical bone window was replaced and ensured to have no mobility (Figure 13). The flap was closed with Ethicon 5-O prolene monofilament sutures (Figure 14), and a postoperative radiograph was taken (Figure 15). The patient was directed to use 800 mg of Advil® and 1000 mg of acetaminophen for pain and to rinse with chlorhexidine. Sutures were removed in 7 days, and the patient was reappointed for reassessment. The re-evaluation radiograph taken at 9 months showed substantial osseous regeneration (Figure 16), and a postoperative CBCT scan was taken after 1 year, showing complete bone regeneration and continuity of the buccal plate. (Figure 17).

Conclusions Along with surgical operating microscopes and piezotomes, integration of optical scanners and CBCT DICOM files to 3D-printed stereolithographic surgical guides is yet another iteration in the advancement Volume 12 Number 2

of endodontic microsurgery. This novel, digitally guided approach used in this case report, along with the intraoperative use of a 3D-printed osteotomy guide, allows for greater efficiency and accuracy for creation of the access window to the roots. The technique gives the advantage of bone preservation by allowing the cortical plate to be replaced, yet still provides adequate access for the apical root preparation. The 3D-printed guide provides a control for the osteotomies without risking damage to vital structures. This digitally guided microsurgical approach provides accuracy, access, control, and bone preservation to the endodontic apical surgery procedure. As we come upon the dawn of a new age of digital dentistry, we can see the future applications to be endless.

Acknowledgment Special thanks to Dr. Milan Madhavji of Canaray Oral Radiology for his technical expertise in helping to make our vision a reality. EP

treatment. J Endod. 2008;34(3);258-263. 4. Wang N, Knight K, Dao T, Friedman S. Treatment outcome in endodontics: the Toronto Study. Phases I and II: apical surgery. J Endod. 2004;30(11):751-61. 5. Tsesis I, Rosen E, Taschieri S, et al. Outcomes of surgical endodontic treatment performed by a modern technique: an updated meta-analysis of the literature. J Endod. 2013;39(3):332-339. 6. Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature — Part 2: Comparison of endodontic microsurgical techniques with and without the use of higher magnification. J Endod. 2012;38(1):1-10. 7. Floratos S, Kim S. Modern Microsurgical Concepts: A Clinical Update. Dent Clin North Am. 2017;61(1):81-91. 8. Ahlowalia MS, Patel S, Anwar HM, et al. Accuracy of CBCT for volumetric measurement of simulated periapical lesions. Int Endod J. 2013;46(6):538-546. 9. Venskutonis T, Plotino G, Juodzbalys G, et al. The importance of cone-beam computed tomography in the management of endodontic problems: a review of the literature. J Endod. 2014;40(12):1895-1901. 10. Kuhl S, Payer M, Zitzmann NU, Lambrecht JT, Filippi A. Technical accuracy of printed surgical templates for guided implant surgery with the coDiagnostiX™ software. Clin Implant Dent Relat Res. 2015;17(suppl 1):e177-e182. 11. D’Haese J, Van De Velde T, Komiyama A, Hultin M, De Bruyn H. Accuracy and complications using computerdesigned stereolithographic surgical guides for oral rehabilitation by means of dental implants: a review of the literature. Clin Implant Dent Relat Res. 2012;14(3):321-335. 12. Pinsky HM, Champleboux G, Sarment DP. Periapical surgery using CAD/CAM guidance: preclinical results. J Endod. 2007;33(2):148-151.

REFERENCES

13. Strbac GD, Schnappauf A, Giannis K, Moritz A, Ulm C. Guided Modern Endodontic Surgery: A Novel Approach for Guided Osteotomy and Root Resection. J Endod. 2014;43(3):496-501.

1. Weller RN, Niemczyk SP, Kim S. Incidence and position of the canal isthmus. Part 1. Mesiobuccal root of the maxillary first molar. J Endod. 1995;21(7):380-383.

14. Abella F, de Ribot J, Doria G, Duran-Sindreu F, Roig M. Applications of piezoelectric surgery in endodontic surgery: a literature review. J Endod. 2014;40(3):325-332.

2. Guerreo CG, QuijanoGuaugue S, et al. Predictors of clinical outcomes in endodontic microsurgery: a systematic review and meta-analysis. Giornale Italiano di Endondonzia. 2017;31(1):2-13.

15. Stropko JJ, Canal Morphology of maxillary molars: clinical observations of canal configurations. J Endod. 1999;25(6):446-450.

3. de Chevigny Dao TT, Basrani B, et al. Treatment outcome in endodontics: the Toronto Study — Phase 4: initial

16. Hwang JI, Chuang AH, The effectiveness of endodontic solvents to remove endodontic sealers. Mil Med. 2015;180(suppl 3):92-95.

Endodontic practice 23

REF: EP V12.2 MOHAMED, ET AL.

FULL NAME

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The cortical window â&#x20AC;&#x201D; part 2 MOHAMED, ET AL.

1. Lateral canals, canal deltas, isthmus connections, and microcracks can be identified prior to root _________. a. resection b. retro-preparation c. retro-sealing d. all of the above 2. A study by Wang, et al., reported an overall healed rate of ___ of assessed teeth; root filling length and size of preoperative lesions proved to be important predictors of treatment outcomes. a. 26% b. 58% c. 74% d. 86% 3. __________ access to the apical region is less invasive, minimizes bone loss, and is less traumatic in comparison to alternative techniques. a. A cortical window (bone lid) b. An incision and flap c. A traditional osteotomy d. A papilla-based incision 4. ________ enables the clinician to visualize structures in sagittal, axial, and coronal planes.

24 Endodontic practice

a. CAD/CAM b. Cone beam computed technology (CBCT) c. 2D film radiography d. A microscope 5. Traditional osteotomies use _________ burs, which remove significant cortical bone. a. pear-shaped b. cross-cut c. large, round d. tapered

8. The re-evaluation radiograph taken at 9 months showed substantial osseous regeneration, and a postoperative CBCT scan was taken after 1 year, showing _______. a. incomplete bone regeneration b. complete bone regeneration c. continuity of the buccal plate d. both b and c

6. Piezo surgery enables micrometric saw cuts, which preserve cortical bone loss and facilitates preservation of root length by ________. a. lower resection angles b. enhanced visibility c. higher resection angles d. both a and b

9. Along with surgical operating microscopes and piezotomes, integration of _______ and CBCT DICOM files to 3D-printed stereolithographic surgical guides is yet another iteration in the advancement of endodontic microsurgery. a. optical scanners b. wand transilluminators c. intraoral photographs d. 2D radiographs

7. (In the case study for this patient) The cortical window was placed in ________ while the endodontic microsurgery was completed. a. sterile saline b. methylene blue c. ethylenediaminetetraacetic acid (EDTA) d. mineral water

10. This digitally guided microsurgical approach provides ______ and bone preservation to the endodontic apical surgery procedure. a. accuracy b. access c. control d. all of the above

