Endodontic Practice US Winter 2019 Vol 12 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Winter 2019 – Vol 12 No 4 • endopracticeus.com

ENDODONTICS

Removal of fractured endodontic instruments: a report of two cases Drs. Casper H. Jonker and Carel (Boela) van der Merwe

Practice profile Dr. Renato Miotto Palo — a global view of endodontics

Effective retreatments with the GentleWave® System Dr. Brian T. Wells

Conservative preservation of maxillary incisors with uncommon root anatomy, using an MTA apical plug Drs. Andrea Polesel and Arnaldo Castellucci

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WE LIVE ENDO™. We are Sonendo®, advocate for the endodontist in our shared pursuit of saving teeth. It’s the overall way we approach our business: innovating for the improvement of patient care, educating to increase endodontic awareness and advocating on behalf of the endodontist.

TOGETHER: WE LIVE ENDO.

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.

The last mile

was reading an article recently about how cities around the world are developing new strategies to deal with the proliferation of delivery trucks. In the past, trucks would deliver in bulk to stores (they still do), and customers would go to stores to get items (they still do, less frequently). Relatively few things, such as large items, required actual delivery to a residence. Now, in our Amazon-fueled world, the smallest of items can trigger a shipment that needs to be delivered. The interesting fact in the article that caught my attention was that close to half the cost of shipping an item is incurred for what is called “the last mile.” That’s the part of the shipment in which your package is sorted out from everyone else’s and placed on the Albert (Ace) Goerig, DDS, MS, exact vehicle that will deliver it to you that very day. It’s a management and logistics process that is completely personalized to the specific needs of each customer for every delivery. I’m fairly confident that Amazon, when it opened as an online bookseller, never anticipated that so effectively mastering the final mile of delivery would lead the company to such dizzying heights of success. If Amazon hadn’t had that breakthrough, it probably would have still been a moderately successful online seller of books, but nowhere near what the company is today. In my mind, this is a perfect example of the fundamental issues that hold back a business owner, such as an endodontist, from really experiencing tremendous success. We’re all familiar with saying that 80% of new small businesses fail. And yet, if you look at those businesses, they probably were doing the right things 95% of the time, but they just couldn’t figure out what made it all work. They walked away not knowing how close they really were to success. Similarly, I would go so far as to say 80% or more of ongoing businesses, while not failing, have not figured out their “last mile” — how to bring everything together in a way that really clicks and unlocks the highest level of success possible. Endodontists are no different in this regard. Most endodontists are sitting in a comfort zone that is “good enough” but far less than what it could be. It’s a credit to our profession that few endo practices actually fail despite high barriers and eye-watering costs to enter endodontics today: dental school, residency, buying a practice, investing in upgrades and technology, maintaining a modern facility, and employing a competent, effective team. There’s a lot at stake, and we should not be satisfied with “good enough.” We need to master the last mile with our team, our patients, and ourselves as professionals engaged in the business of endodontics. We especially need to master it with our referring doctors by developing strong collaborative relationships based on clinical trust and value. It is a process of ongoing reinvestment, but when you go the distance on that last mile, the opportunities in endodontics are unlimited. Dr. Albert (Ace) Goerig

Albert (Ace) Goerig, DDS, MS, is a Diplomate of the American Board of Endodontics and a sought-after speaker who has lectured extensively in the field of endodontics and practice success throughout the United States, Canada, and abroad. He has authored over 60 articles and is a contributing author to numerous endodontic textbooks. He currently has a private endodontic practice in Olympia Washington that is in the top 1% of endodontic practices while practicing only 90 days per year. He has over 40 years of experience as an endodontic educator and 22 years as a practice coach to nearly 1,000 endodontists. Dr. Goerig’s dedication to clinical care, business success, and financial freedom for doctors is the driving force behind Endo Mastery. www.endomastery.com

ISSN number 2372-6245

Volume 12 Number 4

Endodontic practice 1

INTRODUCTION

Winter 2019 - Volume 12 Number 4

TABLE OF CONTENTS

Publisher’s perspective

Practice profile

Celebrating 15 years of growth and learning Lisa Moler, Founder/CEO, MedMark Media................................................ 6

Dr. Renato Miotto Palo — a global view of endodontics

Clinical The evolving look of “The Look” Dr. John West offers a quick visual reference guide as a starting point for pretreatment and posttreatment evaluations...................................... 17

Conservative preservation of maxillary incisors with uncommon root anatomy, using an MTA apical plug

Educator profile

S. Ryan Facer, DDS, Greater Endodontics

™

Dental Learning Live platform

Drs. Andrea Polesel and Arnaldo Castellucci show successful combined nonsurgical-surgical endodontic retreatment aided by CBCT..............22 ON THE COVER Inset image on cover courtesy of Drs. Andrea Polesel and Arnaldo Castellucci. See article on page 22.

2 Endodontic practice

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TABLE OF CONTENTS

Case study Effective retreatments with the GentleWave® System Dr. Brian T. Wells discusses a procedure for thoroughly cleaning and disinfecting the root canal system .......................................................28

Drs. Rahul Halkai, Kiran Halkai, and C. Jyothi investigate a common microorganism associated with endodontic persistence and reinfection ....................................................... 32

Product insight BeamReaders® offers insight into CBCT images for endodontists Drs. Poorya Jalali and Mehrnaz Tahmasbi discuss how having the trained eye of a radiologist can offer peace of mind to diagnostics .......................................................41

Continuing education Application of biosynthesized silver nanoparticles to eradicate Enterococcus faecalis from infected root canals — a review

Continuing education

Practice management Practice management Empowering your practice and team for growth and freedom Dr. Albert (Ace) Goerig discusses how to cultivate a more successful practice and get more out of life at the same time.................................................42

Technology More GPs are using CBCT: What does that mean for endodontists? Dr. Cameron Howard discusses how endodontists can work with GPs to use 3D imaging more efficiently.......44

20/20 foresight: how to simplify team management and regain control of your practice Paul Edwards, CEO and co-founder of CEDR HR Solutions, offers guidance on building an effective management system............................................45

Small talk The abundant leader Drs. Joel C. Small and Edwin McDonald love the idea of abundance and promote this concept with their clients..............................................48

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

Volume 12 Number 4

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PUBLISHER’S PERSPECTIVE

Celebrating 15 years of growth and learning As the publisher of Endodontic Practice US, I have had so many opportunities to read, meet, and learn from “master teachers” — their wisdom comes from many fields, from dental KOLs to management gurus to technology and selfimprovement. One of the ways that I keep their tenets in mind is through collecting meaningful quotes — one of my greatest passions. Quotes from Wayne Dyer, Jim Rohn, Zig Ziglar, Marianne Williamson, and Tony Robbins reflect where I’ve been and what I’ve achieved in my half century on this earth. Each insight, opinion, and perspective has served as an integral part of my own personal growth, as well as the growth of each of MedMark Media’s publications. In the coming year, MedMark Media celebrates its 15th birthday! It’s been a growth experience, Lisa Moler Founder/Publisher, MedMark Media not only for me, but also a time of growth, learning, and building relationships among our readers, authors, and advertisers. This issue of Endodontic Practice US offers both clinical and management articles to extend your horizons, both clinically and in business. In their CE, Dr. Rahul Halkai and colleagues delve into fungal-derived silver nanoparticles as antimicrobial agents in eradicating e faecalis from root canal infections. Dr. Casper H. Jonker, et al., provides a CE that includes two case reports and information about removal of fractured endodontic instruments. Dr. Brian Wells illustrates an effective retreatment case using the GentleWave® System. On the business side, Dr. Albert (Ace) Goerig offers guidance on how to cultivate a more successful practice and enjoy life — it is possible at the same time! Paul Edwards, CEO and co-founder of CEDR HR Solutions, offers insight into simplifying team management and regaining control of your practice. Both the clinical and business sides of your practices must be nurtured to reduce your stress and increase your success. Fifteen years ago, MedMark Media’s home office was based here in my hometown of Scottsdale — my corporate headquarters was comprised of a makeshift office in my tiny second bedroom. My sole employee was a 17-year-old intern who found the job from a posting that one of my fellow publishing friends put up at one of the local colleges. I had a hopeful hunch that she would work out. Diving into contracts and paperwork, we shared a computer and a dream of producing a publication that mattered in the dental industry. Within that first year, my Arizona market held the top ranking out of about 12 markets at the time. And amazingly, 15 years later my first employee, Adrienne Good, is still a valued member of the much larger MedMark Media team that now has grown to include departments for editorial, production, advertising, and digital media. I am fortunate to be a part of this beautiful “dental world” and can honestly say that this industry and the amazing people I’ve met within it literally have saved my life. I found my niche, and for 15 years have been striving, along with my team, to help you find and cultivate your niches. We all continue to innovate and seek new ways to help our readers reach new personal and professional heights. Of course, as in any profession, there will be challenges, but we want to provide you with the tools to step back, take a deep breath, and think, “I got this.” Feel free to contact us to share your ideas and articles. Along the way, I have had so many conversations and learned that everyone has a unique way of looking at the world and overcoming obstacles. We start this 15th year with hope, appreciation, and the knowledge that every day is an opportunity for learning. Thank you for being a part of our journey. 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 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 MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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PRACTICE PROFILE

Dr. Renato Miotto Palo — a global view of endodontics What can you tell us about your background? I am Brazilian, with Italian great-grandparents on my father’s side and Austrian on my mother’s. I grew up in the city of São Paulo. I have an uncle who is a successful dentist and has been such an inspiration to me. I applied to Paulista University, the school of dentistry in São Paulo in 1994. As soon as I finished my degree, I had the opportunity to specialize as an endodontist in a center that is a reference for research on cranial and facial changes at the University of São Paulo, located in the city of Bauru, Brazil. At the end of my certification, I was invited to join the team, and so began my teaching life. I have a master’s degree from São Paulo State University, campus São Jose dos Campos, and a PhD in endodontics from São Paulo State University, campus Araraquara.

Dr. Palo carefully examining a patient

master’s and doctorate studies, I participated in the development of a research line to understand the real functioning of whitening materials and their effects on dental tissues. Thus, several studies were conducted to understand the individualization of the teeth and how to achieve more predictable results with a better understanding and control of possible post-whitening sensitivity.

Why did you decide to focus on endodontics?

Dr. Renato Miotto Palo

When did you become a specialist? I completed my specialization in endodontics in 1999.

Is your practice limited solely to endodontics, or do you practice other types of dentistry? My clinical practice is focused on endodontics and teeth whitening. During my 8 Endodontic practice

During my years in dental school, I realized how challenging it is to understand and control the pain and symptomatic processes of patients. Endodontics was the specialty that the students feared at the time, but it encouraged me to understand these processes well, which brings a very comforting feeling when we control, solve, and save a dental element.

Do your patients come through referrals? Yes, my office is a specialized service where each area is led by a specialist. Most

of the time, I receive referrals from dentists to solve complex endodontic cases as well as challenging tooth-whitening cases.

How long have you been practicing endodontics, and what systems do you use? I’ve practiced endodontics since 1999, the year I finished my certification. Of the systems, I think we have two different root canal preparations: mechanical and chemical. The mechanical preparation consists of the different sequences of files and instruments, both rotatory and reciprocation, and the chemical preparation involves the entire decontamination of the contaminated endodontic space. As for the mechanical systems, I like the RECIPROC® System Kit by VDW®. However, in my opinion, a very important part of endodontics is the correct cleaning of the root canal system, where the family of Ultradent products gains prominence, including ChlorCid™ Surf Solution, Consepsis™ solution, Ultradent™ EDTA 18% Solution, UltraCal™ XS calcium hydroxide paste, and MTAFlow™ repair cement. I also serve as an advisor to the clinical affairs department at Ultradent Products, Inc. Volume 12 Number 4

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PRACTICE PROFILE What training have you undertaken? After receiving my dental title, I earned a degree as a certified endodontist, a master’s degree in endodontics, and a doctorate in endodontics. I also hold a laser certification from the Academy of Laser Dentistry (ALD).

Who has inspired you? Definitely my greatest inspiration was my uncle, Dr. Antonio Fernando Miotto, an endodontist. In my academic life, the following professors were great teachers for me: Renato Leonardi, Celso Nishiyama, and Marcia Valera. And I can’t fail to mention Dr. Dan Fischer as a person who continuously improves daily dentistry.

What is the most satisfying aspect of your practice? To treat patients who arrive in pain. Pain is the most challenging feeling to understand and treat because different people respond differently. Thus, being able to diagnose the painful processes as well as treating them is very rewarding.

Professionally, what are you most proud of?

The waiting room in Dr. Palo’s Brazilian practice

In general, the future of dentistry lies in looking at the patient as a human being — not just as one or a few teeth to be repaired.

My career has given me the opportunity to speak in different parts of the world; more specifically, I’ve been to 65 countries, different universities, and cultures. I have learned that we have different ways to practice dentistry with different ways to regulate it. What is allowed in one country is not allowed in another. Understanding dentistry in different ways is very exciting because we can see that the opportunities for helping people to have a better oral condition are much greater than we think. Previously, I chaired two postgraduate programs in Brazil and have organized several dental meetings, including serving as scientific coordinator of Sao Paulo Dental Meeting. In total, I have given 350 presentations in 65

Dr. Palo consulting with fellow clinicians

countries, and I speak Portuguese, Spanish, and English.

What do you think is unique about your practice? There are three important points that I consider 10 Endodontic practice

exceptional. First is understanding the individuality of the patient, as we receive people who react differently to various clinical situations and prognoses. Second is being in different countries and different cultures helps to understand the different needs of patients. Third is always using high-quality products to promote the best outcome for the patient. Volume 12 Number 4

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PRACTICE PROFILE

Dr. Palo speaking to doctors, as he does regularly around the world (left) and the street view of Dr. Palo’s Brazilian practice (right)

What has been your biggest challenge? Social media: In our office, we receive people from different regions and countries. Today, social media strongly influences patients who often come up with misconceptions about clinical conduct, and it is up to us to explain and deconstruct wrong information. This is challenging.

What career would you have chosen if you had not become a dentist? Since I was 5 years old, I went to my uncle’s office dressed in white clothes and wanted to help and become a dentist. So, I think I would be a dental assistant.

What is the future of endodontics and dentistry? In general, the future of dentistry lies in looking at the patient as a human being — not just as one or a few teeth to be repaired. We live in a challenging situation; when we want an immediate result for all cases and without thinking that each patient is different, most of the time we get non-lasting case results. I also like to ask my students, how many patients do we have inside a patient? Because we have in one mouth, different teeth that were born on different days and suffered different stimuli throughout life, have different degrees of cellular aging with dentin showing different organic percentages. Keeping that in mind, we dentists will always improve the individualized diagnosis and thus, we will be able to present the best 12 Endodontic practice

Dr. Palo with his staff

technique, and always with high-quality products.

Listen to the patient, respect individuality, use high-quality products, and be up-to-date.

money, but financial reward comes when our performance increases, and then our credibility is consolidated. I love to mention the KSA rule: K is knowledge (which we acquire by studying and reading), S is skill (which we gain by practicing and training), and and A is so important, it’s attitude (which is how we act with the patient in everyday situations). Also, use high-quality products.

What advice would you give to a budding endodontist?

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

I understand that in the beginning of any profession, it is very important to make

I like to spend time with my wife and daughters and watch movies. EP

What are your top tips for maintaining a successful specialty practice?

Volume 12 Number 4

EDUCATOR PROFILE

S. Ryan Facer, DDS, Greater Endodontics™ Dental Learning Live platform What can you tell us about your background? I grew up roaming the mountains of Bountiful, Utah — mountain biking, snowboarding, wakeboarding, and rock climbing. I never really wanted to grow up, but eventually reality set in, and responsibility took over. It was time to get serious and focus on a career. It’s kind of a funny story on how I got serious about my education, and why I decided to go into dentistry. Let’s just say it all started with a girl and some friendly competition. I went on to graduate from the University of Utah with a degree in medical biology and attended the University of Iowa College of Dentistry. I graduated with high distinction and continued thereafter, specializing in endodontics. I have been published in peer-reviewed journals such as the Journal of Endodontics and the Journal of Dental Research. My research interests range from sealer coverage, bacteriophage therapy, roentgen therapy, and adult stem cells with an emphasis on bone biology and dental trauma.

Dr. Facer optimizing his microscope for a procedure

What originally attracted you to the specialty of endodontics?

Dr. Facer educating a patient 14 Endodontic practice

While in dental school, I had a natural affinity and attraction to microbiology, anatomy, and physiology. Endodontics offered me a unique understanding and perspective that incorporates these sciences, which is somewhat unique to endodontics and pulp tissue. For me, the prospect of restoring a tooth back to health or giving a tooth a second chance is very appealing and pure. I needed to find a way to incorporate basic sciences into dentistry, and I needed to find a way to use these skills in the way I practice dentistry. I have always looked at teeth differently as plants, not rocks. Rocks can be chipped away and ground down with little consequences, whereas if you over prune a plant it’s the complete opposite, just like teeth.

What aspect of your training inspired you to add educator to your list of accomplishments? I think all of us have had special educators in our lives who have inspired us. My mother was an elementary schoolteacher; she inspired me. I have three sisters, and all are teachers. I grew up around teaching and learning. A joke around my office is that my patients are going to get educated, whether they like it or not. Frankly, I’ve learned after 15 years of practice, that it pays dividends to educate my patients upfront. The same goes for continuing education. When we take the time to actually learn upfront, then we won’t be making excuses for inabilities in arrears. I think that was the reason I wanted to become an educator. When I struggled, whether I learned the solution myself or took inspiration from another, the outcome was very satisfying. This inspired me to dream up an education platform and Volume 12 Number 4

EDUCATOR PROFILE

diversify my practice with something we call Dental Learning Live. Dental Learning Live is a platform for dentists to learn all aspects of dentistry, not just endodontics. So to get it started, we kicked it off with advanced endodontic techniques.

What are your proudest moments in the clinical and teaching aspects of your life? Honestly, it is the interests that my staff have taken to it. They work feverishly to see the educational projects, videos, and classes come to fruition. We all love having guest speakers, other dentists, and endodontists attend and inspire us all to do more, to do better, and to keep true to the calling of taking better care of patients. To see the Dental Learning Live catch on and stand upon its own has just been wonderful.

What do you think is unique about the topics you teach?

Procedural operatory and consult room

I think whatâ&#x20AC;&#x2122;s unique is the perspectives that we try to bring. Everything is real; nothing is staged. This includes imperfections and unique perspectives that come from complex cases. The learning environment offers everyone to have a fresh set of eyes or a beginnerâ&#x20AC;&#x2122;s mindset. It is this openmindedness and diverse perspectives from others that makes the Dental Learning Live platform so powerful. To learn a new skills and to try to better oneself creates a contagious environment. The reality is no one person has all the answers. Collectively, we can become greater together.

On-site endo training

Endo content production (above) and microscope training content (right) Volume 12 Number 4

Endodontic practice 15

EDUCATOR PROFILE

Dr. Facer and wife, Amber, at Castillo San Cristobal in Puerto Rico Unwind with a Jazz game and dad time

As an educator, what have you learned from your clinical students? Great question! Actually, that is the best question that has been asked! Yes, I have learned a great deal from my students. How can you not learn from others, when we are all tasked with the same challenges at hand. We all are trying our very best to successfully take care of our patients.

What has been your biggest challenge in sharing information and educating endodontists? Well, the biggest challenge brings us back to the reason why I created the Dental Learning Live platform. It’s hard for people’s schedules to align along with the time and resources to travel and collaborate. To be able to create this environment remotely is something that I was passionate about. We are constructing a platform that will align all of us and bring us together. We have to always be improving. We need constant inspiration and nudging forward, or we will suffocate in the status quo. Can you imagine how powerful a common and purposeful platform can be? One that will create a community that is very meaningful.

What advice would you give to budding endodontists? Look at teeth as people and not people as teeth. Treat needs and not benefits. Always keep an open mind; you never know what innovations the future holds. 16 Endodontic practice

What is the future of endodontics? The future of endodontics to me falls within the realm of reversible pulpitis in teeth. How great would it be to actually prevent the disease? Why can’t we chase down the causative etiology and stop the progression of a disease? Sometimes I feel like we are playing horseshoes and hand grenades — where close enough is good enough. Meaning we allow bacteria to cause irreversible damage or necrosis to the pulp which leads to root canals or extractions. Why is it that way? Why do we feel drilling and filling is all dentistry can do? The future of dentistry lies in the eradication of the causative insults — namely, bacteria. We need to learn how to keep pulp tissue alive and well and intervene along the pathogenesis of the disease process instead of letting the disease process take over. This would necessitate and incorporate novel diagnosis, early microbial detection, and novel strategies to eradicate bacteria from enamel, dentin, and pulp tissue. Until we have novel ways of controlling bacteria, dental caries will also continue to be treated in a fashion similar to root canal treatments, through gross destruction of tooth structures. So again why is that so? If bacteria can get inside the tooth, why can’t we? Why can’t we hunt bacteria down through the same pathways upon which they encroached the tooth and pulp in the first place? The future should turn preventive maintenance inside out. Current preventive efforts include fluoride, flossing, and toothbrushing, yet these should never be considered good enough. In fact, the great Dr. Charles Horace Mayo,

founder of the Mayo Clinic, made this profound statement: “The next great step in prevention should be made by dentists. The question is will they do it?” There is, without a doubt, a new frontier in regards to microbe hunting and preventive care yet to be discovered and has been so ever since Dr. Mayo made that statement to dental thought leaders in Chicago in 1913.

What would you have become, had you not become a dentist? I would have been a medical doctor specializing in research. I have a love for biology, physiology, and discovery of applications that can make a difference in a patient’s life. I love looking into the past to gain insight into solving problems of the future. I’m more interested in what can be done than what is being done. It is hard to be satisfied with this mindset, but it certainly gives you a drive to push the boundaries.

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

Spending time with my kids Training and exercise Pilates and yoga Running, biking, snowboarding, boating, and wakesurfing Traveling and exploring wondrous destinations Humanitarian service missions Fly-fishing and losing myself to river time Reading biographies, nonfiction, and history books Attending Utah Jazz games EP Volume 12 Number 4

Dr. John West offers a quick visual reference guide as a starting point for pretreatment and posttreatment evaluations

“T

he pulp is a big issue about a little tissue.” This quote is credited to early endodontic educator Dr. Sam Seltzer of Philadelphia. Nothing has changed. Restorative dentists have discovered that endodontics is one of the fastest ways to grow their practices, and, therefore, most dentists want to add more endodontic procedures to their schedules. However, as dentists, we are almost all built alike. We also want to do a better job. Our No. 1 desired outcome in clinical dentistry is predictability. I know this because after more than 30 years of clinical teaching, the most frequent question that students ask me is, “Is it predictable?” And the most frequent question that I ask students is, “Is it predictable?” Why do we ask this question? Because our No. 1 focus is our patients. We want to know that we are doing our best for them. So, consequently, dentists who perform endodontics in their practices always want to know what endodontists are doing. They want to compare their best with the level of care that the endodontic specialists are providing. They often bring endodontists their ﬁnal radiographic images and ask, “What do you think?” Until 3D endodontic imaging, the only comparison for the restorative dentist’s endodontic result versus the endodontist’s result was a 2D image. At this moment, a facial ﬁnal image-quality comparison is still the fastest way for a dentist to evaluate how he/she is doing with his/her treatment. The purpose of this article is to offer

John West, DDS, MSD, received his DDS degree from the University of Washington, where he is an afﬁliate professor. He is the founder and director of the Center for Endodontics in Tacoma, Washington, and a clinical instructor at Boston University, where he earned his MSD degree and was honored with the Distinguished Alumni Award. Dr. West and his two sons, Drs. Jason and Jordan West, are in private endodontic practice in Tacoma. Please contact Dr. West if you have questions to address to any of the contributors. Dr. West can be reached via email at johnwest@ centerforendodontics.com. Disclosure: Dr. West reports no disclosures.

Volume 12 Number 4

the restorative dentist a quick radiographic reference guide of radicular endodontic preparation outline and obturation forms. Of course, this comparison does not include details such as access design, the type of 3D cleaning, or obturation technique. This article represents a quick visual reference guide as a starting point for pretreatment and posttreatment evaluations. While none of the selected respected clinicians used precisely the same treatment protocol (i.e., instruments and technology), this does not matter. The endodontists who were chosen to be showcased in this article are highly trained and skilled. Any of them could prepare the root canal system’s final radicular shapes with literally any modern endodontic tools. They will likely have specific preferences, and most will feel quite strongly about their chosen tools and techniques because, for them, their protocols provide predictability, safety, and ease of delivery. All of us have different skill levels, a unique mix of patients, varied office infrastructure, and a different staff alignment; and we are all at different stages of our endodontic lives, requiring different interests in endodontic procedures. All of these variables make it impossible and inappropriate to actually compare my shape with your shape, but let the conversation begin. How do endodontists give the restorative dentist helpful and honest answers? To answer this question, we have to look at the back story: the Endodontic Triad and “The Look” of the dentist’s final digital radiograph.

Is the Endodontic Triad dead or alive? The purpose of endodontics is to prevent or heal lesions of endodontic origin. The rationale of endodontics is that any endodontically diseased tooth can be saved if its root canal system can be cleaned and sealed, either nonsurgically or surgically; if the periodontal condition is healthy or can be made so; and if the tooth is restorable. Recognizing the purpose of endodontics, Schilder1,2 was the ﬁrst to offer clinical mechanical radicular objectives to make

the rationale of endodontics predictable. Previously, the mechanical objectives were essentially described as “instrument and fill.” Schilder consolidated the 5 mechanical objectives into a simple intentional protocol, which most dentists refer to today as cleaning and shaping (more recently, with the acceptance of the NiTi revolution, some endodontists prefer shaping and cleaning). It should be noted that many earlier “instrumented” canals were neither cleaned nor shaped, based upon in vitro examination of extracted endodontic failures.3 Schilder’s 5 mechanical objectives evolved into the Endodontic Triad: clean, shape, and pack.4,5 These time-tested goals remain with the same validity; only the methods have changed. Endodontics has gotten better, safer, and easier, all the while resulting in an increased predictability for the dentist and the patient. Endodontic biology is part of any medical biology. The rules of Mother Nature remain the same: Eliminate the source of a disease, and the disease is gone! The symptoms of the disease also resolve, as symptoms are not sustainable without a cause. Meanwhile, the ravages of a healed disease may remain. While some authors would suggest the Endodontic Triad is no longer valid, the reader should note that, in these recent writings, the clinician(s) still perform the following: 1. Make an endodontic access followed by one or more endodontic files 2. Perform some form of irrigation cleaning 3. Fill the empty anatomy with a sealing material The only real difference between now versus the past is newer technologies. Examples include the following: the microscope for better vision; digital radiographs for enlarging images for better detail; 3D CBCT to evaluate the root canal system in three dimensions versus two dimensions; NiTi files for increased shaping control, confidence, and consistency; new hopeful technologies to enhance root canal system cleaning; and, finally, improved obturation techniques that better enable filling material Endodontic practice 17

CLINICAL

The evolving look of “The Look”

CLINICAL to ﬂow into all foramina as well as complex internal anatomy. In order for a dentist to better understand the desired preparation silhouette or outline form, it is worth revisiting Schilder’s original 5 mechanical objectives for a brief review. Otherwise, how can the endodontist answer the dentist’s question: “How am I doing?”

2. Each cross-sectional diameter becomes narrower from orifice to physiologic terminus (i.e., Schilder refers here to not only the facial view of the final radiograph but also the complete 360° view). 3. The root canal preparation is to follow the same multiple planes as the original root canal (i.e., flow). 4. Do not transport the foramina internally or externally (i.e., do not block, shelf, tear, or perforate). 5. Keep the foramen as small as is

Schilder’s 5 mechanical objectives 1. Continuously taper the funnel shape from the oriﬁce to the physiologic terminus (i.e., cone shape).

practical (i.e., do not intentionally increase the size of the foraminal physiologic constriction). Mechanical objective No. 4 refers to preserving the position of the original foramina. No. 5 refers to the goal of cleaning to the radiographic terminus in order to stay patent while shaping to, and not intentionally, beyond the physiologic terminus. It is also important to note all foramina are asymmetric to varying degrees. Therefore, if a foramen were determined to be a size No. 20, for example, that diameter is the

Figure 1: The evolution of endodontics’ “The Look.” I asked eight clinicians to submit one or two pretreatment and posttreatment endodontic radiographs that represent their present quality control levels of care based on their patients’ pretreatment and posttreatment radiographic images. I have also included my own examples. These radiographic templates (presented in alphabetical order except for my own) enable restorative dentists to compare their results with leading endodontists. Dentists always ask me, “How am I doing?” Now they can at least answer their own questions by comparing their endodontic finish radiographs with the current “Look” of the endodontists. You can grade yourself using the following simple 30-point scale. Here are three critical elements to consider when comparing your radiographs with theirs: (1) Smooth and appropriately sized preparations, based on the pretreatment and posttreatment images [10 points]. (2) The prepared radicular outline form preparation shapes should follow the shape/flow of the original canal itself [10 points]. (3) The obturation should be a solid obturation of the root canal system from orifice to physiologic constriction [10 points]. A total of 30 possible points. 1A. A 1950s silver cone treatment failing, as well as a lesion of endodontic origin — one tooth distal. While metal was pressed into undershaped systems with under-disinfected anatomy, many of these (crudely performed by today’s standards) silver cone treatments had a sustainable success rate, especially when coronal leakage was not present due to good restorative efforts by the dentist. 1B. Cover of Dr. John Ingle’s original endodontic textbook published in 1965. Students used to affectionally call the textbook “Old Yeller.” When I was a student, Dr. Ingle was dean of the endodontic department at the University of Washington dental school. He was a descendent of Davy Crockett, which explains his willingness to trailblaze many new standards in endodontics. For many years, students wanted to be just like Dr. Ingle. I was one of them. 1C. In this golden book of endodontics, Dr. John Ingle asked the then young and up-and-coming endodontic teacher at the Boston University School of Graduate Endodontics to submit a patient case. His name was Dr. Herbert Schilder. Pictured is Dr. Schilder’s submitted endodontic results. Note that the appropriate shapes speak for themselves — no rotary, microscope, 3-D CBCT, digital imaging, apex locators, EndoActivator® (Dentsply Sirona), Gentlewave® (Sonendo), or even sodium hypochlorite! Dr. Schilder had only principles, files, reamers, and a dedication to the minimally invasive preparations. Note Dr. Schilder’s 2-in-a-row treatment results! The bridge abutments both needed endodontic treatment. He taught his students that if you could do it once, you could do it twice, and so on. 1D and 1E. Clinical endodontics by Dr. L. Stephen Buchanan (Santa Barbara, California). He has always mastered the skill of having one foot in the past (timeless principles) and one foot in the future. 1F and 1G. Clinical endodontics by Dr. Thomas McClammy (Scottsdale, Arizona). Ever since I have known Dr. McClammy, he has been full of passion and purpose. He continues to discover how transformational technologies in 3D cleaning directly affect his shaping and obturation techniques. 1H and 1I. Clinical endodontics by Dr. Terry Pannkuk (Santa Barbara, California). Dr. Pannkuk’s shapes are a perfect example that “The Look” must be dictated by the original “Nature’s Look.” In both patients, Dr. Pannkuk, who is also a master innovator, demonstrates appropriate shapes for the roots in which they live: Figure 1H is a simple labyrinth, and Figure 1I is a complex labyrinth 18 Endodontic practice

Volume 12 Number 4

CLINICAL

Figures 1J-1T: 1J and 1K. Clinical endodontics by Dr. Reid Pullen (Brea, California) shows two elegant results, both heading down the road of predictable healing. Dr. Reid understands that different treatment technologies are case-speciﬁc. 1L. Clinical endodontics by Dr. Clifford J. Ruddle (Santa Barbara, California). He is the quintessential endodontic teacher. Every endodontic clinician has leaned valuable skills from him. Dr. Ruddle has made us better. 1M. Clinical endodontics by Dr. Wyatt Simons (San Clemente, California). Minimally invasive shapes for a delicately shaped natural root canal system. Dr. Wyatt is one of the young pioneers in endodontics and is always asking, “How can I make this easier and more predictable?” 1N and 1O. Clinical endodontics by Dr. Jason West (Tacoma, Washington). Dr. Jason is conﬁdent about his endodontic results because he has mastered preparing endodontic shapes that are appropriate for different roots. The trickier they are, the more fun for him. 1P and 1Q. Clinical endodontics by Dr. Jordan West (Tacoma, Washington). He deeply cares about his patient, the result, and the pride of a job well done. When patients are treated by Dr. Jordan, they receive his best. 1R to 1T. Clinical endodontics by Dr. John West (Tacoma, Washington). The “appropriate” Look has the same features regardless of anteriors, premolars, or molars

minimal diameter. The oval dimension (size) may be quite different — for example, a size No. 60 or greater! This is the reason for fully understanding mechanical objective No. 5, which suggests that the funnel shape is, more often than not, an oval or asymmetric apical shape. This knowledge facilitates obturation since the clinician is asking for a round cone of gutta percha to ﬁt into a non-round foramen, and it therefore must be distorted to minimize the gutta-percha/dentin interface. Newer obturation materials are offering the promise that the gutta-percha cone Volume 12 Number 4

serves only as a plunger to press nonresorbable material into the body of the root canal system, including the foramina. We just have to wait 5 years to be sure that these newer protocols will deliver what is being claimed.