Volume 12 Number 2

CE CREDITS

ENDODONTIC PRACTICE CE

Drs. Sandra Tipanta, Osvaldo Zmener, and Cornelis H. Pameijer investigate the effectiveness of three different irrigation/agitation techniques (EndoActivator®, Eddy, and XP-endo Finisher) at removing debris and the smear layer from root canal systems

omplete removal of debris (DE) and the smear layer (SL) from the root canal system is an essential step for endodontic success (Schafer and Zapke, 2000; Paque, et al., 2011). Although during root canal preparation the operator relies foremost on endodontic instruments, an effective irrigation protocol is of critical importance as it cleans the root canal system from the SL, flushes out DE, and acts as a tissue solvent, bactericidal agent, and lubricant. The use of a sodium hypochlorite solution (NaOCl) removes loosely attached DE and organic material, while chelating agents such as ethylenediaminetetraacetic acid (EDTA) are necessary to effectively remove the inorganic part of the SL (Hülsmann, et al., 1997; Svec and Harrison, 1977). Historically, different protocols have been recommended for root canal irrigation, but all have demonstrated that some amount of DE and the SL remained on the canal walls after instrumentation and irrigation (Svec and Harrison, 1977; Haapasalo, et al., 2014; Zehnder, 2006). The use of a conventional needle irrigation technique is the traditional method of delivering irrigating solutions to the root canals. However, when using this technique, solutions do not always come into contact with all irregularities of the root canal walls (Schafer and Zapke, 2000; Paque, et al., 2011; Blank-Gonçalves, et al., 2011). To improve the efficacy of irrigation, agitation of the irrigating solution has been

Sandra Tipanta, DDS, is a postgraduate student of specialized endodontics at the School of Dentistry, University of El Salvador, Buenos Aires, Argentina. Osvaldo Zmener, DDS, Dr Odont, is professor emeritus of specialized endodontics at the School of Dentistry, University of El Salvador, Buenos Aires, Argentina. Cornelis H. Pameijer DMD, MScD, DSc, PhD, is a professor emeritus of the School of Dental Medicine, University of Connecticut Health Center.

Volume 12 Number 2

Educational aims and objectives

The aim of this article is to compare the efficacy of EndoActivator®, Eddy polyamide tips, XP-endo Finisher, and conventional needle irrigation in the removal of debris and smear layer from root canals walls.

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: •

Realize that whatever technique or device is used for final irrigation, agitation of the irrigating solution should always be performed in order to improve the effectiveness of debris and smear layer removal.

•

Recognize the importance of an effective irrigation protocol.

•

Realize some drawbacks to the conventional needle irrigation technique.

•

Identify some characteristics of EndoActivator, Eddy, and XP-endo Finisher.

proposed (Blank-Gonçalves, et al., 2011; Caron, et al., 2010). Among these techniques, the EndoActivator® (Dentsply Sirona) was found to improve, to some extent, the effectiveness of irrigation. The EndoActivator is a cordless battery-activated sonic handpiece that uses non-cutting polymer tips for a safe intracanal agitation of the irrigation solutions. The tips are available in three different sizes, producing 2,000 to 10,000 cycles per minute. The instrument produces a threedimensional movement with high-amplitude acoustic oscillations (Gu, et al., 2009). It was also recommended to use the EndoActivator after the cleaning and shaping of canals (Uroz-Torres, et al., 2010). Eddy® (VDW) is another sonic device that activates irrigating solutions by means of a 25/.04 smooth flexible non-cutting polyamide tip, powered by a sonic scaler at a frequency of 5,000 to 6,000 cycles per minute. Eddy (EPt) produces an acoustic streaming, which effectively removes DE and the SL that adhere to root canal walls, including in difficult-to-access areas of the canal system (Khaord, et al., 2015; Urban, et al., 2017; Bayari, et al., 2017). More recently, the XP-endo Finisher (FKG Dentaire SA) has also been introduced for the activation of irrigants. The XP-endo

Finisher (XPe) consists of a size 25/.00 nontapered instrument constructed of MaxWire martensite-austenite electro-polish-flex alloy (FKG Dentaire SA) (Bao, et al., 2017), which is a special nickel-titanium alloy capable of producing an expanding movement when the instrument is used at body temperature (35°C-37°C). Under these conditions, the instrument can adapt three-dimensionally to the canal anatomy. To be effective, the XP-endo Finisher must be used at 800 rpm and, after canal preparation, to a size 25 or larger (Bao, et al., 2017). The purpose of this in vitro SEM study was to compare the efficacy of Endoactivator, Eddy, and XP-endo Finisher in the removal of DE and the SL from root canal walls as a final step in irrigation. Conventional needle irrigation technique served as the control. The null hypothesis was that there would be no significant differences among the tested irrigation systems in their efficacy to remove DE and the SL from the root canal walls.

Materials and methods The protocol of this study was approved by the Ethics Committee of the Argentina Dental Association (protocol 0119/18). Forty (n = 40) extracted human lower premolars Endodontic practice 25

CONTINUING EDUCATION

Efficacy of smear layer removal from root canals using three agitation devices

CONTINUING EDUCATION

Figure 1A: Representative scanning electron micrographs of scores for DE – score 1: note the presence of an isolated DE particle (arrow)

Figure 1B: Representative scanning electron micrographs of scores for DE – score 2: more areas of surface DE contamination can be seen (arrow)

Figure 1C: Representative scanning electron micrographs of scores for DE – score 3

Figures 1D, 1E, and 1F: Representative scanning electron micrographs of scores for SL (D) score 1 (E) score 2 (F)

with single straight root canals were used. They were stored at 4°C in 0.1% thymol solution before being treated. The teeth were decoronated to a standardized length of 18 mm. After the removal of gross pulpal tissues, the working length (WL) was established by advancing a size 10 K-file into the canal until just visible at the apex under a stereomicroscope (Carl Zeiss, Oberkochen, Germany) followed by subtracting 1 mm. All teeth were assigned to four groups of 10 teeth each (n = 10), using a stratified sampling method to ensure that all groups had teeth of similar average dimensions. This was accomplished by the use of the Minitab Statistical Analysis Package (Minitab 10.1, Minitab Inc., State College, Pennsylvania). In all groups, the canals were prepared with ProTaper Next™ NiTi instruments (Dentsply Sirona, Tulsa, Oklahoma), strictly according to the manufacturer’s recommendations. Biomechanical preparation of the apical part of the canals was considered complete when an instrument No. X3 (equivalent to a size No. 30/.07 taper) could easily be inserted to the WL while maintaining apical patency. Throughout preparation, the canals were irrigated with 5 ml of 26 Endodontic practice

5.25% NaOCl before and after each instrument using a 30-guage NaviTip™ needle (Ultradent Products, Inc, South Jordan, Utah) placed 1 mm short of the WL without binding. After preparation, the canals of each group were subjected to different final irrigation/agitation techniques — Group 1: EAc; Group 2: PTe; Group 3: XPe; Group 4: CNi. To ensure retention of the irrigants in the canal space, the root apex was sealed with cyanoacrylate (La Gotita, Buenos Aires, Argentina) taking care to prevent getting cyanoacrylate in the canal. The final irrigation/activation procedures were performed according to the following protocols: Group 1: EAc (n = 10): 2 ml of 5.25% NaOCl was injected with a No. 30-gauge NaviTip needle (Ultradent Products, Inc.) and the solution activated for 30 seconds with a No. 25/.04 non-cutting polymer tip powered to 10,000 cycles per minute. The tip was used with in-and-out movements of approximately 6 mm-8 mm to the full WL. After flushing with saline, the irrigation/activation procedure continued by filling the canals with 17% EDTA and agitation with EAc for another 30 seconds. The cycle of irrigation/activation