“The Look”: dead or alive? “The Look” is far from simply a pretty image of a ﬁnal radiograph that has visible foramina sealed. Instead, what “The Look” has referred to in modern endodontics is the radiographic achievement of the 5 mechanical objectives for predictable

endodontics. That’s it! Because radiographically, “The Look” often reflects a replication of Mother Nature’s complex root canal system’s unique complexities; there was, and is, an element of pride and satisfaction for the clinician when the final image reflects this complex and often unpredictable anatomy. Endodontic clinicians often discover the anatomy when the root canal system is packed. Undiscovered anatomy becomes discovered through the hydraulics of vertical compaction plunger effect! I call this the endodontic seal. Endodontic practice 19

CLINICAL

Figures 2A-2F: 2A. Schematic of typical maxillary first molar root canal system prior to shaping. (Graphic Courtesy of Advanced Endodontics, Santa Barbara, California). 2B. The dots represent minimal apical physiologic dimension of the DB root. 2C. The dots indicate an appropriate diameter of radicular preparation approaching the canal orifice, thus preserving peri-cervical dentin in the mesial-distal direction as well as the precious ferrule itself. 2D. Proper radicular preparations connect the dots from minimally appropriate apical width to minimally appropriate coronal width. 2E. The DB conefit proves the funnel shape and defines the canal as ready for 3D obturation. Resistance form has been created throughout the 3D canal preparation surface from apex to orifice. 2F. A clinical example of three successful conefits to be easily followed by predictable 3D obturation

Replicating Mother Nature’s original anatomy has an element of beauty to it, but more importantly, it validates or proves that the dentist has been there physically through ﬁnding, following, and ﬁnishing each canal within the root canal system. “The Look” has evolved in recent years with the advent of previously mentioned new technologies that have literally turned the lights on for the endodontic clinician (Figure 1).

“Appropriate”: its role in minimally invasive endodontics Minimally invasive shapes are not new (Figure 1C). However, in achieving “The Look,” endodontists are not in full agreement about one characteristic, and that is the size of the clinician’s prepared funnel — how wide it is, and how tapered it is. The current trend in endodontics is for narrower shapes. Of course, all dentists and endodontists alike aspire to the concept of minimally invasive endodontics from access to apex. The only difference is really the size of the root with which one begins. It is more accurate for me to refer to minimally appropriate (Figure 2). The guideline is to “connect the dots” from foramen to access orifice. Nature makes root canals anywhere from one-fifth to one-third of the width of the root as it enters the canal orifice. This should also be the clinician’s 20 Endodontic practice

goal. Then, of course, root canals experience calcific degeneration to varying degrees with age. Some may even appear to fully calcify, but Mother Nature does not do a root canal treatment; and in fact, when calcific degeneration or calcific metamorphosis does occur, it occurs in a crown-down direction. The point here is that, if the clinician’s preparation is no wider than one-fifth to one-third of the width of the root (equivalent to Mother Nature’s natural state), sufficient tooth structure will remain to sustain the tooth for a lifetime, just as Mother Nature intended (Figure 2). The pericervical dentin is protected, and the ferrule must be preserved.

Closing comments Indeed, “The Look” has radiographic esthetics, but more importantly, it serves as a marker for biologic success. Certainly, a 2D image does not tell the whole story when a restorative dentist asks an endodontist, “Is this a good result?” The vertical extent, the shape of the radicular preparation, the density of the obturation, and the quality of the cleaning of vital or nonvital pulp and bacteria are all unknown variables. The greater variables are perhaps none of these, since the greatest variables of all are the host and host resistance to endodontic disease and the capacity for endodontic success. The threshold of the patient’s required

treatment thoroughness to achieve success is unknown. For example, an endodontic obturation halfway down the canal may be successful, while one filled with multiple lateral canals does not. Why? In endodontics, I have estimated thousands of chances each day to make mistakes or successes. Endodontics are truly in the clinician’s hands. In summary, the final radiograph gives us a glance into reality and suggests our level of attention to detail. And finally, now the restorative dentist can compare his/her final result with the endodontist’s. Michelangelo said it best: “Trifles are perfection, and perfection is no trifle.” What is your “Look”? EP

REFERENCES 1. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2):269-296. 2. Schilder H. Vertical compaction of warm gutta- percha. In: Gerstein H, ed. Techniques in Clinical Endodontics. Philadelphia, PA: WB Saunders Co; 1982. 3. West J. The Incidence of Underﬁlled Foramina in Endodontic Failures [master’s thesis]. Boston, Massachusetts: Henry M. Goldman School of Dental Medicine; 1974. 4. West JD. Endodontic predictability—“Restore or remove: how do I choose?” In: Cohen M, ed. Interdisciplinary Treatment Planning: Principles, Design, Implementation. Hanover Park, IL: Quintessence Publishing; 2008. 5. West J, Chivian N, Arens DE, et al. Endodontics and esthetic dentistry. In: Goldstein RE, Chu S, Lee E, et al, (eds.) Esthetics in Dentistry. 3rd ed. Hoboken, NJ: WileyBlackwell; 2018.

This article has been reprinted with permission from Dentistry Today.

Volume 12 Number 4

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CLINICAL

Conservative preservation of maxillary incisors with uncommon root anatomy, using an MTA apical plug Drs. Andrea Polesel and Arnaldo Castellucci show successful combined nonsurgical-surgical endodontic retreatment aided by CBCT Abstract The aim of this article is to present the conservative preservation of two maxillary incisors with uncommon root anatomies (dens invaginatus). The first case shows the retreatment, an apical plug of an extra large foramen (gauging 300), the subsequent endodontic surgery and healing of a lesion in a lateral incisor, with a 4-year recall. The patient presented in emergency with a sinus tract and an access cavity prepared 10 years previously. The cone beam computed tomography (CBCT) showed a large lesion, an extra large foramen, and unique anatomy. After the orthograde retreatment, an apicoectomy with retrograde obturation in mineral trioxide aggregate (MTA) was performed. The second case shows an apical plug with MTA in a central incisor with unusual root anatomy. The 8-year-old patient presented with an acute alveolar abscess. MTA was used to seal the main central canal and cap the pulp exposure of the distal canal. A radiographic recall after 14 years is shown. The aim of this article is to present the conservative preservation of two maxillary incisors with uncommon anatomies (dens invaginatus). â&#x20AC;˘ First case, lateral incisor: retreatment, apical plug of large foramen (gauging 300), surgery, and healing. â&#x20AC;˘ Second case, central incisor: apical plug and cap with MTA and 14-year recall.

Introduction Dens invaginatus is a rare malformation of teeth described first in a human tooth by a dentist called Socrates in 1856. It Andrea Polesel, DDS, is an active member of the Italian Society of Endodontics (SIE), an active member of the Italian Academy of Restorative Dentistry, an International Member of the American Association of Endodontists (AAE), an Adjunct Professor of Endodontics University of Genoa, and is in private practice in Arenzano (GE), Italy. Arnaldo Castellucci, MD, DDS, is an active member of both the Italian Society of Endodontics (SIE) and the American Association of Endodontists (AAE) and is in private practice in Firenze, Italy.

22 Endodontic practice

demonstrates a low incidence and a prevalence of 43% in the maxillary lateral incisors.1 Dens invaginatus is a developmental anomaly that results in an enamel-lined cavity intruding into the crown or root before the mineralization phase.2 The crown and root canal anatomical variations associated with the dens invaginatus are so numerous that it is very difficult to describe a classification. The first classification of invaginated teeth was proposed by Hallett in 1953,3 but the most commonly used classification was proposed by Oehlers,4 who described three subtypes, which are based on the extent of apical migration of an enamel-lined invagination. Schulze and Brand5 proposed a more detailed classification. The most common clinical finding associated with dens invaginatus is early pulpal involvement, which is explained by the existence of canals extending from the invagination into the pulp.6 Endodontic treatment of a tooth with dens invaginatus is considered a potentially complicated procedure. A survey of 307 Flemish dentists showed that if a tooth with dens invaginatus requires endodontic treatment, 38.4% of them will refer the patient to a specialist.7 The introduction of cone beam computed tomography (CBCT) has improved the diagnosis, the therapy, and the prognosis in many fields of dentistry. Endodontics has been the specialty that received the most important advantages from three-dimensional radiography, especially in a case of anatomical variations, traumatic injuries, complex retreatments, difficult differential diagnosis, and endodontic surgery. CBCT imaging in endodontics allows for three-dimensional evaluation of the external and internal anatomy.8 The success of endodontic treatment in teeth with complex internal anatomy depends on the use of CBCT and dental operating microscope.9 The following case report presents successful combined nonsurgical-surgical endodontic retreatment of a maxillary lateral incisor with dens invaginatus anatomy with the aid of CBCT.

Case report 1 A 22-year-old male patient was referred for evaluation and possible treatment of the left maxillary lateral incisor (tooth No. 10). He presented to the dental office complaining of symptoms with several episodes of swelling in the left anterior maxilla and a bad taste in the mouth. The patient reported a previous endodontic treatment in a maxillary left lateral incisor about 10 years previously. The root canal treatment had been initiated, but not completed, by the general dentist, and the tooth had been left open. The patientâ&#x20AC;&#x2122;s medical history was noncontributory. At the intraoral examination, a sinus tract was noted in the buccal periapical area of the maxillary left lateral incisor (Figure 1). The tooth showed an access cavity on the palatal side and a crown larger than the maxillary right lateral incisor. A panoramic radiograph, taken by the general dentist who referred the patient, and the periapical radiograph revealed a dens invaginatus and a periapical lesion involving especially the

Figure 1: During the intraoral examination, a sinus tract was noted in the buccal periapical area of the maxillary left lateral incisor Volume 12 Number 4

combined root canal retreatment (orthograde and surgical) was proposed, and an informed consent was taken. At the first treatment visit after isolation of the operating field with rubber dam, an access cavity was prepared and finished using an operating microscope (Leica, Switzerland); the coronal interferences were removed using burs and ultrasonic tips Start-X 2 and 3 (Dentsply Maillefer, Baillagues, Switzerland); and the root canal system was negotiated with K-files (Dentsply Maillefer). The mesial canal was thinner with a calcified canal, and scouting was obtained with C+ Files (Dentsply Maillefer). The irrigation was improved by using a sonic handpiece, EndoActivator® (Dentsply Maillefer). The anatomy found during

Figure 2A and 2B: 2A. A panoramic radiograph taken by the general dentist who referred the patient. 2B. The periapical radiograph revealed a dens invaginatus with a periapical lesion involving the mesial part of the root

Figures 3A-3D: The CBCT scan showed 3A. the presence of a dens invaginatus with three main canals: a mesial, a middle, and a distal canal. The images revealed also 3B. the presence of a periradicular lesion extending on the mesial side of the root and 3C. a very large foramen (3 mm). 3D. Axial section showing the three canals

Figures 4A-4C: First visit. 4A. Coronal interferences were removed using burs and ultrasonic tips, Start X 2 and 3 (Dentsply Maillefer, Baillagues, Switzerland). Irrigation was improved using a sonic handpiece, EndoActivator (Dentsply Maillefer). 4B. The root canal system was shaped, cleaned, medicated with calcium hydroxide, and temporary obturated with Cavit and a glass ionomer cement. 4C. Postoperative radiograph Volume 12 Number 4

scouting confirmed the anatomic anomalies revealed in the 3D radiograph with a thin mesial canal and two larger canals: one distal and one in the middle of the root. The root canal system was shaped, cleaned, medicated with calcium hydroxide, and temporarily coronally sealed with Cavit® and a glass ionomer cement (Stomidros Stomygen, Funo, Italy, and Ionolux Voco, Cuxhaven, Germany) (Figures 4A-4C). Two weeks later the patient returned, reporting that he felt better, but the sinus tract was still present. During the second visit, the rubber dam was placed, temporary access filling removed, and the medication removed; the root canal system was cleaned, shaped, and obturated. The key steps of the shaping were obtained by using a No. 10 K-file for scouting, PathFile® 1, 2, 3 (Dentsply Maillefer) to obtain the glide path and ProTaper Next™ nickel-titanium rotary instruments (Dentsply Maillefer) for final shaping. A radiograph with the instruments at the working length was obtained. During scouting, EDTA gel (RC-Prep; Premier Dental Products, Norristown, Pennsylvania) was used as a lubricant, and irrigation was performed with 5% sodium hypochlorite at each change of file. The irrigating solutions were delivered with a 30-G openended needle (NaviTip™; Ultradent, South Jordan, Utah) and activated after finishing shaping by using a sonic device, EndoActivator (Dentsply Maillefer). A rinse with 17% EDTA for 1 minute and a final flush with 5% hypochlorite were performed at the end of instrumentation. The root canal system was dried with paper points and obturated with two different techniques. The mesial canal was obturated with a gutta-percha cone X3 (Dentsply Maillefer), Pulp Canal Sealer™ EWT (Kerr Corp., Orange, California) and the vertical compaction of warm guttapercha. The middle and the distal canals were sealed with ProRoot® MTA (Dentsply Tulsa Dental, Tulsa, Oklahona), using a carrier (MAP One System, Produits Dentaires) to place the material at the apical foramen and a Thermafil plastic carrier (number 80 in the middle canal and number 50 in the distal canal) in order to adapt it more precisely in the apical third, preventing the voids. A wet cotton pellet and a temporary access filling was placed (Figures 5A-5E). Two weeks later during the third visit after rubber dam isolation of the operating field, the temporary obturation was removed, the setting of the MTA was checked, the coronal third of each canal was obturated with warm gutta percha, and an adhesive direct composite restoration was performed10 (Figure 6) (Optibond™ FL Kerr, Scafati, Italy; Enamel Plus Micerium, Avegno, Italy). Endodontic practice 23

CLINICAL

mesial part of the root (Figures 2A and 2B). Circumferential periodontal probing did not reveal pockets exceeding 2 mm around the tooth. In order to ascertain the variations of the root canal system, a CBCT scan was performed. Informed consent was obtained from the patient, and a multislice CBCT was taken with a Carestream CS81003D scanner (Carestream, Rochester, New York), and 3D-reconstruction images were obtained. A small field of view (FOV), 4 cm per 4 cm, was chosen. The images demonstrated the presence of a dens invaginatus with three main canals: a mesial, a middle, and a distal canal. They revealed also the presence of a periradicular lesion extending on the mesial side of the root and a very large foramen (3 mm) (Figures 3A-3D). A treatment plan with a

CLINICAL The patient was symptom-free, but the sinus tract was still present. Surgical endodontic retreatment was indicated. After local anesthesia, incision, and elevation of a full-thickness flap, the lesion was curetted, osteotomy was obtained with a round bur, and root-end resection was performed. A mineralized structure, covering the buccalapical surface of the root, was observed and removed by using a stainless-steel ultrasonic tip. The scaling of the surrounding area was performed in order to remove any bacterial biofilm from the outer root canal surface. A retrograde cavity was prepared by using a ProUltra® ultrasonic tip (Dentsply Maillefer) and sealed with ProUltra® MTA (Dentsply Tulsa). A collagen matrix was gently positioned in the cavity, and the flap repositioned and sutured (Figures 7A-E) with Ethicon® polyamide monofilament 6-0, (Johnson & Johnson Medical NV Belgium) Postoperative instructions were given to the patient. The patient was recalled for subsequent clinical and radiographic evaluation. During the first follow-up after 3 months, the sinus tract had resolved and was not present. The patient was symptom-free, and the periapical radiograph showed an appreciable decrease in the size of the lesion (Figure 8). After 2 years, the inspection showed the complete

healing of the sinus tract (Figure 9), and the periapical radiograph revealed healing of the lesion with healthy periapical and periodontal tissues in a symptom-free patient (Figure 10).