with 5.25% NaOCl was repeated, and the canals were finally flushed with 5 ml of 5.25% NaOCl followed by rinsing with copious amounts of saline and dried with capillary suction tips and paper points. The polymer tip was discarded after each use. Group 2: EPt (n = 10): The procedure was similar to that used in Group 1; however, the agitation was performed with EPt using a No. 20/.02 non-cutting polymer tip powered at a frequency of 6000 Hz by an air scaler (NSK AS2000; NSK, Japan) set at maximum speed. The Eddy tip was discarded after each use. Group 3: XPe (n = 10): A similar procedure was used as in to Group 1 and 2, but agitation was performed with the XPe activated at 800 rpm in a torque controlled contra-angle. To control the proper length a rubber stop was used at a predetermined length. The XPe was also discarded after each use. Group 4: CNi (n = 10): After instrumentation, a No. 30-gauge NaviTip needle was placed 1 mm Volume 12 Number 2

was superimposed on the photographs, and a determination was made as to the presence of DE and SL remnants. Each square was considered as an assessment unit, and the examination space was set at 600 microns square. The total area of each of the experimental levels was analyzed by two evaluators who were blinded to the experimental groups and who independently scored the presence of DE and SL. Before the analysis, both evaluators were calibrated by having them analyze a set of SEM photomicrographs at a magnification of 1000x obtained from the canal walls of teeth subjected to endodontic instrumentation and different irrigation regimens. Inter-observer reproducibility was measured by the Kappa coefficient. The amount of DE and SL layer in each measuring unit was assessed based on a score of 1-3. For DE, a Score 1 was assigned when no DE or isolated small particles were present. Score 2 indicated that DE covered more than 30% of the canal walls, and a Score 3 indicated that DE covered the entire canal wall. For the SL, a score 1 was assigned when a regular pattern of open dentinal tubules and no SL was present. Score 2 indicated that some dentinal tubules were open, and the others were covered by SL. Score 3 was assigned when a continuous SL covered the canal walls, and no dentinal tubules were seen.

Statistical analysis The average score of each level was calculated by dividing the sum of all individual scores by the number of evaluation units. Mean scores for DE and SL were then calculated for each tooth and for each group and statistically analyzed for significance between groups using the Kruskal-Wallis non-parametric Anova and Dunn’s tests. The results obtained at each evaluation level within each group were analyzed using the Friedman test and Tukey’s multiple comparison test. The level of significance was set at p <0.05.

Results The inter-observer reproducibility was 94%, which constituted a strong agreement. Therefore, the scoring of the samples was considered reliable. The mean scores of DE and SL recorded at 1 mm, 5 mm, and 10 mm from the WL are listed subsequently Tables 1 and 2. Figure 1 is a representative image of scores 1, 2, and 3 for DE and SL, respectively. In all groups, SEM observation showed cleaner canals at 5 mm and 10 mm compared to 1 mm from the WL. Comparison between groups showed that at all evaluation levels, the canals in which the irrigants were agitated with either EndoActivator, Eddy, or XP-endo Finisher had significantly less surface DE and SL than those in which the control was used. XP-endo Finisher removed significantly more DE and SL than EndoActivator and Eddy, while no significant differences were observed between EndoActivator and Eddy. Based on these results, the null hypothesis was rejected.

Discussion This study evaluated the cleanliness of root canals after the use of different irrigation/ agitation systems. After root canal preparation, remnants of DE or the SL may prevent the adaptation of filling materials to the root canal walls, thus jeopardizing their sealing properties. Therefore, DE and SL remnants should be totally removed before canal obturation. As per protocol, a combination of NaOCl and EDTA solutions were used during root canal instrumentation, as well as for the final irrigation/agitation step. This combination of irrigants was found to be one of the more effective irrigation regimes to produce clean root canal walls (Baumgartner and Mader, 1987; Hülsmann, et al., 1997; Mayer, et al., 2002). However, several studies (Schafer and Zapke, 2000; Peters and Barbakow, 2000; Ahlquist, et al., 2001) have demonstrated that none of the irrigants and irrigation techniques

Table 1: Mean (SD) scores of debris removal at 1 mm, 5 mm, amd 10 mm from the WL

Table 2: Mean (SD) scores of smear layer removal at 1 mm, 5 mm, amd 10 mm from the WL

Group

1 mm

5 mm

10 mm

Group

1 mm

5 mm

10 mm

EAc

1.6 (0.5)

1.4 (0.5)

1.3 (0.5)

EAc

1.9 (0.5)

1.5 (0.6)

1.4 (0.5)

EPt

1.6 (0.5)

1.3 (0.5)

EPt

1.8 (0.6)

1.5 (0.5)

1.3 (0.5)

XPe

1.4 (0.5)

1.1 (0.5)

1.0 (0.0)

XPe

1.6 (0.4)

1.2 (0.5)

1.1 (0.3)

CNi

2.7 (0.6)

2.4 (0.6)

2.1 (0.6)

CNi

2.7 (0.5)

2.5 (0.7)

1.9 (0.4)

SD: Standard deviation Volume 12 Number 2

SD: Standard deviation Endodontic practice 27

CONTINUING EDUCATION

short of the WL and the canal rinsed with 3 ml of 5.25% NaOCl. The irrigating solution was left in place for 30 seconds, evacuated, and followed by 3 ml of 17% EDTA for 30 seconds. This cycle of irrigation was repeated, and the canals were finally flushed with 5 ml of 5.25% NaOCl followed by rinsing with copious amounts of saline. They were then dried with capillary suction tips and paper points. The needle was used for one canal only. Irrigation for all groups was performed in a temperature-controlled environment of 37°C. The access openings were sealed with Cavit™ (3M ESPE, Seefeld, Germany) and the samples coded to allow for a blinded evaluation. In preparation for scanning electron microscopy, a groove was prepared on the buccal and lingual root surface with a diamond disc under copious water cooling, making sure not to penetrate the root canal space. The samples were then immersed in liquid nitrogen and split longitudinally with a mallet and chisel. Note the seal of the access openings prevented the liquid nitrogen from penetrating the root canal. Teeth with evidence that the groove had penetrated into the canal space or that exhibited an irregular cleavage were discarded and replaced with new specimens. The paired halves of each tooth were mounted side by side on an aluminium stub, coated with gold-palladium and examined in a scanning electron microscope (JEOL JSM 6490LV, Tokyo, Japan) operated at 15.5 Kv. Serial SEM photomicrographs were made at 1000x magnification and aligned in such a manner that they generated a horizontal panoramic view covering the total circumference of the canal walls at levels of 1 mm, 5 mm, and 10 mm from the WL. Digital images were transferred to a computer and analyzed, using Image-Pro® plus 6.0 software (Media Cybernetics, Bethesda, Maryland). For evaluation, a slight modification of the method described by Mayer, et al. (2002), was used. Briefly, a 300-micron square grid

CONTINUING EDUCATION are totally efficient in completely cleaning the irregular areas of canal walls. For that reason, an additional irrigation/agitation step has been proposed (Duque, et al., 2017). In this study EndoActivator, Eddy, and XP-endo Finisher irrigation/agitation techniques were tested, while a conventional needle irrigation technique was used as control since the last, a no-agitation method, is still frequently used in endodontic treatment. The results reported here are in support of Caron, et al. (2010), Jiang, et al. (2012), Kumar, et al. (2015), Mendonça, et al. (2015), Bayari (2017), demonstrating that improved DE and SL removal is accomplished with supplementary irrigation/agitation techniques. Previous studies (Peters and Barbakow, 2000; Paque, et al., 2006) have shown that regardless of the instrument or instrumentation technique, the most apical part of the root canal is the least clean. Findings by Abou-Rass and Piccinino (1982) have shown that instruments used for irrigation have to be in close proximity to the root canal walls in order for irrigants to be effective. In the present study, the 30-gauge needle used for the final step of irrigation in canals prepared to a size 30/.07 did not allow the irrigants to reach the canal wall surfaces. In contrast, the action of EndoActivator, Eddy, or XP-endo Finisher not only depends on irrigant agitation, but also on agitating action closer to the canal walls without removing dentin. EndoActivator and Eddy generate intracanal agitation of irrigants though acoustic streaming and cavitation (Bayari, et al., 2017). At all evaluation levels, no significant differences were found between both sonic irrigation/agitation systems, while they were significantly more effective than the control (a conventional needle irrigation technique). On the other hand, other studies (Takeda, et al., 1999; Saber and Hashem, 2011) have shown that irrigation/agitation systems do not result in significant cleaning differences with the conventional needle irrigation technique. These findings are not supported by the current study or by others (BlankGonçalves, et al., 2012). Sonic agitation systems increase the effectiveness of the irrigating solutions, especially in hard-to-reach areas such as the apical third and, in particular, in the area 1 mm from the WL. The difference between studies may be due to the use of different instruments and/or instrumentation techniques, as well as different experimental models and evaluation protocols. 28 Endodontic practice

Complete removal of debris (DE) and the smear layer (SL) from the root canal system is an essential step for endodontic success. In the current study, the method used for observation of canal wall surfaces was similar to one used in a previous study (Zmener, et al., 2005). This method allows for examination of both halves of the root, thus examining the entire circumference of the root canal at a predetermined distance from the WL. The XP-endo Finisher provided significantly cleaner canal walls at all evaluation levels. These results confirmed the claim of the manufacturer stating that the phase transformation of the alloy of the instrument when used at body temperature causes the file to expand, which as a result improves the cleaning activity on wall irregularities. It should be noted that previous in vitro studies did not use EndoActivator and Eddy at body temperature (Khaord, et al., 2010; Uroz-Torres, et al., 2010; Bayari, et al., 2017; Duque, et al., 2017; Urban, et al., 2017). In this study, the final irrigation/agitation techniques were tested under similar temperature conditions, with the objective to standardize the experimental procedures and to mimic as much as possible the clinical conditions of the oral environment.

Conclusions Within the limitations of this study, the results indicate that EndoActivator, Eddy, and XP-endo Finisher, along with 5.25% NaOCl and 17% EDTA solution, as a final step in irrigation of root canals have greater potential for DE and SL removal when used in straight root canals. Although the XP-endo Finisher was superior to EndoActivator, Eddy, and a conventional needle irrigation technique, none of the tested techniques was able to completely clean the root canal walls. EP

REFERENCES 1. Abou-Rass M, Piccinino MV. The effectiveness of four clinical irrigation methods on the removal of root canal debris. Oral Surg Oral Med Oral Pathol. 1982;54(3):323-328. 2. Ahlquist M, Henningsson O, Hultenby K, Ohlin J. The effectiveness of manual and rotary techniques in the cleaning of root canals: a scanning electron microscopy study. Int Endod J. 2001;34(7):533-537. 3. Bao P, Shen Y, Lin J, Haapasalo M. In vitro efficacy of XP-endo Finisher with 2 different protocols on biofilm removal from apical root canals. J Endod. 2017;43(2):321-325. 4. Baumgartner JC, Mader CL. A scanning electron

microscopic evaluation of four root canal irrigation regimens. J Endod. 1987;13(4):147-157. 5. Bayari L, Forner L, Villanueva D, Almenar A, Llena C. Elimination of the root canal dentin smear layer by irrigation with new polyamide sonic activated tips. Endodoncia. 2017;35(1):23-33. 6. Blank Gonçalves LM, Nabeshima CK, Martins GH, Machado ME. Qualitative analysis of the removal of the smear layer in the apical third of curved roots: conventional irrigation versus activation systems. J Endod. 2011;37(9):1268-1271. 7. Caron JI, Nham K, Bronnec F, Machtou P. Effectiveness of different final irrigant activation protocols on smear layer removal in curved canals. J Endod. 2010;36(8):1361-1366. 8. Duque JA, Duarte MAH, Canali ICF, Zancan RF, Vivan RR, Bernardes RF, Bramante CM. Comparative effectiveness of new mechanical irrigant agitating devices for debris removal from the canal and isthmus of medial roots of mandibular molars. J Endod. 2017;43:326-331. 9. Gu L, Kim JR, Ling J, et al. Review of contemporary irrigant agitation techniques and devices. J Endod. 2009;35(6):791-804. 10. Haapasalo M, Shen Y, Wang Z, Gao Y. Irrigation in endodontics. Br Dent J. 2014;216(6):299-303. 11. Hülsmann M, Rümmelin C, Schäfers F. Root canal cleanliness after preparation with different endodontic handpieces and hand instruments: a comparative SEM investigation. J Endod. 1997;23(5):301-306. 12. Jiang LM, Lak B, Eijsvogels LM, Wesselink P, van der Sluis LW. Comparison of the cleaning efficacy of different final irrigation techniques. J Endod. 2012;38(6):838-841. 13. Khaord P, Amin A, Shah MB, et al. Effectiveness of different irrigation techniques on smear layer removal in apical thirds of mesial root canals of permanent mandibular first molar. A scanning electron microscopic study. J Conserv Dent. 2015;18(4)321-325. 14. Kumar VR, Bahuguna N, Manan R. Comparison of efficacy of various root canal irrigation systems in removal of smear layer generated at the apical third. An SEM study. J Conserv Dent. 2015;18(3):252-256. 15. Mayer BE, Peters OA, Barbakow F. Effects of rotary instruments and ultrasonic irrigation on debris and smear layer scores: a scanning electron study. Int Endod J. 2002;35(7):582-589. 16. Mendonça DH, Colucci V, Rached Junior FJ, et al. Effects of various irrigation/aspiration protocols on cleaning of flattened root canals. Braz Oral Res. 2015;29:1-9. 17. Paqué F, Boessler C, Zehnder M. Accumulated hard tissue debris levels in mesial roots of mandibular molars after sequential irrigation steps. Int Endod J. 2011;44(2):148-153. 18. Peters OA, Barbakow F. Effects of irrigation on debris and smear layer on canal walls prepared by two rotary techniques: a scanning electron microscopic study. J Endod. 2000;26(1):6-10. 19. Schafer E, Zapke K. A comparative scanning electron microscopic investigation of the efficacy of manual and automated instrumentation of root canals. J Endod. 2000;26:660-664. 20. Svec TA, Harrison JW. Chemomechanical removal of pulpal and dentinal debris with sodium hypochlorite and hydrogen peroxide vs. normal saline solution. J Endod. 1977;3(2):49-53. 21. Urban K, Donnermeyer D, Schäfer E, Bürklein S. Canal cleanliness using different irrigation activation systems: a SEM evaluation. Clin Oral Invest. 2017;21(9):2681-2687. 22. Uroz-Torres D, Gonzales-Rodriguez MP, Ferraz-Luque CM. Effectiveness of the EndoActivator System in removing the smear layer after root canal instrumentation. J Endod. 2010;36(2):305-311. 23. Zehnder M. Root canal irrigants. J Endod. 2006;32(5): 389-398. 24. Zmener O, Pameijer CH, Banegas G. Effectiveness in cleaning oval-shaped root canals using Anatomic Endodontic Technology, ProFile and manual instrumentation: a scanning electron microscopic study. Int Endod J. 2005;38(6):356-363.