Case report 2 An 8-year-old female patient presented with an acute alveolar abscess in the maxillary right central incisor (Figure 11). The preoperative radiograph showed a periapical radiolucency, an unusual anatomy (dens invaginatus), with a main central canal and a wide open apex (Figure 12). During the first visit after placement of the rubber dam and preparation of an adequate access cavity, the root canal system was cleaned with copious irrigation with sodium hypochlorite. The root canal system was cleaned more than shaped in order not to increase the fragility of the dental structure. To improve disinfection and to raise the level of pH, the main central root canal was medicated with calcium hydroxide (Figure 13). One week later after removal of the intracanal medication, the root canal was irrigated with 5% sodium hypochlorite and dried with sterile paper points. By using an operative microscope, the apical foramen (Figure 14) was sealed with an apical plug of MTA, 3-mm thickness. MTA powder was mixed with saline solution and positioned

Figures 5A-5E: Second visit. 5A. The rubber dam was placed, irrigation was performed with 5% sodium hypochlorite at each file change, and irrigant solutions were activated after finishing shaping by using a sonic device, EndoActivator (Dentsply Maillefer). 5B. The mesial canal was obturated with a X3 gutta-percha cone (Dentsply Maillefer), Pulp Canal Sealer EWT (Kerr Corp., Orange, California), and a vertical condensation technique. 5C. The middle and the distal canals were sealed with ProRoot MTA (Dentsply Tulsa Dental, Tulsa, Oklahoma), using a carrier (MAP One System, Produits Dentaires, Vevey, Switzerland) to place the material at the apical foramen. 5D. A number 80 Thermafil carrier was used to adapt the MTA in the middle canal. 5E. A number 50 carrier was used in order to place material more precisely in the apical third of the distal canal. A wet cotton pellet and temporary medication was placed

exactly at the foramen (Figure 15) by using a Dovgan carrier (Dovgan, Vista Dental Products, Racine, Wisconsin). The material was adapted in direct contact with periapical tissues without overfilling. A thin layer of MTA was used for a direct pulp capping of the pulp exposure of the distal canal. An intraoperative radiograph was taken to check the extension of the apical plug (Figure 16). A wet paper point was introduced in the root canal for the setting of the apical plug, a cotton pellet was positioned in the pulp chamber in contact with the MTA, and the access cavity was sealed with a temporary obturation. During the third visit, the rubber dam was placed; the temporary restoration, the paper point, and the cotton pellet were removed; the MTA setting was checked with an endodontic probe; and the rest of the root canal system was filled with thermoplastic gutta percha (Figure 17). The access cavity was sealed with a direct adhesive composite restoration. The radiographic recall at 2 years (Figure 18) and 14 years (Figure 19) demonstrated healthy periodontal and periapical tissues in a symptom-free patient.

Discussion The success in endodontic complex cases depends on several factors: the experience and the skill of the clinician, the presence of specific instruments, and the respect of clinical protocols. In this case, it

Figure 6: Third visit. After isolating the operating field, the temporary obturation was removed, setting of the MTA was checked, the coronal third of each canal was obturated with warm gutta percha, and a direct adhesive composite restoration was placed

Figures 7A-7E: Fourth visit — micro-endodontic surgery. 7A. After local anesthesia, 7B. incision and elevation of a full-thickness flap, the lesion was curetted, the osteotomy was obtained with a round bur, and the root-end resection was performed. A mineralized structure, covering the buccal-apical surface of the root, was observed and removed by using a stainless-steel ultrasonic tip. 7C. Scaling of the surrounding area was performed in order to remove bacterial biofilm from the outer root canal surface. 7D. A retrograde cavity was prepared using a ProUltra ultrasonic tip (Dentsply Maillefer) and sealed with ProUltra MTA (Dentsply Tulsa). 7E. A collagen sponge was gently positioned in the cavity, and the flap repositioned and sutured. Radiograph after the endodontic surgery 24 Endodontic practice

Volume 12 Number 4

CLINICAL Figures 8-10: 8. The recall after 3 months showed an appreciable decrease in the size of the lesion. The patient was symptom-free. 9. After 2 years, inspection showed complete healing of the sinus tract. 10. The radiographic recall after 4 years showed healthy periodontal and periapical tissues in a symptom-free patient

Figure 11: Clinical view of the crown of the maxillary right central incisor in an 8-year-old female patient with an acute apical abscess

Figures 12 and 13: 12. The preoperative radiograph showed a periapical radiolucency, an unusual anatomy (dens invaginatus) with a main central canal and a wide-open apex. 13. Radiograph showing the main central root canal medicated with calcium hydroxide

Figure 14: The apical foramen as seen through the operating microscope (20x)

Figure 15: MTA powder was mixed with saline solution and positioned at the foramen Volume 12 Number 4

Figure 16: Intraoperative radiograph taken to check the extension and the quality of the apical plug

was very important to save the natural tooth because of the young age of the patient and the esthetic implications. The key factors for the resolution of this case can be summarized in some key points. 1. 3D radiography is mandatory in order to analyze the shape of the dens invaginatus, its internal anatomy, and the diameter of the foramen, and to evaluate the dimensions of the lesion. Many recent articles in the literature report the clinical advantages of the CBCT in the management of complex anatomies11,12 and dens invaginatus.2 The international guidelines give precise indications for the use of the CBCT.13,14 In this case, two clinical conditions indicated the use of a 3D radiograph: a dens invaginatus with complex root and canal anatomy and a surgical endodontic retreatment in the treatment plan. A small field of view (FOV) was chosen in order to reduce the dose of the ionizing radiation, to reduce the area of responsibility, and to increase the resolution.15 Endodontic practice 25

CLINICAL the operative field, the respect of the basic principles in cleaning, shaping and obturating the root canal system, and the anatomical and biological knowledge are the key factors to obtain predictable results in heavily compromised teeth. On the other side, experience, common sense, and the skill of the clinician are able to increase the long-term success in endodontic complex cases. EP REFERENCES 1. Hülsman M. Dens invaginatus: aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J. 1997;30:79-90.

Figures 17-19: 17. After checking MTA setting with an endodontic probe, the remainder of the root canal system was obturated with warm gutta percha. 18. Radiographic recall after 2 years. 19. Radiographic recall after 14 years showed healthy periodontal and periapical tissues in a symptom-free patient

2. The dental operating microscope is mandatory in order to analyze and treat the root canal system during an orthograde and surgical approach. It has been shown that its use could help in locating additional canals during endodontic treatment,16 improving treatment accuracy and expediting treatment.17 The microscope provides a high level of magnification and illumination, essential factors in managing a very complex anatomy. Another fundamental instrument to perform a precise apical plug is the carrier, used to position the material exactly at the foramen. Selection of specific instruments is a crucial factor, but not enough to obtain success. 3. Cleaning is a key factor for a good prognosis of invaginated treated teeth. The large and irregular volume of the root canal system makes proper shaping and cleaning difficult. Irrigation supported by ultrasonic cleaning has been described as an efficient means of disinfection18 and has been recommended for cleaning of the complex morphology of the root canal system in teeth with dens invaginatus.19 4. A combined nonsurgical-surgical approach is mandatory to resolve the case. The most common difficulties encountered with management of dens invaginatus include inadequacies with biomechanical cleaning and threedimensional obturation of the dysmorphic root architecture and the frequent lack of an apical and/or periradicular canal constriction, leading to potentially excessive overextension of the root filling material.20 The literature reports the healing of lesions in dens invaginatus after a surgical approach in most cases. The presence of an extra large, foramen ovale, visualized and measured 3-mm diameter in the 3D radiograph, is an 26 Endodontic practice

anatomical complication very difficult to handle in orthograde retreatment. MTA is the elective material in order to seal large apical foramina with nonsurgical and surgical approaches.21 5. The management of an extraradicular infection is another crucial factor to obtain healing of lesions and symptoms. Apical periodontitis is a disease caused by bacterial infection of the root canal system. The infection is usually restricted to the intraradicular space, but occasionally, it can spread to the extraradicular space. In some cases, the cause of symptoms was associated with the presence of extraradicular biofilms. In other cases, areas of mineralization with a calculus-like appearance were found on the external surface of the roots.22 In this clinical case, the extraradicular contamination was clearly present on the outer buccal root surface. A calculus-like structure could be appreciated in the apical third. Long-standing sinus tracts may function as a route of communication between the periradicular area and the external environment, permitting the passage of minerals and salts from the oral fluids into the apical periodontitis lesion.23 In this case, a double source of contamination (through the sinus tract and through the access cavity) could be the reason of the extraradicular infection. The removal of the calculus and the scaling of the surrounding area with stainless-steel ultrasonic tip are two essential steps of the endodontic surgery. Saving the natural tooth is the first choice in dentistry, especially in young patients and esthetic areas. The advanced technology, the operating microscope, ultrasonics, CBCT, and mineral trioxide aggregate (MTA) are essential instruments and materials to treat extra large foramina. A proper diagnosis, the isolation of

2. Vier-Pellisier FV, Pellisier A, Recuero LC, et al. Use of cone beam computed tomography in the diagnosis, planning and follow up of a type III dens invaginatus case. Int Endod J. 2012;45:198-208. 3. Hallett GE. The incidence, nature, and clinical significance of palatal invagination in the maxillary incisor teeth. Proc R Soc Med. 1953;46(7):491-499. 4. Oehlers FA. Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crowns forms. Oral Surg Oral Med Oral Pathol. 1957;10(11):1204-1218. 5. Schulze C, Brand E. Dens invaginatus (dens in dente). ZWR. 1972;8:569-660. 6. Rotstein I, Stabholz A, Heling I, Friedman S. Clinical considerations in the treatment of dens invaginatus. Endod Dent Traumatol. 1987;3(5):249-254. 7. Hommez GM, De Moor RJ, Braem M. Endodontic treatment performed by Flemish dentists. Part 2. Canal filling and decision-making for referrals and treatment of apical periodontitis. Int Endod J. 2003;36(5):344-351. 8. Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG.. Endodontic application of cone-beam volumetric tomography. J Endod. 2007;33(9):1121-1132. 9. Nosrat A, Schneider C. Endodontic management of a maxillary lateral incisor with 4 root canals and a dens invaginatus tract. J Endod. 2015;41(7):1167-1171. 10. Polesel A. Restoration of the endodontically treated posterior tooth. Giornale Italiano di Endodonzia. 2014;28(1):2-16. 11. Byun C, Kim C, Cho S, et al. Endodontic treatment of an anomalous anterior tooth with the aid of a 3-dimensional printed physical tooth model. J Endod. 2015;41(6):961-965. 12. Cunha RS, Junaid A, Mello I. Unilateral fusion of a supernumerary tooth to a maxillary permanent lateral incisor: a report of a rare case. J Endod. 2015;41(3):420-423. 13. Special Committee to Revise the Joint AAE/AAOMR Position Statement on Use of CBCT in Endodontics. AAE and AAOMR Joint Position Statement. Use of the Cone Beam Computed Tomography in Endodontics 2015 Update. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;120(4):508-512. 14. European Society of Endodontology developed by Patel S, Durack C, Abella F, et al. European Society of Endodontology position statement: the use of CBCT in endodontics. Int Endod J. 2014;47(6):502-504. 15. Barnett F. Cone Beam Computed Tomography in Endodontics. Summer 2011 ENDODONTICS: Colleagues for Excellence. Chicago, IL: American Association of Endodontics and AAE Foundation. 16. Perrin P, Neuhaus KW, Lussi A. The impact of loupes and microscopes on vision in endodontics. Int Endod J. 2014;47(5):425-429. 17. Bowers DJ, Glickman GN, Solomon ES, He J. Magnification’s effect on endodontic fine motor skills. J Endod. 2010;36(7):1135-1138. 18. Cunningham W, Martin H, Pelleu G, Stoops D. A comparison of antimicrobial effectiveness of endosonic and hand root canal therapy. Oral Surg Oral Med Oral Pathol. 1982;54:238-241. 19. Skoner JR, Wallace JA. Dens invaginatus: another use for the ultrasonics. J Endod. 1994;20(3):138-140. 20. Brooks JK, Ribera MJ. Successful nonsurgical endodontic outcome of a severely affected permanent maxillary canine with dens invaginatus Oehlers Type 3. J Endod. 2014;40(10):1702-1707. 21. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review — Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413. 22. Ricucci D, Siqueira JF Jr. Biofilm and apical periodontitis: study of prevalence and association with clinical and histopathologic findings. J Endod. 2010;36(8):1277-1288. 23. Ricucci D, Candeiro GTM, Bugea C, Siqueira JF Jr. Complex apical intraradicular infection and extraradicular mineralized biofilms as the cause of wet canals and treatment failure: report of 2 cases. J Endod. 2016;42(3):509-515.

Volume 12 Number 4

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CASE STUDY

Effective retreatments with the GentleWave® System Dr. Brian T. Wells discusses a procedure for thoroughly cleaning and disinfecting the root canal system

s endodontists, our job is to be specialists in saving teeth. And making the decision of whether a tooth can be saved is not always black and white. There are essentially three options with previously root canal-treated teeth to consider: orthograde retreatment, surgical retrograde treatment, or extraction. Determining a prognosis with treatment decision should be the first step. Many patients elect to save their tooth despite a guarded or poor prognosis. Particularly when a tooth has had a root canal treatment and is now in need of further assistance, we need to put our diagnostic and treatment skills to the test to properly answer: “Can the patient’s tooth be saved?” A retreatment is the least invasive way to save the tooth. My philosophy when it comes to retreatments is to stay conservative, making sure to retain as much structural integrity as possible. Most importantly, it is imperative to ensure adequate cleaning and disinfection of all spaces inside the root canal system where bacteria has reached. All of these aspects of this retreatment philosophy were addressed for me when I integrated the GentleWave® System from Sonendo® into my practice over 3 years ago. In the GentleWave System’s unique mechanism of action, procedure fluids are degassed, and the concentration is adjusted to the optimal level. The fluids are circulated throughout the root canal system and continuously refreshed throughout the procedure. Broad spectrum acoustic energy and vortical flow are induced for maximum debridement and dissolution, which results in unmatched cleaning and disinfection with minimal instrumentation — and in a single visit. Brian T. Wells, DMD, received his dental degree at Harvard University and completed his clinical training at Tufts University in Boston, where he earned his Endodontic Certificate. Dr. Wells has qualified as a Board Eligible Endodontist with the American Board of Endodontics. He currently maintains a private practice specializing in endodontics in the Tampa, Florida, area. Disclosure: The opinions, recommendations, and best practices given are a compilation of my experience with the GentleWave® System. Readers should note that I have entered into a professional consulting agreement with Sonendo®.

28 Endodontic practice

It is imperative to ensure adequate cleaning and disinfection of all spaces inside the root canal system where bacteria has reached.

Each of the cases to follow represents a decision point that was not necessarily straightforward — in each case, there was some critical factor to consider, whether it was the amount of bone loss, the size of the post, or amount of dentin initially removed. In each of these cases, retreatment was successful despite a guarded-to-poor prognosis.

Case studies In the following retreatment case studies, I had to ask myself, What do we do here — extraction, retreatment, or surgery? These cases are just a handful of the 1,000s I have treated using the GentleWave System that have given me a higher level of confidence to pursue retreatments in difficult cases and enable patients to save their natural teeth. Case 1 45-year-old male Retreatment on tooth No. 19 This case is not only a retreatment of a retreatment, but also the patient is a periodontist. Tooth No. 19 was retreated by an endodontic colleague 2 years prior. The patient had a persistent draining sinus tract and wanted to save his tooth. The key challenge in a second retreatment is the degree to which this tooth had been instrumented during its two earlier treatments. Prior treatment appeared to have reached reasonable goals based on radiographic findings. Following prior access, I troughed a fracture on distal wall that did not reach the floor, located the canals, and removed the gutta percha. Upon establishing patency, I realized the importance of cleaning, debriding, and disinfecting the

Figure 1: Case 1 — Pre-GentleWave Procedure

Figure 2: Case 1 — Post-GentleWave Procedure

Figure 3: Case 1 — 5-month recall Volume 12 Number 4

CASE STUDY

Figure 4: Case 2 — Pre-GentleWave Procedure

Figure 5: Case 2 — Post-GentleWave Procedure

Figure 6: Case 2 — 11-month recall

Figure 7: Case 3 — Pre-GentleWave Procedure

Figure 8: Case 3 — Post-GentleWave Procedure

Figure 9: Case 3 — 3-month recall

Figure 10: Case 3 — 9-month recall

I accessed the tooth, removed the post and all gutta percha from tooth No. 8, utilized the GentleWave Procedure on both teeth, and obturated. I scheduled follow-up appointments at 1, 3, and 6 months, but she failed to show. She eventually revisited her dentist at 11 months when she began experiencing some discomfort and was referred back to me. As you can see in Figure 6, her pain was not related to any endodontic issues — the alveolar bone had healed remarkably well. I found that the discomfort was related to food impaction, which was easily resolved.

Case 3 46-year-old female Retreatment on tooth No. 4 This case represents a difficult starting situation with a large post, large apical lesion, and concern of fracture. Surgery does not appear to be a viable option in this case, as a resection would put us right up against the post. For many, extraction would be the most likely course of action. After removing the post and saving the crown, the GentleWave Procedure was completed. She returned for 3- and 9-month recall, where we can see excellent healing.

tooth without overinstrumentation any further than it had been previously. In utilizing the GentleWave® Procedure, I was able to debride and fill a lateral canal on the mesial root, leading to the nidus of the lesion, which gave me a great deal of hope for the future of the tooth. That hope was clearly realized at the 5-month followup, where we are able to see near complete bone reformation. Case 2 59-year-old female RCT on Tooth No. 7/Retreatment on tooth No. 8 In November 2014, the patient’s dentist noticed a lesion on tooth No. 7 and recommended seeing an endodontist for evaluation. Unfortunately, the patient waited quite a while to follow through on the dentist’s advice. She had undergone RCT on tooth No. 8 2½ years prior and was experiencing intermittent pain. A sinus tract on the palate was drained, and she was given an antibiotic, which relieved her symptoms before coming to see me. I discussed with her my concern regarding the amount of bone loss, and that extraction or apical surgery may be necessary. The patient, however, was quite eager to save her teeth, so we decided to retreat tooth No. 8 and treat tooth No. 7 — both using the GentleWave System. I also recommended close follow-up to ensure apical healing and determine if apical surgery would still be necessary. Tooth No. 8 was at 2-plus mobility but was not depressible. There was no periodontal communication. Rather than isolate both teeth individually, I isolated the canine and lassoed over to the central. Volume 12 Number 4

Endodontic practice 29

CASE STUDY

Figure 11: Case 4 — Pre-GentleWave Procedure

Figure 12: Case 4 — Post-GentleWave Procedure

Figure 13: Case 4 — 9-month recall

Three years, and thousands of cases into using the GentleWave System, I am no longer surprised when I see rapid and sustained healing, even following complex retreatments, where previously apical surgery or extraction may have been necessary. Figure 14: Case 4 —16-month recall

Figure 15: Case 4 — 22-month recall

Case 4 23-year-old female Retreatment on tooth No. 7 There was some additional pressure in this case, as the patient was a dental assistant for one of my referring practices. Prior RCT was completed 8 years prior on tooth No. 7. She started experiencing swelling approximately 6 months before she came to see me. She presented with a buccal draining sinus tract, and probing was at 2 mm-3 mm. Upon removing the post, the crown fell off, and I saw there was no fracture, but not much tooth structure was left. I discussed extraction, initially, but the patient (and her dentist) wanted to try to save the tooth, so

we proceeded to the GentleWave Procedure and finished the case. At the 2-week followup, the patient was symptom-free, and the buccal drain was no longer present. The 9-month follow-up revealed that the lesion had decreased significantly but was still quite prominent. We again discussed the possibility of apical surgery if the tooth did not heal. At 16 months, though, the lesion continued to decrease. At 22 months, we saw a complete bony trabecular pattern — the area had fully healed.

30 Endodontic practice

Conclusion Each of these cases reinforces the need for an effective approach to retreatment,

one that preserves the structure of the tooth while still providing thorough cleaning and disinfection. Since integrating the GentleWave System into my practice, I have found that this new technology meets all these criteria. Prior to using the GentleWave Procedure, all retreatments were treated in two visits. Three years, and thousands of cases into using the GentleWave System, I am no longer surprised when I see rapid and sustained healing, even following complex retreatments, where previously apical surgery or extraction may have been necessary. When we ask: “Can the patient’s tooth be saved?” more often now than before, we are finding that the answer is YES. EP Volume 12 Number 4

Recent Transactions Silent Partners Invest In Endodontic Practices (Invisible DSOs)

Silent partners buy PART of your practice for cash now. You retain ownership and continue operating under your leadership, team and brand. But you access the resources of a larger group, including patient referrals. In more than $200,000,000+ of transactions during the last 12 months, great practices achieved values of 2X, 3X and 4X collections. Visit FindMyEndoPartner.com to register for the next webinar. Call 877-557-5119 or email EndoUS@LargePracticeSales.com to arrange a confidential discussion with an LPS principal. You might be surprisedâ&#x20AC;Ś

CONTINUING EDUCATION

Application of biosynthesized silver nanoparticles to eradicate Enterococcus faecalis from infected root canals — a review Drs. Rahul Halkai, Kiran Halkai, and C. Jyothi investigate a common microorganism associated with endodontic persistence and reinfection Abstract Enterococcus faecalis (e faecalis) is a common microorganism associated with endodontic persistence and reinfections. It is one of the most resistant microbes and poses a severe challenge for its eradication during endodontic treatment. Antimicrobial agents in the form of irrigants and intracanal medicaments play an important role in root canal disinfection. Fungal-derived biosynthesized silver nanoparticles (AgNPs), owing to their improved properties — including small size (1-100 nm), eco-friendly, no chemicals used during synthesis, low cost, and broad spectrum of antimicrobial activity without drug resistance — create a new horizon in root canal disinfection. This article highlights the facts of e faecalis related to endodontic infections and the importance of fungal-derived silver nanoparticles as antimicrobial agents in eradicating e faecalis from root canal infections.

Introduction The main aim of endodontic treatment is to completely eliminate the bacterial infection and prevent reinfection. However, even after contemporary dental surgery with more sophisticated treatment approaches and techniques, we still encounter failures. It is mainly because of the persistence of microorganisms in tissues even after treatment and growing resistance of most of the microorganisms to the available antimicrobial agents (Siqueira, et al., 2010). Rahul S. Halkai, MDS, PhD, is an assistant professor in the department of endodontics at Gulf Medical University, Ajman, United Arab Emirates. Kiran R. Halkai MDS, PhD, is a lecturer in the department of endodontics at Gulf Medical University, Ajman, United Arab Emirates. C. Jyothi, BDS, MDS, is a postgraduate student in the department of periodontics, Oxford Dental College and Hospital, Bengaluru, India.

32 Endodontic practice

Educational aims and objectives

This article aims to inform the reader of enterococcus faecalis, a common microorganism associated with endodontic persistence and reinfection.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 35 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize that fungal-derived silver nanoparticles can be used as root canal disinfectant for effectively eliminating the resistant microorganisms, including Enterococcus faecalis (e faecalis) and increase endodontic success rates.

•

Recognize some characteristics of e faecalis that are integral to finding measures for eradicating this microorganism from root canal infections.

•

Recognizing some characteristics of nanoparticles (NPs) for endodontic disinfection.

•

Realize some advantages to using fungal-derived silver nanoparticles (AgNPs) as antimicrobial agents.

•

Realize the increased stability of nanoparticles.

Enterococcus faecalis (e faecalis) is a gram-positive, facultative microorganism with pathogenicity ranging from life-threatening diseases in compromised individuals, systemic diseases such as endocarditis, brain abscesses, septicemia, to root canal infections of obturated root canals with chronic apical periodontitis (Halkai, et al., 2012). It occurs in both asymptomatic endodontic primary infections and persistent infections with a high prevalence in secondary infections — 24%-77% (Stuart, et al., 2006). It is also detected from periodontal pockets of refractory periodontal diseases. Culturebased studies have reported e faecalis with a 1%-5% prevalence rate in subgingival sites of periodontitis cases where as PCR evaluation showed 48% (Ram, et al., 1992; Colombo, et al., 2013). E faecalis possesses several virulence factors such as cytolysis, lytic enzymes, aggregation substances (AS), pheromones, surface proteins, and lipotechoic acid (Halkai, et al., 2012). It produces collagen-binding proteins such as angiotensin-converting enzyme (ACE) and serine protease and gelatinase, which helps for bacterial adhesion and penetration even under stress (Halkai,

et al., 2013). ACE promotes resistance to killing by human neutrophils. E faecalis invades dentinal tubules and root cementum probably through lipoteichoic acids (LTA), and to the collagen through aggregation substance (AS) and other surface adhesins (Halkai, et al., 2013). It gets attached to protruding obturating material in periapical tissues (Nair, 2004). E faecalis can penetrate into root cementum even after obturation (Halkai, et al., 2014). Possession of these virulence factors might be an advantage over other species for its surveillance in infected root canals (Halkai, et al., 2013). It can grow at 10°C and 45°C, at pH 9.6, in 6.5% NaCl broth, and survive at 60°C for 30 minutes. It can withstand harsh environmental conditions. It can adapt to adverse conditions such as after pre-exposure to sublethal stress conditions. It becomes less sensitive to normal lethal levels of sodium dodecyl sulfate, bile salts, hyperosmolarity, heat, ethanol, hydrogen peroxide, acidity, and alkalinity (Halkai, et al., 2012). E faecalis cells remain viable for extended periods even in starvation and become resistant to UV irradiation, heat, sodium hypochlorite, hydrogen peroxide, ethanol, and acid Volume 12 Number 4

properties as a root canal disinfectant for effectively eliminating the resistant microorganisms, including e faecalis and increasing the endodontic success rate. Figure 1: Enterococcus faecalis SEM

(Giard, et al., 1996). E faecalis, moreover, can enter the viable but non-cultivable (VBNC) state â&#x20AC;&#x201D; a survival mechanism adopted by a group of bacteria when exposed to environmental stress and resuscitate upon returning to favorable conditions (LleĂ˛, et al., 2001). VBNC e faecalis adapts to cell wall alterations that might protect the microbe even in stressful conditions and it can adhere to the root canal surfaces (Signoretto, 2000). The ability of e faecalis to tolerate or adapt to harsh environmental conditions is an advantage over other species. Hence, it can survive in root canal infections, where nutrients are scarce, and there are limited means of escape from root canal medicaments (Halkai, et al., 2012). E faecalis resists root canal treatment procedures and can penetrate into dentinal tubules and survive even in nutrition-depleted conditions of obturated canals leading to persistent or reinfections (Halkai, et al., 2014; Halkai, et al., 2016). It forms communities organized in biofilm, which resist the destruction by enabling the bacteria to become 1,000 times more resistant to phagocytosis, antibodies, and antimicrobials than non-biofilm-producing organisms (Halkai, et al., 2018). Along with instrumentation, thorough root canal disinfection as well as irrigation and intracanal medication play an important role in bacterial elimination (Halkai, et al., 2018). Several root canal disinfectants with effective antimicrobial efficacy have been used; however, it is still difficult to eradicate e faecalis completely from root canal system. It is resistant to most of the antimicrobial agents and exhibit intrinsic resistant mechanisms. It harbors antibioticresistant determinants carried on transferable plasmids (Sedgley, 2005). E faecalis has the ability to invade dentinal tubules and provides protection from chemomechanical preparation and intracanal medicaments. It even resists the high pH of calcium hydroxide (Halkai, et al., 2012). E faecalis binds to collagen even in the presence of serum. It congregates with other bacterial species and survives in root canals in the form of multispecies biofilms, and as the e faecalis biofilms Volume 12 Number 4

mature on root surfaces, it calcifies for more stability (Johnson, et al., 2006). A few studies suggest e faecalis penetrates and adheres into root cementum and can entomb into the critical areas beyond minor constriction even after three-dimensional obturation (Halkai, et al., 2014; Halkai, et al., 2016). E faecalis colonies were found under confocal laserscanning microscope and confirmed by PCR techniques and suggested MTA sealing in apical 1 mm-2 mm before obturation, as an effective way to prevent e faecalis colonization (Halkai, et al., 2016). However, through this approach, periapical lesions can be prevented, but concern is raised regarding the entombed e faecalis in dentinal tubules, lateral canals, irregularities of root canal, which harbors e faecalis even after thorough root canal instrumentation, root canal disinfection, and 3D obturation and also with MTA apical sealing as suggested. Therefore, to overcome this, newer antimicrobial agents with increased antimicrobial activity without causing drug resistance have to be developed to completely eliminate such resistant microbes for successful endodontic treatment outcomes (del Pozo, 2007).

Introduction of nanoparticles Recently nanoparticles (NPs) have gained popularity for endodontic disinfection. They are particles in the size range of 1-100 nm. Due to the extremely small size, they penetrate the deeper tissues and exhibit potent antimicrobial activity (Halkai, et al., 2016). Due to growing concern about various chemicals used during synthesis and causing hazards to human health and environment, there is shift to biological approaches for production of nanoparticles. Among the several nanoparticles, silver nanoparticles (AgNPs) exhibit a broad spectrum of activity and are biocompatible (Halkai, et al., 2017). AgNPs can be produced using several biological vectors such as bacteria, fungi, yeasts, leaf extracts, roots, bark, and so on. Biosynthesized AgNPs have emerged as novel antimicrobial agents with efficient antimicrobial activity against several pathogens

(Halkai, et al., 2018; Halkai, et al., 2017; Ninganagouda, et al., 2013), but among these, fungal-derived AgNPs are widely used in medical field. They possess a broad spectrum of activity and are biocompatible (Halkai, et al., 2017). Advantages of fungi include the following: 1. They require simple media to grow. 2. They are not technique-sensitive. 3. They can be produced on large scale. 4. They are low cost. 5. They do not require toxic chemicals in synthesis and are therefore considered as naturally occurring nanofactories (Halkai, et al., 2016).