Volume 12 Number 2

REF: EP V12.2 TIPANTA, ET AL.

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Efficacy of smear layer removal from root canals using three agitation devices TIPANTA, ET AL.

1. Although during root canal preparation the operator relies foremost on endodontic instruments, an effective irrigation protocol is of critical importance as it cleans the root canal system from the SL, flushes out DE, and acts as a _______. a. tissue solvent b. bactericidal agent c. lubricant d. all of the above 2. The use of a ________ technique is the traditional method of delivering irrigating solutions to the root canals. a. conventional needle irrigation b. three-dimensional movement c. sonic scaling d. martensite-austenite electro-polish-flex alloy 3. To improve the efficacy of irrigation, ________ of the irrigating solution has been proposed. a. heating b. cooling c. agitation d. dilution 4. (For this study) Irrigation for all groups was performed in a temperature-controlled environment of _______. a. 26째C

Volume 12 Number 2

b. 37째C c. 46째C d. 50째C 5. Comparison between groups showed that at all evaluation levels, the canals in which the irrigants were agitated with either EndoActivator, Eddy, or XP-endo Finisher had ________ than those in which the control was used. a. slightly more surface SL b. slightly less surface DE c. significantly less surface DE and SL d. significantly more surface DE and SL 6. This combination of irrigants (NaOCl and EDTA solutions) was found to be ________ irrigation regime(s) to produce clean root canal walls. a. the least effective b. one of the more effective c. equally as effective as all other d. a totally efficient 7. Previous studies (Peters and Barbakow, 2000; Paque, et al., 2006) have shown that regardless of the instrument or instrumentation technique, the ___________ of the root canal is the least clean. a. pulp chamber b. neck

c. most apical part d. top of the pulp tissue 8. Findings by Abou-Rass and Piccinino (1982) have shown that instruments used for irrigation have to be in close proximity to the root canal walls in order _______ . a. for irrigants to be effective b. for the anesthetic to work properly c. for a proper fit d. for irrigants to maintain their temperature 9. In the present study, the 30-gauge needle used for the final step of irrigation in canals prepared to a size 30/.07 ________ the canal wall surfaces. a. did not allow the irrigants to reach b. allowed the irrigants to reach c. had no effect on the irrigants reaching d. none of the above 10. At all evaluation levels, _______ were found between both sonic irrigation/agitation systems, while they were significantly more effective than the control (a conventional needle irrigation technique). a. significant differences b. no significant differences c. many irregularities d. none of the above

Endodontic practice 29

CE CREDITS

ENDODONTIC PRACTICE CE

TECHNOLOGY PROFILE

The CS 9600 CBCT System: Five advanced features you didn’t know you needed, and how they benefit your patients Dr. John Khademi illustrates the benefits of CBCT imaging for diagnosing and treating endodontic patients

one beam computed tomography (CBCT) has been allowing endodontists to practice at the highest level for the past decade, and we’ve seen more and more doctors adopting the technology as its benefits to diagnosis, treatment planning, and treatment are undeniable. However, new CBCT systems released within the past year utilizing the latest “smart” technology have taken endodontic diagnosis, treatment planning, and treatment outcomes even higher. With its intuitive interface and intelligent features that automate much of the scanning process, the CS 9600 (Carestream Dental) is designed for doctors who are seeking to do more for their patients.

to more accurately target the imager on the desired structures. In fact, the scouting feature has eliminated retakes due to missing the desired structures in our office; in the months we have been using the CS 9600, we have not had a single miss. This ability to hit the target 100% of the time has

allowed us to routinely use the smallest 4 cm x 4 cm FOV and reduce patient dose. For many studies, we simply select the appropriate FOV using the letter matching on the target area on the bite tab and confirming the area with the two video feeds (Figure 1). Small adjustments in the

Advanced video and radiographic scouting aid in capturing the region of interest Scout imaging has a long history of use with medical CT and is a welcome addition to the field of oral health. There are two aspects to scouting that go hand-inhand: Reducing retakes due to misses and allowing a smaller FOV, which reduces patient dose. With the CS 9600, my technologists use both advanced video systems — not lasers — and radiographic scouts

Figures 1A and 1B: A. Selecting the FOV with the matching letters on the bite tab. B. Small adjustments to the FOV and center of rotation may be made with the camera

John Khademi, DDS, MS, received his dental degree from the University of California, San Francisco, and his certificate in endodontics and MS on digital imaging from the University of Iowa. He is in full-time private practice in Durango, Colorado, and was associate clinical professor in the Department of Maxillofacial Imaging at USC, and is Adjust Assistant Professor at SLU. In his “prior life,” he wrote software for laboratory automation, instrument control, and digital imaging. He lectures internationally about computer use and dental practice and conventional endodontic technique. As a Radiological Society of North America member, Dr. Khademi comes from a background in medical radiology and imaging that allows him a unique perspective on the issues surrounding CBCT imaging. Disclosure: Dr. Khademi is a paid consultant for SS White and receives honoraria and lecture support from Carestream Dental.

30 Endodontic practice

Figure 2: The ability to take larger FOVs at high resolution (150µm and 75µm) allows both endodontic and periodontal/implant imaging to be done in a single study. In this follow-up case with multiple endodontically treated teeth, implants, and potential implant sites, both arches are imaged at 150µm at a lower dose. This is adequate for endodontic follow-up needs, and more than adequate for implant treatment planning and assessment purposes Volume 12 Number 2

site to re-evaluate in one quick scan (Figure 2). This can also facilitate referral-based imaging for colleagues.

A 120 kV generator plays a significant role in quality of images There is very complicated relationship with kVp, mAs (milliamp seconds, pronounced “mass”), and filtration on image quality and patient dose. On one end, higher kVp and mAs generally result in higher quality images but at an increase in patient dose. Increasing mAs linearly increases dose — that is, increasing mAs by 25% increases dose by 25%, and doubling the mAs doubles the dose. The relationship with kVp is more complicated because of filtration. A simple increase

in the kVp increases patient dose; however with the CS 9600, the increase in kVp is accompanied by an increase in filtration after 90kVp (Figures 1A, 4A, 4B, 5A, and 5B). This reduces dose dramatically. What this nets out to for the clinician is similar, identical, or often improved image quality at a lower dose to the patient (Figures 3A and 3B).

Patented algorithms aid with Metal Artifact Reduction (MAR) Dental and especially endodontic imaging is confounded by the presence of highly attenuating materials in the planes of interest.1 These highly attenuating materials create a number of artifacts with CBCT images that have no analog with projection radiography

High resolution and larger FOVs support multi-specialty diagnosis While most endodontists don’t often work with larger FOVs, that doesn’t mean there aren’t situations when it’s incredibly beneficial. Just this week, I had a long-time patient on whom I had performed several endodontic procedures in all four quadrants and wanted to follow up on those teeth. She also reported that she had three implant procedures done in the URQ several years ago, one of which had failed. With the ability to do larger FOVs at high resolution, the CS 9600 made it easier to get all the follow-ups I needed at endodontic resolution, as well as to provide the implant surgeon with a new, high-resolution view of the potential implant

Figures 3A and 3B: On this skull phantom, Figure 3A was done with a technique of 90kVp/2mA/15s, while the study in Figure 3B was done with a technique of 91kVp/2mA/15s. The studies are indistinguishable from an image-quality standpoint. The dose (DAP) of the study in Figure 3A with lower kVp was 640mGy*cm2, while the other visually identical study in Figure 3B with the higher kVp was 173mGy*cm2 — about a quarter of the dose