Benefits Fungal-derived AgNPs act synergistically in distinct targets, and there is no interference with antimicrobial resistance mechanisms. AgNPs can penetrate the tissues owing to their extremely small size and high-surface area; hence, their potential use for resistant microbes (Sapra, et al., 2014). Recent studies have shown application of fungal-derived AgNPs against grampositive, gram-negative, and multi-drug resistant (MDR) strains (Halkai, et al., 2017; Ninganagouda, et al., 2013). They exhibit potent antimicrobial activity against the resistant endodontic pathogen e faecalis even in biofilm form (Halkai, et al., 2018; Halkai, et al., 2017; Halkai, et al., 2018). Fungal-derived AgNPs were also employed as antimicrobial agents against endo-perio pathogens such as e gingivalis, e faecalis, and bacillus pumilus with effective antimicrobial efficacy (Halkai, et al., 2017; Halkai, et al., 2018). E gingivalis is one of the most common microorganisms associated with different types of periodontal diseases and is also seen with primary endodontic infections, periapical diseases, and endoperio lesions (Halkai, et al., 2017). Recent studies show effective antimicrobial efficacy of fungal-derived AgNPs against p gingivalis (Halkai, et al., 2017; Halkai, et al., 2018; Halkai, et al., 2017). Bahadoor, et al., (2013) incorporated fungal-derived AgNPs in MTA Endodontic practice 33

CONTINUING EDUCATION

Fungal-derived AgNPs show a new horizon with their

CONTINUING EDUCATION (Nanosilver MTA) and evaluated antimicrobial efficacy against p gingivalis by the agar diffusion method. NSMTA exhibited effective antimicrobial efficacy with 9 mm-13 mm zones of inhibition against p gingivalis (Bahadoor, et al., 2013).

More benefits It is shown that fungal-derived AgNPs are biocompatible and exhibit least cytotoxicity. Han, et al., (2014) reported cytotoxicity of biosynthesized AgNPs on human lung epithelial adenocarcinoma cell lines with IC50 values of 20µg/ml compared to the synthetic AgNPs with IC50 values of 70µg/ ml, indicating biosynthesized AgNPs are more effective at a minimum dose compared to synthetic AgNPs. Halkai, et al., (2016) reported at a minimum concentration of 8 µg/ml. The percentage inhibition of fungalderived AgNPs against human gingival fibroblasts (HGF) cell line by MTT assay was found to be 2.11%. A maximum cytotoxicity of 65.24% was found at the concentration of 512 µg/ml. At concentration 256 µg/ml AgNPs exhibited 46.36% inhibition. Some 50% inhibition (CTC50) was found at a concentration of 260 µg/ml. A concentration less than 260 µg/ml will be effective against diseased cells and is safe for the healthy cells (Halkai, et al., 2017). Therefore, biosynthesized AgNPs can be considered for endodontic applications as well; however, further studies need to be done before confident use of these particles.

Increased stability of nanoparticles Sapra, et al., (2014) described the advantages of nanoparticles such as they possess increased stability, controlled release rate, and high dispersibility in aqueous medium. Owing to their small size, NPs can penetrate deeper regions that may be inaccessible to other drugs. Therefore, the clinician should reduce the frequency of administration and provide uniform distribution of active agents (Sapra, et al., 2014). Since e faecalis is associated with different types of infections, it is recommended that fungal-derived AgNPs can be used as an alternative to the root canal irrigants or ICMs; they can be incorporated with other ICMs such as calcium hydroxide for synergetic action and can be used as drug delivery systems during periodontal therapy (Halkai, et al., 2016). They can be effectively used as antimicrobial agents during management of endo-perio lesions eradicating the different types of microorganisms including e faecalis. 34 Endodontic practice

Figures 2A and 2B: A. UV–Vis absorption spectra of colloidal solution of AgNPs with different concentrations of green tea leaf extract (5%40%). B. Visual images of the AgNPs with different concentrations of tea leaf extracts at room temperature

Conclusion Due to complexity of the root canal morphology and persistence of endodontic infections, as well as e faecalis being the dominant microorganism associated with persistent and re-infections, fungal-derived AgNPs show a new horizon with their properties as a root canal disinfectant for effectively eliminating the resistant microorganisms, including e faecalis and increasing the endodontic success rate. However, further in vivo, in vitro studies must be done for effective use of these particles in clinical use. EP

REFERENCES 1. Ansari MA, Khan HM, Khan AA, et al. Evaluation of antibacterial activity of silver nanoparticles against MSSA and MRSA on isolates from skin infections. Biol Med. 2011;3(2):141-146. 2. Bahadoor A, Esmaeili D, Khaledi A, Ghorbanzadeh R. An in vitro assessment of the antibacterial properties of nanosilver Iranian MTA against Porphyromonas gingivalis. J Chem Pharm Res. 2013;5:65‑71. 3. Colombo AV, Barbosa GM, Higashi D, et al. Quantitative detection of Staphylococcus aureus, Enterococcus faecalis and Pseudomonas aeruginosa in human oral epithelial cells from subjects with periodontitis and periodontal health. J Med Microbiol. 2013;62(P10):1592-1600. 4. del Pozo JL, Patel R. The challenge of treating biofilmassociated bacterial infections. Clin Pharmacol Ther. 2007;82(2):204-209. 5. Giard JC, Hartke A, Flahaut S, et al. Starvation-induced multi-resistance in Enterococcus faecalis JH2-2. Curr Microbiol. 1996;32(5):264-271. 6. Han JW, Gurunathan S, Jeong JK, et al. Oxidative stress mediated cytotoxicity of biologically synthesized silver nanoparticles in human lung epithelial adenocarcinoma cell line. Nanoscale Res Lett. 2014;9(1):459. 7. Halkai R, Hegde MN, Halkai K. Enterococcus faecalis can survive extreme challenges - an overview. NUJHS. 2013;2(3):49-53.

11. Halkai KR, Mudda JA, Shivanna V, Rathod V, Halkai RS. Evaluation of antibacterial efficacy of biosynthesized silver nanoparticles derived from fungi against endo-perio pathogens Porphyromonas gingivalis, bacillus pumilus, and Enterococcus faecalis. J Conserv Dent. 2017;20(6):398-404. 12. Halkai KR, Mudda JA, Shivanna V, Rathod V, Halkai R. Antibacterial efficacy of biosynthesized silver nanoparticles against Enterococcus faecalis biofilm: An in vitro study. Contemp Clin Dent. 2018;9(2):237-241. 13. Halkai R, Hegde MN, Halkai K. Root cementum invasion and adhesion by Enterococcus faecalis confocal analysis. NUJHS. 2012;2:44-49. 14. Halkai KR, Mudda JA, Shivanna V, Rathod V, Halkai R. Biosynthesized silver nanoparticles from fungi as antimicrobial agents for endo-perio lesions – a review. Annual Res Rev Bio. 2016;10(6):1-7. 15. Halkai KR, Mudda JA, Shivanna V, Rathod V, Halkai R. Evaluation of antibacterial efficacy of fungal-derived silver nanoparticles against Enterococcus faecalis. Contemp Clin Dent. 2018;9:45-48. 16. Halkai KR, Halkai R, Mudda JA, Shivanna V, Rathod V. Antibiofilm efficacy of biosynthesized silver nanoparticles against endodontic-periodontal pathogens: An in vitro study. J Conserv Dent. 2018;21(6): 662-666. 17. Halkai KR, Mudda JA, Shivanna V, Rathod V, Halkai RS. Biosynthesis, characterization and antibacterial efficacy of silver nanoparticles derived from endophytic fungi against P. Gingivalis. J Clin Diagn Res. 2017; 11(9):ZC92-ZC96. 18. Johnson EM, Flannagan SE, Sedgley CM. Coaggregation interactions between oral and endodontic Enterococcus faecalis and bacterial species isolated from persistent apical periodontics. J Endod. 2006;32(10):946-950. 19. Lleò MM, Bonato B, Tafi MC, et al. Resuscitation rate in different enterococcal species in the viable but non-culturable state. J Appl Microbiol. 2001;91(6):1095-1102 20. Nair PNR. Pathogenesis of apical periodontitis and the causes of endodontic failures. Crit Rev Oral Biol Med. 2004;15(6):348‑381 21. Ninganagouda S, Rathod V, Jyoti H, Singh D. Extracellular biosynthesis of silver nanoparticles using Aspergillus flavus and their antimicrobial activity against gram negative MDR strains. Int J Pharma Bio Sci. 2013;4(4):222-229. 22. Rams TE, Feik D, Young V, Hammond BF, Slots J. Enterococci in human periodontitis. Oral Microbiol Immunol. 1992;7(4):249-252. 23. Sapra P, Patel BD, Patel DV, Borkhataria CH. Review: Recent advances in periodontal formulations. Int J Pharm Chem Anal. 2014;1:65‑74.

8. Halkai R, Hegde MN, Halkai K. Enterococcus faecalis cause for persisting infection a confocal analysis. NUJHS. 2013;3:67-72.

24. Sedgley CM, Molandar A, Flannagan SE, et al. Virulence, phenotype and genotype characteristics of endodontic Enterococcus spp. Oral Microbiol Immunol. 2005;20(1):10-19.

9. Halkai R, Hegde MN, Halkai K. Evaluation of the presence of Enterococcus faecalis in root cementum: A confocal laser scanning microscope analysis. J Conserv Dent. 2014;17(2):119-123.

25. Signoretto C, Lleò MM, Tafi MC, Canepari P. Cell wall chemical composition of Enterococcus faecalis in the viable but nonculturable state. Appl Environ Microbiol. 2000;66(5):1953-1959.

10. Halkai RS, Hegde MN, Halkai KR. Evaluation of Enterococcus faecalis adhesion, penetration, and method to prevent the penetration of Enterococcus faecalis into root cementum: Confocal laser scanning microscope and scanning electron microscope analysis. J Conserv Dent. 2016;19(6):541-548.

26. Siqueira JF Jr, Rôças IN, Ricucci D. Biofilms in endodontic infection. Endodontic Topics. 2010;22(1):33-49. 27. Stuart CH, Schwartz SA, Beeson TJ Owatz CB. Enterococcus faecalis: its role in root canal treatment failure and current concepts in retreatment. J Endod. 2006;32(2):93-98.

Volume 12 Number 4

REF: EP V12.4 HALKAI, ET AL.

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Application of biosynthesized silver nanoparticles to eradicate Enterococcus faecalis from infected root canals — a review HALKAI, ET AL.

1. Enterococcus faecalis (e faecalis) is a gram-positive, facultative microorganism with pathogenicity ranging from life-threatening diseases in compromised individuals to systemic diseases such as endocarditis, ________. a. brain abscesses b. septicemia c. root canal infections of obturated root canals with chronic apical periodontitis d. all of the above 2. Culture-based studies have reported e faecalis with a 1%-5% prevalence rate in subgingival sites of periodontitis cases whereas PCR evaluation showed _______. a. 10% b. 34% c. 48% d. 55% 3. E faecalis possesses several virulence factors such as cytolysis, _________, surface proteins, and lipotechoic acid. a. lytic enzymes b. aggregation substances (AS) c. pheromones d. all of the above 4. It (E faecalis) can grow at 10°C and 45°C, at pH

Volume 12 Number 4

9.6, in 6.5% NaCl broth, and survive at 60°C for _______. a. 30 minutes b. 6 hours c. 1 day d. 2 days 5. It (E faecalis) ________ in root canal infections, where nutrients are scarce, and there are limited means of escape from root canal medicaments. a. cannot adapt b. can survive c. cannot survive d. cannot tolerate 6. _________ have emerged as novel antimicrobial agents with efficient antimicrobial activity against several pathogens. a. Biosynthesized silver NPs (AgNPs) b. solid lipid NPs (SLN) c. Synthetic gold NPs (AuNPs) d. Super paramagnetic iron oxide NPs (SPIONPs) 7. _______ is one of the most common microorganisms associated with different types of periodontal diseases and is also seen with primary endodontic infections, periapical diseases, and endoperio lesions. a. Treponema denticola

b. Actinobacillus actinomycetemcomitans c. E gingivalis d. E forsythus 8. NSMTA (nanosilver MTA) exhibited effective antimicrobial efficacy with _______ zones of inhibition against p gingivalis. a. 2 mm- 4 mm b. 5 mm-8 mm c. 9 mm-13 mm d. 14 mm-16 mm 9. ________ described the advantages of nanoparticles such as they possess increased stability, controlled release rate, and high dispersibility in aqueous medium. a. Sapra, et al. b. Ninganagouda, et al. c. Sedgley CM, et al. d. Siqueira JF, et al. 10. Owing to their small size, NPs can penetrate deeper regions that may be inaccessible to other drugs. Therefore, the clinician should _______ and provide uniform distribution of active agents. a. increase the frequency of administration b. reduce the frequency of administration c. eliminate this type of NP d. provide a higher concentration of this NP

Endodontic practice 35

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Removal of fractured endodontic instruments: a report of two cases Drs. Casper H. Jonker and Carel (Boela) van der Merwe report on treatments for this stressful and unpleasant situation for endodontists Abstract The separation of an endodontic instrument within the root canal system can be one of the most stressful and unpleasant situations with which the clinician can be confronted. These fractures often occur due to incorrect use of instruments. The clinician is confronted with a few options when considering this situation. These options can include leaving the fragment where the fracture occurred and incorporating the fragment to form part of the final obturation or removal from the root canal. Once the decision is made to remove the fractured instrument, the clinician must realize that the procedure can be one of the most difficult treatments to attempt. According to the literature, there is no standardized method to follow when attempting to remove fractured instruments. The presented cases illustrate effective techniques to remove fractured endodontic instruments from the root canal system. Two cases are discussed where fractured instruments are removed using various manual instruments, ultrasonics, chemicals, and the dental operating microscope (DOM). Satisfactory endodontic outcomes were achieved, and the fractured instruments were successfully removed without causing iatrogenic damage to the remaining tooth structure.

Introduction Root canal treatments are attempted with the knowledge that certain unforeseen accidents can occur during any part of the treatment. These accidents can include fracture of instruments, perforation of the root on different levels, and the formation of ledges. Once a tooth is exposed to procedural accidents and unforeseen complications, there is an increased risk of failure of the endodontic Casper H. Jonker, BChD, Dip Odont, Msc, runs the module of Endodontics, Department of Operative Dentistry, School of Oral Health Sciences, Sefako Makgatho Health Sciences University, Gauteng, South Africa. Carel (Boela) van der Merwe, BChD, BSc Hons, Dip Odont, MSc, is in private practice, Dental Wellness Dimensions, Bryanston, South Africa.

36 Endodontic practice

Educational aims and objectives

This article aims to present an analysis of fractures of instruments.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 40 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify successful effective approaches to remove two different instruments from root canals while limiting the loss of tooth structure during removal.

•

Recognize several factors can attribute toward instrument failure.

•

Realize the benefit of the use of the dental operating microscope in these situations.

•

Identify various techniques and equipment for instrument removal from root canal systems.

•

Realize the need for careful consideration of the creation of a staging platform when using certain techniques.

treatment and reduction of long-term prognosis (Iqbal, 2016; Sjögren, et al., 1990; Siqueira, 2001). The complete treatment can be jeopardized from the cleaning and shaping sequence to the ultimate obturation and 3D sealing of the root canal system (Sjögren, et al., 1990; Siqueira, 2001). The reason why a root canal treatment is performed is to eliminate microorganisms within the root canal system, removal of necrotic or infected pulp tissues, and complete sealing of the root canal spaces (Iqbal, 2016). The separation of an endodontic instrument within the root canal system can be one of the most stressful and unpleasant situations with which the clinician can be confronted. These fractures often occur due to incorrect use of instruments. Operators can utilize incorrect movements during cleaning and shaping or use deformed instruments, pushing them beyond their ability to absorb the workload (Grossman, 1969; Parashos, et al., 2004). Once an instrument fractures, a detailed approach should be followed to assess the possibility of removal. The clinician should be thoroughly aware of the complicating factors when attempting the removal. These factors may include the following: • the unique anatomy of the root canal system • the availability of materials, instruments, and devices to dislodge and remove separated instruments

• the clinician’s experience and ability • the location, size, position, and diameter of the fractured portion (Parashos, et al., 2004; Suter, et al., 2005) The treating clinician is confronted with a few options when considering an approach. These options are leaving the fragment where the fracture occurred and incorporating the fragment to form part of the final obturation or attempting removal from the root canal (Saunders, et al., 2004). There is also an alternative technique that can be considered — namely, “bypass” of the separated fragment. Although a tedious exercise, creating space and inserting a small manual file between the fragment and the root canal may lead to full working-length negotiation. Occasionally, the fragment can be loosened and removed during bypassing, but often the fragment remains in situ, ending up forming an integrated part of the final obturation (Saunders, et al., 2004). Once the decision is made to remove the fractured instrument, the clinician must realize that the procedure can be one of the most difficult treatments to attempt (Saunders, et al., 2004). According to the literature, there is no standardized method to follow when attempting to remove fractured instruments (Frota, et al., 2004). The importance of proper vision, illumination, and magnification cannot be emphasized enough Volume 12 Number 4

when attempting retrieval (HĂźlsmann, 1994; Gencoglua and Helvacioglub, 2009). The dental operating microscope (DOM) can create direct visualization of the fractured instrument fragment deep in root canals where normal vision is inadequate (Shiyakov and Vasileva, 2014). The following case presentations aim to describe an effective approach to remove a fractured instrument using documented techniques and a combination of instruments and equipment, including manual fine ultrasonic tips, small-sized manual files, and the DOM.