Figures 4A-4B: As a first insight into the counterintuitive nature and relationship between dose, kVp, and filtration, we consider that X-ray tube-head emits a spectrum of radiation that may be thought of similarly to the rainbow of colors that comprise white light, with red being lower energy and violet being higher energy. We draw the distinction between the energy of the photons denoted by the kVp, and the volume of the photons given by their number. To contribute to dose, photons must be absorbed. To contribute to exposure, photons must reach the sensor. Low energy photons (reddish end) are nearly completely absorbed by soft tissue and bone and contribute to dose and not exposure. Middle energy photons (orange-green) contribute to dose and exposure. Higher energy photons (blue-violet), since they are more penetrating, are absorbed less and, as a consequence, contribute relatively less to dose and relatively more to exposure. In 4A, we see the volume of photons in the raw, unfiltered 90kVp beam (black) comprised primarily of the low energy photons below ~30-40kVp that would be nearly completely absorbed by the soft tissue before even reaching the bone and contribute nearly all of their energy to patient dose, and none to exposure. Increasing filtration to the standard 3.0 mm of aluminum (blue), then to 0.15 mm of copper (red), the 90kVp beam is seen to remove progressively more of the low energy photons that contribute to dose, but not exposure…all the while losing volume. Filtration is ultimately limited by the lower 90kVp of the beam. Increasing filtration further reduces the beam intensity unacceptably. In 4B, we see that the raw, unfiltered 120kVp beam still has a predominance of lower energy photons, but an increase in the proportion of high energy photons due to the higher kVp. This allows for increased filtration with 0.7mm of copper, dramatically reducing the amount of low energy photons contributing to dose, but not exposure. For comparison with the 90kVp beams, the 120kVp/0.7mm copper-filtered beam is overlaid on the 90kVp graph in 4A. We see whole curve is moved to the right, which dramatically decreases the relative number of photons contributing to dose and increases the relative number of photons contributing to exposure Volume 12 Number 2

Endodontic practice 31

TECHNOLOGY PROFILE

anteroposterior (AP) and crainiocaudal (CC) directions, as well as the center-ofrotation, are easily accomplished using the live camera feed. We’re finding that centerof-rotation is a little trickier, and the feed from under the chin really helps with this adjustment. The two systems can be used in concert as well, with a radiographic 2D scout showing the AP and CC dimensions of the FOV, and then a center-of-rotation adjustment with video. For tricky setups with unusual arch-forms or unusual tooth positions, the full 2D and SmartAuto 3D scouts produce a perfect shot ever time. The combination of these two scout views shows the AP and CC dimensions of the FOV, and the exact center-of-rotation on the patient as they are positioned in the system.

TECHNOLOGY PROFILE

Figures 5A and 5B: The effects of filtration on dose are shown in this 8x8 dual-arch study. Figure 5A is at 90kVp/8mA/18.8s with 0.15 mm of copper filtration. Figure 5B is just slightly higher at 91kVp/8mA/18.8s, but with 0.7 mm of copper filtration. Since the exposed areas are identical, one may compare the dose (DAP) of 3200mGy*cm2 at 90kVp with the dose of 870mGy*cm2 at a slightly higher 91kVp but with about a quarter of the dose

Figures 6A and 6B: The value of alternate reconstruction algorithms such as the patented MAR algorithm can be appreciated on this case. The arrow in Figure 6A points to an area that is likely to be artifact but could also be resorption. The MAR algorithm used in Figure 6B clearly shows that it is an artifact of the FDK reconstruction algorithm. The area was normal when examined clinically

and have led to many errors in interpretation in textbooks, lectures, and research. That said, any means to improve image quality and reduce the appearance of these artifacts is always welcome, and I was delighted that the CS 9600 has two separate algorithms for CBCT study reconstruction — the traditional Feldkamp-Davis-Kress (FDK) and a second patented Metal Artifact Reduction (MAR) algorithm. This is implemented in software in two ways: 1) switching between the FDK and MAR algorithms for the entire study; 2) a highlighter type tool that shows the alternate algorithm as the mouse is moved around in the study. As an example of the value of the larger FOV and MAR, the patient in Figure 8 presented with left-side pain not localized to any particular tooth. He reported cold and pressure-biting sensitivity as well as more recent heat sensitivity. The clinical testing was equivocal, with teeth Nos. 12, 15, and 17, responding to cold while tooth No. 18 and the previously treated mesial root of tooth No. 19 were not responding to cold. Teeth Nos. 15, 17, and 18 were all percussion-sensitive, consistent with clenching/ grinding and their terminal positions in the arch. Projection radiography was unremarkable. I ordered a half-mouth study to see if there were any findings at CBCT (Figure 8). 32 Endodontic practice

Figures 7A-7C: 7A. A closer look at the same case from Figure 2 in thick section pseudo-panoramic view. Note the radiolucent area of beam-hardening between the implants on the 7B. FDK versus the 7C. MAR

Tooth no. 15 had a finding that was likely artifact, but could have been resorption (Figure 6A). Switching to MAR shows that it was artifact (Figure 6B). Tooth no. 18 had a small radiolucency consistent with recent pulp necrosis (Figure 8). Other structures in the area were WNL.

Smart features recall patient parameters for faster follow-up exams Another great feature of the CS 9600 is its ability to “memorize” patient positioning to deliver highly reproducible studies for evaluating interval change. Interval change is the language used to describe comparing two studies taken at different times to evaluate things such as radiographic evidence of healing of an endodontically treated tooth; bone growth in an extraction site in treatment planning a possible implant; or the progression of a resorptive defect on a tooth. A second advantage is that tricky setups and difficult-to-image patients may be adjusted from the previously known position in an earlier study to a slightly altered position to optimize the study in a subsequent study. My experience with the CS 9600 has changed the way I diagnose and treat patients, as well as my relationship with referrals. There’s no doubt that introducing a

Figure 8: The half-mouth study is quite useful in the endodontic domain as both the maxillary and mandibular posterior teeth can be imaged in a single study. Here, there was a subtle periapical finding on tooth No.18, which was percussion-sensitive and did not respond to cold. Pulp necrosis was confirmed upon entry

CBCT system to the endodontic practice will take doctors to the next level of care, but the advanced intelligent features of this newest system help doctors reach the pinnacle. EP

1. The interested reader is referred to “Advanced CBCT for Endodontics: Technical Considerations, Perception, and Decision-Making 1st Edition” by John A. Khademi, Gary B. Carr, Richard S. Schwartz, and Michael Trudeau for an introduction and description of the issues, along with strategies, for optimizing image quality.

Volume 12 Number 2

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PRODUCT PROFILE

The elements™ e-motion Dr. Gary Glassman describes a product that improves the ease and effectiveness of root canal treatment

ith the world of dental technology continuing to rapidly evolve and change, KaVo Kerr remains at the top of its game with a strong commitment to dental excellence. As the company succeeds in producing advanced dental products, the attention paid to the quality of their work results in bringing great challenges for their competitors. This month the spotlight is on the new elements™ e-motion motor, a modernized endo motor that provides optimal efficiency. This German-manufactured and designed model comes equipped with intuitive menus, an easy-to-use, large, colored touch screen (one of the largest on the market), and an interface that allows five fully customizable presets with up to 10 file options each in addition to 24 preset file systems, making it more manageable to set up the clinician’s specific file sequence out of the database. It is also very easy to get software updates, if necessary, and one need only use a laptop with Windows 7 or higher and an adapter program to do so. The new elements e-motion Endodontic motor makes it a great investment for those practicing endodontics. With superior strength, providing high durability, and the continuous run of the file till, a torque of about 0.2 Ncm is reached, which means that the Adaptive Motion will only start after a higher torque is reached. The elements e-motion motor has made great strides when measured against the company’s current motor with Adaptive Motion, as it comes with an improved higher cutting efficiency and is better able to resist breakage/deformation and canal transportation.

The elements™ e-motion

When compared to other endodontic motors on the market, the more contemporary-looking elements e-motion is both smaller and lighter and can be best compared, by its resemblance, to the successful ELECTROmatic™ system. The elements e-motion also comes with a small footprint, occupying less space than those in its class. This perfectly balanced instrument has a lightweight controller system of approximately 680 g/24 ounces and a footprint of approximately 148 x 168mm/5.83" x 6.61". Another reason to favor the elements e-motion is its smaller volume when compared other endodontic motors on the market in addition to the

Gary Glassman, DDS, FRCD(C), graduated from the University of Toronto, Faculty of Dentistry in 1984 and was awarded the James B. Willmott Scholarship, the Mosby Scholarship, and the George Hare Endodontic Scholarship for proficiency in endodontics. A graduate of the Endodontology Program at Temple University in 1987, he received the Louis I. Grossman Study Club Award for academic and clinical proficiency in endodontics. The author of numerous publications, Dr. Glassman lectures globally on endodontics, is on staff at the University of Toronto, Faculty of Dentistry in the graduate department of endodontics, and is Adjunct Professor of Dentistry and Director of Endodontic Programming for the University of Technology, Kingston, Jamaica. Dr. Glassman is a fellow of the Royal College of Dentists of Canada, fellow of the American College of Dentists, endodontic editor for Oral Health dental journal, endodontic editor for Inside Dentistry, Faculty Chair for DC Institute, and Chief Dental Officer for dentalcorp in Canada. Dr. Glassman maintains a private practice, Endodontic Specialists, in Toronto, Ontario, Canada. His personal/professional website is www.drgaryglassman.com, and his office website is www.rootcanals.ca He can be reached at gary@rootcanals.ca. Disclosure/Disclaimer: Dr. Glassman is a paid consultant for Kerr. The information in this article is Dr. Glassman’s opinion. Kerr is a medical device manufacturer and does not provide medical advice.

34 Endodontic practice

current Elements Motor. It also includes, in the package, a foot control, a 2-meter power supply cable, an 8:1 handpiece, and a motor cable with a KL 703 KaVo motor. One of the superior features of this model that makes it of a higher rank is the KaVopowered, flexible, 8:1 stainless steel handpiece, with a handpiece holder that offers four multiple mounting options, which is suitable for both right-handed and left-handed users. This furthers ease and precision while finding comfort in navigating the system during treatment. In a world with continual research and development, many devices enter the market every day. Excellent endodontic clinicians know how important it is to find ways to improve their technique and will keep reaching for outstanding products. This is why the elements e-motion motor is a game changer for clinicians. It is a functional improvement due to the updated KaVo design (and software) with the added Adaptive Motion feature. The elements e-motion is also a wise investment since it will improve the ease and effectiveness of root canal treatment, while adding great value to your practice. EP Volume 12 Number 2

It does more than save you time. It completely changes how you spend it. With adaptive technology motion, 196 pre-loaded file settings, and a remarkably intuitive touch-screen interface, the new elements™ e-motion is equipped to streamline the endo experience. Learn more at kerrdental.com/e-motion

elements™ e-motion

PRACTICE MANAGEMENT

Shift your practice into high gear by turning your endo marketing upside-down! Dr. Mark Reber discusses reaching out to GPs each month and sharing practice-building information

hat are you doing to grow your endodontic practice? If you are like most of the specialists who reach out to me as a general dentist, you’ll call my office and set up a time to take me to lunch. We’ll make small talk over a nice meal and as we wrap up, you’ll share some new information about endo. “Hey, let me tell you about my new bioceramic sealer!” We’ll shake hands and each run back to our busy afternoons. “Take care! See you in a few years!” Sound familiar? Is that really the best you can do? Thankfully, there is now a much better way to reach out to all your local GPs and really catch their attention. Imagine what would happen if you really did “turn your marketing upside-down” and didn’t talk about yourself at all? What if instead you turned all your focus on to the GPs and their practices? Instead of meeting GPs one at a time and talking about warm versus cold gutta percha, imagine sending all the GPs a warm personalized letter, introducing yourself and including some of the latest general dental news from the Chicago Midwinter Convention or the Annual ADA Convention. Now they are listening to you! For example, a few years ago, a new anesthetic technique was developed that allows the dentist to instantly anesthetize any tooth … even mandibular molars. We aren’t even talking about a 60-second wait. You can now literally put down the syringe after using it on tooth No. 30, immediately pick up the handpiece, and start working. Here’s the even bigger news: 99% of the dentists out there have never even heard of this groundbreaking anesthetic technique!

Mark Reber, DDS, MS, is a general dentist with a private practice in Morgan Hill, California. He is the owner of The Referral Bridge, a company that helps specialists grow their practices by sharing GP news, clinical tips, and other ideas each month while the specialist quickly creates a following of the appreciative GPs in the community. A sample letter can be seen at TheReferralBridge.com.

36 Endodontic practice

This technique was just demonstrated to senior dental students at one dental school in 2018 and will certainly be taught at others in the years to come. A decade from now, most dentists will probably be aware of it. But your GPs can hear about it next month — from you! As you reach out to your GPs with golden nuggets like this each month, you quickly develop an all-new stature. The GPs now see you as their friend and ally because you are sharing things that they can use in their practice every day. You are helping them and impacting their bottom line. They return the favor by now referring their endo patients to their new friend and ally — you. What is reassuring is that you don’t have to hold yourself out as an “expert” on these monthly topics or necessarily endorse the techniques and ideas that you will be sharing each month. Instead, you will be openly giving credit where credit is due and steering your GPs to the appropriate primary sources if they are seeking more information about the tips you are sharing to help build their practices.

We all know that dentistry is changing and improving at a breakneck pace. It’s difficult for even the best dentist to keep up with everything. Now you are gaining a loyal following of GPs because you are helping them do exactly that. You can certainly research, organize, edit, and rewrite a newsletter like this yourself each month. Or you can reach out to The Referral Bridge, a company that works exclusively with dental specialists, to do all this for you, including creating the personally addressed letters for every GP in town each month. All you’ll have to do is press “Print,” sign the letters, and include a few referral slips with each one before you drop them in the mailbox. Done. And the great news is that it can be done for as little as a few hundred dollars a month! Now can you see the benefit of “turning your marketing upside down” and talking to the GPs in town about them instead of about you? And as you see your own practice grow while your GPs are seeing their practices grow, you can sit back and enjoy the perfect definition of a true “win-win.” EP Volume 12 Number 2

Silent Partners Invest Cash In Endodontists Claim Your No Cost Valuation In the last six months we have helped our client doctors put over $100,000,000+ in their pockets from silent partners. Doctors remain as partial owners, running their practice under the doctor’s brand and management. The silent partner provides capital, support and broad resources as needed to accelerate growth. When ready to retire, years or decades in the future, doctors have a known exit for their retained practice ownership. Clients (average age under 50) are not seeking a short term retirement strategy, but a cash secured future

and a silent partner which provides the tools and ammunition to compete more effectively and profitably. We have advised clients across the U.S. that values are peaking. The unique LPS approach creates value not possible with other advisors. We can confidentially show you the value of your practice under various custom structures at no cost or obligation. Even if you are not interested in monetizing all or part of your practice today, it pays to understand what makes your practice more or less valuable to an