Case report 1 A 31-year-old female patient with an uncomplicated medical history reported with a referral letter from a nearby practice requesting removal of a fractured instrument from her mandibular second incisor. The clinician fractured an instrument during cleaning and shaping and incorporated the fragment into the final obturation. The patient

Figure 3C: The 0.6 K-file engaged in the pathway created by the 0.6 C+ file Volume 12 Number 4

Figures 3A and 3B: 3A.The 0.6 C+ file used with viscous 15% EDTA paste to locate a portal of entry for the size 0.6 K-file to follow. 3B. The 0.6 K-file used in a watch-winding motion with viscous 15% EDTA paste after the initial penetration of the 0.6 C+ file

developed discomfort after a period of time, and after discussion with the treating clinician, the patient was referred for removal of the fragment. A preoperative radiograph was taken, and it was noted that a large portion of an endodontic instrument fractured inside the root canal with extrusion beyond the apical foramen (Figure 1). Possible complications were explained before any treatment was carried out. The tooth was anesthetized and the restoration removed to expose the obturation material. Gutta percha was removed to the level of the fractured instrument using a combination of solvents (Chloroform BP, Medicolab, Johannesburg, South Africa) and K-files. The dental operating microscope (DOM) (Carl Zeiss, Oberkochen, Germany) was used to obtain straight line access and visualize the fractured instrument. A staging platform was created by altering a No. 3 Gates Glidden bur (Dentsply Sirona Endodontics, Ballaigues, Switzerland)

Figures 4 and 5: 4. The gentle pulling action on the 0.6 K-file with ultrasonic activation moving the fragment in a coronal direction. 5. Full working length reached with the 0.6 K-file and fragment moving coronally

(Figure 2) to the level of the coronal portion of the fragment. The root canal space was flooded with 17% liquid EDTA (Vista Dental Products, Racine, Wisconsin) and activated using the ultrasonic E7 tip (NSK, Kanuma Tochigi, Japan) in an effort to remove debris and inorganic matter and improve visualization of the fragment. The tip was placed on the coronal part of the fractured instrument and activated on a low setting of 3 on the ultrasonic unit (NSK, Kanuma Tochigi, Japan). This sequence was repeated 4 times to ensure proper removal of debris in the coronal region of the fractured instrument. The canal was dried and a 0.6 C+ file (Dentsply Sirona Endodontics, Ballaigues, Switzerland) (Figure 3A) was introduced in a gentle pecking motion with slight apical pressure, ultrasonic activation, and viscous 15% EDTA paste (GlydeÂŽ, Dentsply Sirona Endodontics, Ballaigues, Switzerland) as a lubricating agent. Ultrasonic energy was

Figures 6 and 7: 6. Fractured instrument removed with limited amount of destruction of tooth structure. 7. A large segment of a fractured instrument viewed under magnification after removal from the root canal Endodontic practice 37

CONTINUING EDUCATION

Figures 1 and 2: 1. Preoperative radiograph revealing a large fragment of a fractured instrument in the mandibular second incisor. 2. Magnified image of the modified head of the size 3 Gates Glidden bur used to create the staging platform

CONTINUING EDUCATION transferred to the small hand instruments by placing an ultrasonic tip against the shaft of the file. Once slight apical progression was noted, the 0.6 C+ file was removed, and a 0.6 K-file (Dentsply Sirona Endodontics, Ballaigues, Switzerland) (Figures 3B and 3C) was introduced and used in a similar technique to allow apical progression. A simultaneous action of gentle pulling, sideways pressure and ultrasonic vibration transferred from the small hand instruments to the fragment was used in an effort to loosen and move the segment in a coronal direction. The preceding sequence was repeated until full working length was reached with the size 0.6 (Figures 4 and 5). Once movement of the fractured instrument could be observed under magnification, the engaged K-file was tightened by gently rotating the file in a clockwise direction until sufficient resistance was created, and the file was tightly engaged around the segment. A gentle pulling motion with lateral pressure was used in an effort to remove the fractured instrument. The engagement created sufficient resistance to lift the fractured instrument coronally and safely remove from the root canal system (Figures 6 and 7).

Case report 2 A patient with uncomplicated medical history was referred for the removal of fractured instruments in a mandibular second molar. The preoperative radiograph revealed a fractured instrument in the shape of a Lentulo spiral filler in the disto-buccal canal (joining in the apical third with the disto-lingual canal) as well as a fractured endodontic instrument in the mesio-buccal canal (Figure 8). Periapical radiolucencies were noted on both roots. The tooth was obturated by the referring clinician 4 years ago incorporating the fractured instruments, but the patient developed

discomfort over time. After possible complications of the suggested treatment were explained, the tooth was anesthetized, and rubber dam isolation was achieved. A No. 1 Gates Glidden bur (Dentsply Sirona Endodontics, Ballaigues, Switzerland) with a flooded root canal space with 90% chloroform (Chloroform BP, Medicolab, Johannesburg, South Africa) was used to soften the gutta percha. A No. 0.6 C+ file (Dentsply Sirona Endodontics) was used to create a pathway to the level of the fractured instrument, and softened coronal gutta percha was removed (Figure 9). A similar technique as described in case report 1 was used to bypass and remove the fragment in the mesio-buccal root. In the disto-buccal root, a similar technique was followed to scout for space around or through the fractured spiral filler and reach full working length. The 0.6 C+ file sequence was followed by a precurved K-file sequence through the fractured fragment until a size 30 K-file (Dentsply Sirona Endodontics, Ballaigues, Switzerland) was reached to full working length. Glyde 15% EDTA paste (Henry Schein®, Melville, New York) was used as lubricating agent, and in between each file sequence, the root canal space was irrigated using 6% sodium hypochlorite (Vista Dental Products, Racine, Wisconsin), patency confirmed with a size 10 K-file (Dentsply Sirona Endodontics, Ballaigues, Switzerland), recapitulation performed, and the root canal re-irrigated to remove debris. A new size 30 Hedstrom file (Dentsply Sirona Endodontics, Ballaigues, Switzerland) (Figure 10) was precurved, and gentle apical pressure was applied in an effort to engage the fragment (Figure 11). A Steiglitz fractured instrument retrieval forceps (Tinman Dental, Redding, California) was used to lift the fragment coronally

Figures 8 and 9: 8. Preoperative radiograph revealed a fractured spiral filler in the disto-buccal canal as well as a fractured endodontic instrument in the mesio-buccal canal. 9. Obturation material removed and fractured fragments exposed using the No. 1 altered Gates Glidden bur 38 Endodontic practice

Figure 10: A new size 30 Hedstrom file used to engage the fragment after the initial path of insertion was created to a size 30 K-file

using the remaining tooth structure as support. Shaping of all canals was completed using the ProTaper® Universal system (Dentsply Sirona Endodontics, Ballaigues, Switzerland) and all root canals were irrigated in a similar technique as described previously. The canals were dried using large paper points, and a final rinse with 17% liquid EDTA (Vista Dental Products, Racine, Wisconsin) was performed in an effort to remove the smear layer. Obturation was completed using the continuous wave technique with System B™ (Kerr Dental, Orange, California) and Obtura III (Obtura Spartan Endodontics, Algonquin, Illinois) (Figure 12).

Discussion To encounter instrument fracture in clinical practice is not uncommon. In a survey that was conducted in the United Kingdom where clinicians were ask to report on the incidence of instrument fracture during endodontic treatment, 89% reported that they have experienced the unfortunate event (Madarati, et al., 2008). Several factors can attribute toward instrument failure. These factors can include the creation of inadequate access into the root canal system, anatomical challenges and extreme root curvatures, multiple treatments of the same instrument, and the skill set and experience of the treating clinician (Parashos and Messer, 2006; Nevares, et al., 2012). Varela-Patiño, et al., (2005) also described the importance of glide path preparation to reduce the fracture of endodontic instruments. These authors found that fewer fractures occurred when using rotary instruments when a wide and smooth-walled glide path was created, and the canal was preflared before the introduction of rotary files. In the presented cases, it can be speculated that inadequate access, lack of proper glide path, and increased torsional stress could have attributed to instrument fracture(s), although other factors could also have played a role. Yum, et al., (2011) have concluded that torsional stress and torsional failure are more prevalent in straight canals. Further, the use of spiral fillers must be used with great care in endodontics as they require experience and good tactile sensation to avoid instrument fracture. The instrument possesses a very low fracture resistance to torsional fatigue, and any engagement to the root canal wall can result in instrument separation as observed in case report 2. The use of the dental operating microscope in endodontics has been advocated by numerous authors in the literature and provided a breakthrough in endodontic treatments. This invaluable piece of equipment has been advocated for the treatment of Volume 12 Number 4

Volume 12 Number 4

instruments from root canals while limiting the loss of tooth structure during removal. EP This paper is reprinted from International Dentistry – African Edition. 2018;8(5):8-12.

REFERENCES 1. Beer FP, Johnston. Mechanics of Materials. 3rd ed. New York NY: McGraw-Hill; 1992. 2. Carr GB, Murgel, CAF. The use of the operating microscope in endodontics. Dent Clin North Am. 2010;54(2):191-214. 3. Castellucci A. Magnification in endodontics: the use of the operating microscope. Pract Proced Aesthet Dent. 2003;15(5):377-384. 4. Frota LMA, Aguiar BA, Aragão MGB, de Vasconcelos BC. Removal of Separated Endodontic K-File with the Aid of Hypodermic Needle and Cyanoacrylate. Case Rep Dent. 2016;2016:1-5. 5. Gencoglua N, Helvacioglu D. Comparison of the different techniques to remove fractured endodontic instruments from root canal systems. Eur J Dent. 2009;3(2):90-95. 6. Grossman LI. Guidelines for the prevention of fracture of root canal instruments. Oral Surg Oral Med Oral Pathol. 1969;28(5):746-752. 7. Hülsmann M. Removal of fractured instruments using a combined automated/ultrasonic technique. J Endod. 1994;20(3):144-146. 8. Iqbal A. The factors responsible for endodontic treatment failure in the permanent dentitions of the patients reported to the College of Dentistry, the University of Aljouf, Kingdom of Saudi Arabia. J Clin Diagn Res. 2016;10(5):146-148. 9. Lopes HP, Elias CN, Mangelli M, et al. Buckling resistance of pathfinding endodontic instruments. J Endod. 2012;38(3):402-404. 10. Madarati AA, Watts DC, Qualtrough AJ. Opinions and attitudes of endodontists and general dental practitioners in the UK towards the intracanal fracture of endodontic instruments. Part 1. Int Endod J. 2008;41(8):693-701. 11. Madarati AA, Qualtrough AJ, Watts DC. Vertical fracture resistance of roots after ultrasonic removal of fractured instruments. Int Endod J. 2010;43(5):424-429. 12. Monea M, Hantoiu T, Stoica A, Sita D, Sitaru A. The impact of operating microscope on the outcome of endodontic treatment performed by postgraduate students. Eur Sci J. 2015;11(27):305-311. 13. Nevares G, Cunha RS, Zuolo ML, Bueno CE. Success rates for removing or bypassing fractured instruments: a prospective clinical study. J Endod. 2012;38(4):442-444. 14. Pai AR, Kamath MP, Basnet P. Retrieval of a separated file using Masserann technique: a case report. Kathmandu Univ Med J. 2006;4(2):238-242. 15. Parashos P, Gordon I, Messer HH. Factors influencing defects of rotary nickel-titanium endodontic instruments after clinical use. J Endod. 2004;30(10):722-725. 16. Parashos P, Messer HH. Rotary NiTi instrument fracture and its consequences. J Endod. 2006;32(11):1031-1043. 17. Ruddle CJ. Micro-endodontic nonsurgical retreatment. Dent Clin North Am. 1997;41(3):429-454. 18. Sattapan B, Palamara JEA, Messer HH. Torque during canal instrumentation using rotary nickel-titanium files. J Endod. 2000;26(3):156-160. 19. Saunders JL, Eleazer PD, Zhang P, Michalek S. Effect of a separated instrument on bacterial penetration of obturated root canals. J Endod. 2004;30(3):177-179. 20. Shiyakov KK, Vasileva RI. Success for removing or bypassing instruments fractured beyond the root canal curve – 45 clinical cases. J of IMAB. 2014;20(3):567-571. 21. Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J. 2001;34(1):1-10. 22. Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498-504. 23. Suter B, Lussi A, Sequeira P. Probability of removing fractured instruments from root canals. Int Endod J. 2005;38(2):112-123. 24. Patiño PV, Biedma BM, Liébana CR, Cantatore G, Bahillo JG. The influence of a manual glide path on the separation rate of Ni-Ti rotary instruments. J Endod. 2005;31(2):114-116. 25. Yum J, Cheung GS, Park JK, Hur B, Kim H. Torsional strength and toughness of nickel-titanium rotary files. J Endod. 2011;37(3):382-386.

Endodontic practice 39

CONTINUING EDUCATION

forces along its axis (Beer and Johnson, 1992). In a study conducted by Lopes, et al., (2012) pathfinding endodontic instruments were compared for buckling resistance. In this particular study, it was found that C+ files showed increased buckling resistance compared to other instruments investigated. In case report 1, the 0.6 C+ instrument managed to bypass the fractured instrument and allowed Figure 11: Working length determination Figure 12: Completed obturation with subsequent instruments for and engagement of the fractured spiral System B continuous wave technique filler with a size 30 Hedstrom file and Obtura III successful removal. It must be emphasized that the C+ file is used for scouting and engagement, but matching size K-files must perforations, removal of fractured instrureplace the C+ files once progress is made. ments, location of orifices, and other appliAccording to the literature, there is no cations in endodontics (Castellucci, 2003; standardized method of instrument removal Carr and Murgel, 2010; Monea, et al., 2015). from root canal systems and often require Once the decision was made for the removal some initiative from the treating clinician of a fractured instrument in the presented (Hülsmann, 1994; Gencoglua and Helvaciocase, magnification and optimal illuminaglub, 2009). However, various techniques tion played a vital role. The creation of the and equipment have been suggested, staging platform and use of ultrasonics including the Masserann kit (Micro-Mega SA, required proper illumination and magnificaBesancon, France), but even the availability tion and avoid further iatrogenic damage. of specialized equipment does not guarantee Further, proper vision under magnification success. Minimally invasive endodontic allowed the location of the space between access must also be considered when using the fractured instrument flutes and created a the Masserann kit. This system must be used pathway for small hand instruments (0.6 C+ with great care in teeth with small diameter file and 0.6 K-file). roots, curved roots, or where instruments It can be speculated that without proper are fractured in the apical region. A great vision, the fractured segment could not have deal of root dentin is removed with increased been predictably bypassed or removed. One risk of perforation and root fracture (Pai, et of the treatment options to consider in a case al., 2006). The creation of a staging platpresenting with a fractured instrument is form (Ruddle, 1997) with an altered Gates bypassing the segment. Often small manual Glidden bur size 3 should be considered instruments cannot bypass large fragments, as a maximum diameter for the platform. especially when these instruments fractured This technique should only be considered due to tight contact to the root canal wall. in cases where the fractured instrument can The instrumentation of root canals of smaller be visualized. diameter generates more torsional stress Removal of fractured instruments beyond during the cleaning and shaping procecurvatures where no direct vision is possible dure than when dealing with root canals can be very challenging. There is a high risk of larger diameter (Sattapan, et al., 2000). of procedural errors and complications, and Attempts to remove these large fragments the creation of a staging platform should be of fractured instruments with ultrasonics can carefully considered. In the present case, an cause excessive removal of tooth structure effective approach was followed for removal. and weakening of the root (Nevares, et al., It must be emphasized that successful 2012; Madarati, et al., 2010). removal of fractured instruments requires In the presented case, a small 0.6 C+ an adequate skill set, experience, and thorfile was used for scouting between the flutes ough understanding of the use of specialized and finding a pathway for small K-files to equipment. follow. This instrument was chosen for its unique properties and increased resistance Conclusion to buckling. Buckling resistance can be The case reports illustrate successful defined as elastic lateral deformation when effective approaches to remove two different an endodontic instrument is subjected to

REF: EP V12.4 JONKER, ET AL.