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PRODUCT PROFILE

XLDent Endo Suite A software solution made for you and your patients

ndodontic practices are unique, requiring software solutions that are equally distinctive. When your business is referralbased and patient-focused, a “one-sizefits-most” dental software solution just doesn’t cut it. The XLDent Endo Suite is the simple stress-free solution you need for your growing endodontic practice. XLDent Endo features customizable endodontic forms allowing you to obtain treatment consent chairside using digital ink technology. This mobile, tablet-friendly feature is entirely paper-free. Charting and treatment plans can be done using touchscreen technology, while treatment-triggered progress notes make thorough documentation quick and convenient. XLDent’s ImageXL digital imaging software integrates seamlessly to provide an efficient and comprehensive charting experience.

The XLDent Endo Suite works for you While you are working chairside, XLDent Endo is working to improve office efficiency and productivity. The software features interactive sorting, filtering, and grouping of practice data that allows you to see exactly what you need without the clutter. XLDent Endo has referral tracking and customizable follow-up letters to fit the needs of the busy endodontic practice — everything you need to handle insurance claims plus patient statements, to receive electronic EOBs plus payments, and to manage your business in one comprehensive platform.

A patient-centered approach The successful patient-centered endodontic practice wants patients to feel connected to their dental care, and the XLDent Endo Suite provides the tools to do just that. A patient portal allows patients to view upcoming appointments, planned treatments, statements, and more. Patients can fill out registration and health history forms and even pay an outstanding balance, all from the comfort of their own home. Automated appointment reminders will keep missed appointments to a minimum and help fill holes in the schedule. When your patient walks into the office, check-in is efficient and paperless. Once in the operatory, clinicians can review planned treatments and images directly in the chart together with patients, helping to make the best choices regarding their health.

Smart technology. Efficient solutions. The XLDent Endo Suite has everything you need to take your practice to the next level. As your practice grows, the software has the ability to evolve to fit your needs. Both cloud- and server-based options are available, with unique solutions to seamlessly join multiple specialties and connect and manage multiple locations. XLDent Endo is the comprehensive management solution that ensures you and your team have all 38 Endodontic practice

the tools needed to run your practice more efficiently and profitably and will provide you with the platform you need to grow your business. What truly sets XLDent Endo apart from its competitors is not only best-inclass software, but also the service and support that comes with it. The company has been developing software and serving the dental community since 1971. When you call XLDent, you can expect outstanding customer service from staff that are experts in the industry. They are known for their commitment to providing innovative software solutions and listening to client needs to offer the best solutions in the industry. XLDent is the perfect partner for you and your endodontic practice. To learn more, call 800-328-2925, or visit www.xldent.com to schedule a demo. EP This information was provided by XLDent.

Volume 12 Number 2

I needed a software solution that was made for me and my patients.

Simple. Stress-Free. Solutions. XLDent offers an all-inclusive software solution that provides your endodontic practice with the tools you need to focus on what is most important. www.xldent.com/endo

Call to learn more. 800.328.2925 or 763.479.6166

SMALL TALK

Think to succeed Dr. Joel C. Small discusses skills that can positively impact the trajectory of your practice

“O

f all the things you can do, the quality of your thinking has the greatest consequences of all. The quality of your thinking determines the quality of your choices and decisions. Your choices and decisions determine the actions you take. And the actions you take determine the quality and quantity of your results.” ~ Brian Tracy, Bull’s-Eye Many of you have heard me say that leaders of extraordinary practices think in exceptional ways. I am firmly convinced that the difference between a mediocre and wildly successful clinical practice lies in the mind of the owner. Unlike other practice owners, highly successful practitioners have acquired skills that have positively impacted the trajectory of their practice. Some of the cognitive skills that highly successful practitioners have acquired include the following: • Seeing the big picture: Successful healthcare practitioners are “divergent” thinkers — seeing how problems and their solutions impact their practices in relationship to other dental practices and the industry as a whole. Thinking in a divergent manner is the benchmark of an entrepreneurial mindset. • Creative thinking: Creative thinkers are the ones who view old issues in a new light. They see things from a different perspective and provide unique solutions and answers that others often fail to see. Creative thinking creates generative energy that exudes passion and goal orientation for the entire organizational team. • Exceptional communication: Successful practitioners not only think differently, but also are skilled communicators. They are able to offer clear explanations to complicated issues.

Interestingly, the doctors who think in this extraordinary manner are also the ones that find the most joy and fulfillment in their professional endeavors. They are the thought leaders, not only for their individual practices, but also for the profession as a whole. • Decisiveness: Successful healthcare practitioners are not always the quickest to make decisions, but they are often the most committed to the decisions once they are made. This is because they make decisions only after thoughtful review rather than compulsive “knee-jerk” reactions. • Scaling capabilities and capacity: Successful entrepreneurs understand that change is inevitable and that keeping pace with change is a prerequisite for long-term success. As the complexity and demands of our business environment increase, our knowledge, skill, and capacity to do more must also increase. Strong leaders are visionaries who do not respond to change. They foresee change and are proactive by ensuring that their organization has the skill, knowledge, and capacity to respond appropriately. • A philosophy of abundance: The most successful people, in any industry, will tell you that they achieve lasting success by making those around them successful. Yes, financial success is achievable with a “scarcity philosophy,” but it is, more often than not, short-lived.

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.

40 Endodontic practice

Not all great practices are led by people who naturally possess these unique qualities. Many entrepreneurial practitioners have worked hard to develop these critical skills. Some have taken courses or have become avid readers in areas that enhance these skills. Others have surrounded themselves with a team of advisors who collectively provide these cognitive skills when addressing practice-related issues. And some practitioners have relied on coaches to help them uncover these essential skills that they never knew they possessed. Interestingly, the doctors who think in this extraordinary manner are also the ones who find the most joy and fulfillment in their professional endeavors. Why? Because they exude confidence and are willing to change course or take bold steps when their analysis indicates the need for change. They do not see themselves as being trapped in the status quo. To them, everything is fluid and subject to change. They find the path to success challenging and exciting rather than intimidating and fearful. They are fully engaged in the game. If loss of passion and clarity is the etiology of “burnout,” these folks are the living antithesis of these symptoms. Finally, those who have developed these cognitive skills are successful leaders. People are attracted to them because of their positive energy and their focus on creating cultures that breed success. You will find that these are the ones who surround themselves with high performance teams and experience little turnover in their staff. They become magnets for high achievers that are interested in developing their capabilities. Ask yourself if you are one of these exceptional leaders. Do you find joy in what you do? Are you energized and fully committed to succeed? Are you excited about your future or fearful? Is dentistry just a job for you, or is it more? EP Volume 12 Number 2

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Change the way you communicate with your patients. Learn more at www.zeiss.com/us/extaro300.

So smart,

so simple. Introducing the CS 9600 scanner for endodontists. There’s nothing simple about endodontic treatment. But now there is a simpler way for your staff to capture the high-quality images you need to achieve faster diagnoses and treatment plans. Learn more about this simply brilliant scanning solution at carestreamdental.com/CS9600.

CS 9600