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

Removal of fractured endodontic instruments: a report of two cases JONKER, ET AL.

1. The reason why a root canal treatment is performed is __________. a. to eliminate microorganisms within the root canal system b. removal of necrotic or infected pulp tissues c. complete sealing of the root canal spaces d. all of the above 2. The importance of __________ cannot be emphasized enough when attempting retrieval (of the fractured instrument). a. proper vision b. illumination c. magnification d. all of the above 3. The ________ can create direct visualization of the fractured instrument fragment deep in root canals where normal vision is inadequate. a. dental operating microscope (DOM) b. dental loupe c. visual inspection d. transilluminator 4. (In case report 1) The root canal space was flooded with ________ and activated using the ultrasonic E7 tip in an effort to remove debris and inorganic matter and improve visualization of the fragment. a. 15% EDTA b. 17% liquid EDTA c. 12% MTAD

40 Endodontic practice

d. 10% NaOCl 5. (In case report 1) A simultaneous action of gentle pulling, sideways pressure, and ultrasonic vibration transferred from ________ was used in an effort to loosen and move the segment in a coronal direction. a. the ultrasonic tip b. the rotation c. the small hand instruments to the fragment d. the gutta percha 6. (In case report 2) A No. 1 Gates Glidden bur with a flooded root canal space with 90% chloroform was used to ________. a. soften the gutta percha b. anesthetize the patient c. create resistance d. tightly engage the file 7. In a survey that was conducted in the United Kingdom where clinicians were ask to report on the incidence of instrument fracture during endodontic treatment, ______ reported that they have experienced the unfortunate event (instrument fracture in clinical practice). a. 27% b. 58% c. 89% d. 92% 8. These authors (Varela-PatiĂąo, et al.) found that ________ when using rotary instruments when a

wide and smooth-walled glide path was created, and the canal was preflared before the introduction of rotary files. a. fewer fractures occurred b. more fractures occurred c. no fractures occurred d. more complicated fractures occurred 9. In the presented cases, it can be speculated that _________ could have attributed to instrument fracture(s), although other factors could also have played a role. a. inadequate access b. lack of proper glide path c. increased torsional stress d. all of the above 10. Yum, et al., (2011) have concluded that torsional stress and torsional failure are more prevalent in _______. a. curved canals b. straight canals c. bifurcated canals d. tortuous canals 11. ________ can be defined as elastic lateral deformation when an endodontic instrument is subjected to forces along its axis. a. The Masserann effect b. Hedstrom engagement c. Buckling resistance d. Varela-PatiĂąo resistance

Volume 12 Number 4

CE CREDITS

ENDODONTIC PRACTICE CE

Drs. Poorya Jalali and Mehrnaz Tahmasbi discuss how having the trained eye of a radiologist can offer peace of mind to diagnostics

s the role of CBCT imaging continues to grow in the specialty of endodontics, a BeamReaders® Oral and Maxillofacial Radiologist is an essential partner for your practice. Integrating a radiologist into your CBCT workflow is the best defense against deficient interpretations — helping ensure optimum outcomes for your patients and a reduction in your liability related to 3D imaging.

Satisfaction of search bias Clinicians utilize CBCT scans to answer specific clinical questions, such as, “Is there a periapical radiolucency present?” Some may be so focused on answering the original question that additional findings, which may be present, may be overlooked. Satisfaction of search bias occurs when an abnormal radiographic finding (e.g. periapical radiolucency) is detected, leading clinicians to believe their search is over. As such, the additional findings (e.g. invasive cervical root resorption of the adjacent tooth) may be missed. This is where a BeamReaders radiologist plays a valuable role. A radiologist is trained to thoroughly and interactively examine the multiplanar images in three dimensions and provide a comprehensive evaluation of the study. This structured method of evaluating a CBCT scan minimizes the risk of missing an important incidental finding. For example, Figure 1 shows foci of gas in the right buccal space, Dr. Poorya Jalali, DDS, is a Clinical Assistant Professor in the Department of Endodontics Texas A&M College of Dentistry. Dr. Jalali received his Doctorate of Dental Surgery in 2008, and he received his Certificate in Endodontics from Columbia University College of Dental Medicine in New York in 2015. Dr. Jalali is a Diplomate of the American Board of Endodontics. Dr. Mehrnaz Tahmasbi, DDS, earned her Doctor of Dental Surgery in 2011. She completed the residency program in Oral and Maxillofacial Radiology at the University of Florida College of Dentistry in 2016. Dr. Tahmasbi is a Diplomate of the American Board of Oral and Maxillofacial Radiology. Currently she is a Clinical Assistant Professor at the Texas A&M College of Dentistry. Disclosure: Dr. Tahmasabi is a member of BeamReaders® team of highly skilled Oral and Maxillofacial Radiologists.

Volume 12 Number 4

consistent with subcutaneous emphysema. This incidental finding was detected by a radiologist when evaluating a CBCT obtained for endodontic evaluation.

Availability bias Another bias that can contribute to an error in interpreting CBCT studies is availability bias. Availability bias occurs when clinicians rely on easily recalled examples when making a diagnosis, therefore preventing them from considering alternative options. As an old saying goes, “To a man with a hammer, everything looks like a nail.” This type of bias is well-known in radiology and can best be avoided when radiographic and clinical findings are correlated, and the most probable etiologies are considered in the differential diagnosis. Figure 2 shows a periapical radiolucency similar to an endodontic pathosis. However, the endodontist noticed a normal response to sensibility testing. Correlated with the clinical testing, the radiologist considered the traumatic bone cyst foremost in the differential diagnosis, which was then confirmed by exploratory surgery. With busy practices, practitioners don’t have the significant time to fully examine and document each CBCT study. The reports crafted by BeamReaders radiologists illustrate the clinical findings, reduce the dentists’ liability, and save clinical time. The provided information in the CBCT report includes, but is not limited to, periapical pathosis, dental anomalies, accessory/ anomalous canals, root morphology, root fracture, root resorption, and surgical planning. The latter includes information regarding the size and location of a lesion or root apex in relation to vital structures and the presence of an accessory neurovascular canal in proximity to the region of interest before a surgical procedure. A BeamReaders report provides a great platform to easily educate the patient, engage other treatment providers, increase confidence in treatment planning, and reduce

Figure 1: Coronal CBCT image shows foci of gas in the right buccal space

Figure 2: Sagittal image shows periapical low-attenuation area at tooth No. 19

associated liability. These benefits will invariably help improve outcomes and efficiency, thus helping to strengthen the reputation and productivity of an endodontic practice.

About BeamReaders® BeamReaders is a team of more than 50 Oral and Maxillofacial Radiologists working to help you succeed. Submit your first case for free today by registering at www.BeamReaders.com and using the registration code BR4ENDO. EP Endodontic practice 41

PRODUCT INSIGHT

BeamReaders® offers insight into CBCT images for endodontists

PRACTICE MANAGEMENT

Empowering your practice and team for growth and freedom Dr. Albert (Ace) Goerig discusses how to cultivate a more successful practice and get more out of life at the same time

or nearly 25 years, I have been coaching endodontists on how to have more successful practices and how to get the most out of life while being an endodontist. For 90% of doctors, the reasons they seek coaching come down to a surprisingly short list of just two priorities. First, on the priorities list is to pursue financial opportunities. This is often expressed directly as a desire to make more money, but it is also expressed in indirect ways, such as to work fewer days, increase referrals, accelerate their retirement goals, or be able to vacation or travel more. All these things are really just deciding how to channel and surface the benefits of becoming more productive and profitable in the practice. Second, on the priorities list is to enjoy the practice and profession more. Doctors want to smooth out the daily issues that create stress. They want a full clinical schedule that is more productive without feeling rushed. They want to stop worrying and micromanaging their team about every detail. They want to end each day at the office feeling happy and energized rather than frustrated and drained. In aggregate, these objectives describe what a great endodontic practice should be like: quality care, stress-free management, enjoyable daily flow, high profitability, and ideal life balance. When you grow your practice to that level of success, you experience an extraordinary sense of freedom and empowerment that transforms both the practice and your life.

Albert (Ace) Goerig, DDS, MS, is a Diplomate of the American Board of Endodontics and a sought-after speaker who has lectured extensively in the field of endodontics and practice success throughout the United States, Canada, and abroad. He has authored over 60 articles and is a contributing author to numerous endodontic textbooks. He currently has a private endodontic practice in Olympia, Washington, that is in the top 1% of endodontic practices while practicing only 90 days per year. He has over 40 years of experience as an endodontic educator and 22 years as a practice coach to nearly 1,000 endodontists. Dr. Goerig’s dedication to clinical care, business success, and financial freedom for doctors is the driving force behind Endo Mastery. www.endomastery.com

42 Endodontic practice

The freedom practice model This “freedom” model of endodontic success is what I practice in my office, and it is the vision we have at Endo Mastery for our coaching clients. We strive to help our clients easily add $200,000 or more to profitability and reduce the number of days worked if desired. That’s a cumulative economic value of at least $4 million over 20 years (not including investment returns), which solves a lot of problems and achieves a lot of goals to say the least. The cumulative time value of fewer days in practice is invaluable. Life is just better. By comparison, the average endodontist-owner operates in a default model for their practice. They took over a practice, and they’ve been working on it incrementally since then. Some years there is growth, some years are flat, and sometimes years go by without much change because they’ve settled into their routine. As a result, the typical endodontic practice is producing about $750,000 per year and taking home $250,000 to $450,000 depending on expenses. At the low end of that range, doctors would do better as an associate. At the high end, it is benefiting them more but only marginally — as if they are paid a small bonus more for being a senior manager (on top of being a clinician), rather than being fully rewarded as a CEO.

In business, CEOs invest in growth, and literally the main thing that separates the default model from the freedom model is growth. Yet many endodontists have reported a decrease in cases over the past few years, creating a general feeling that growth is difficult in today’s market. I want to emphasize that I absolutely do not believe this is the case. The market may be evolving as result of any number of factors you care to name, but if you approach it as a CEO, all you see are opportunities. A study (now 13 years old) by the ADA in 2006 estimated the number of root canals completed annually at 15.1 million with 72% being performed by general dentists. How much things have changed since then is up for debate, but one thing is clear: There is a significant opportunity to grow your endodontic practice. Potentially for every case you do, there are as many as three other cases being completed in general practices on average. In business, that is called a huge marketing opportunity, and any CEO would get excited about it.

Teams and systems drive growth Every practice has the potential and possibilities in place right now to grow, which really depends on empowering the practice team and implementing market and Volume 12 Number 4

Volume 12 Number 4

PRACTICE MANAGEMENT

business-smart practice systems. Usually the systems in the practice are a mixed bag of what the doctor inherited when he/she took over the practice, plus a few changes here and there over time, and a few ideas cherry-picked from seminars. By the same token, doctors face the same challenges with their teams, whose skill levels, experience, aptitudes, and attitudes can vary. Often new team members are hired and just thrown into the mix, which means basically they were trained at their last practice rather than yours. As an analogy, think about the clinical possibilities for patients today given all of the advances in dentistry and what can be achieved restoratively, functionally, and esthetically by a comprehensive GP working collaboratively with specialists. Now consider that barely a fraction of 1% of patients truly experience that level of care on their whole mouth. Everyone else gets it one tooth at time as problems arise from year to year, which means they are never fully in sync with today’s incredible possibilities. It’s the same with the systems and team in your practice: They’ve been cobbled together over time but never perfectly synchronized to today’s full possibilities. Effective business leadership is needed for doctors to achieve growth and freedom. Practice systems need to be brought up to date and streamlined while eliminating grey areas that cause stress and issues. Team members need a full vision that engages them, supported by clear job roles with true accountability to reduce management burden, maintain control, expand delegation, and ensure productive teamwork. With these factors in place, marketing systems that increase the flow of cases can drive a strategically designed doctor schedule for efficiency and high productivity. It sounds like a lot to take on at once, but it’s not. It is many things built upon the foundation you already have in place. Some things are small. Some are a more significant shift that takes effort to adapt to. And you don’t have to reinvent the wheel. There are practices and teams out there, like mine that are achieving this level of growth and success every day. In fact, one of the first things we do with our coaching clients is invite them (doctor and team) to come shadow and observe my practice and witness how effortlessly we enjoy our day while achieving very high productivity. It is a transformative experience for many doctors and team members. A great practice life is about freedom, joy, abundance, and enjoying your family. Endodontics is a great way to get there. It’s dentistry’s best kept secret, and it’s your biggest opportunity. EP

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Endodontic practice 43

TECHNOLOGY

More GPs are using CBCT: What does that mean for endodontists? Dr. Cameron Howard discusses how endodontists can work with GPs to use 3D imaging more efficiently

s more general practitioners incorporate cone beam computed tomography (CBCT) into their workflow, how can endodontists make sure their referrals are using the technology in a way that is useful and effective? Endodontists, with more than a decade of 3D imaging experience, are actually in the perfect position to help GPs get the most out of their equipment while strengthening the referral relationship and ultimately benefiting the patient. Endodontists can help their GP referrals feel more confident in using CBCT by not only emphasizing when a scan would be useful, but also when to rely on the endodontist as the specialist to take the scan. Endodontists can share with their referring doctors some basic rules of thumb to help them determine the value of a a scan: Examples include assessing overall restorative plans, the proximity of IAN to root apices, anatomy (number of roots or proximity of sinus), etc., and, of course, emphasizing the importance of the ALARA (as low as reasonably achievable) principle. However, helping GPs understand not only when a 3D scan might be helpful, but also when not to take scan can save both doctors and patients a lot of time. If there’s ever any doubt, the GP should be comfortable sending the patient to the endodontist who has years of training in reading/interpreting CBCT scans. Therefore, it’s important that endodontists convey to their referrals that part of their consultation fee is for their specialized knowledge and expertise. Cameron Howard, DMD, MScD, is a boardcertified endodontist from Milton, Georgia. He received his Bachelors of Science in Biochemistry from Furman University (Greenville, South Carolina) in 2004. He received his DMD and graduated as Class President from the University of Kentucky in 2008. He received his Certificate in Endodontics and his Masters of Science in Dentistry (MScD) from Nova Southeastern University (Ft. Lauderdale, Florida) in 2010. He has had several articles published, most notably within the Journal of Endodontics. Dr. Howard established Pinnacle Endodontics in 2014 and currently has two locations (Cumming and Alpharetta, Georgia). Disclosure: Dr. Howard has no proprietary, financial, and/or personal interest pertaining to his presentations to disclose

44 Endodontic practice

Typical images shared with GP referrals

Figures 1A-1D: Post-perforation — 2D versus 3D

Figures 2A-2D: Resorption — 2D versus 3D

Even if GPs want to capture the scan with their own in-house system, they may still defer to endodontists to read the scan. In fact, I’ve invited doctors to my practice after hours to read the scan of their patients together. As long as the image is in a DICOM format, 3D-viewing software should be able to access the scan. Additionally, as endodontists, we often have more robust 3D software, such as CS 3D Imaging (Carestream Dental), needed to make a diagnosis and plan treatment. To further aid in education and improve communication, I include screenshots from my CS 3D Imaging software in every report that I send back to the GPs. The scan, with carefully labeled views, canals, etc., paints a better picture for the GPs, and they are generally impressed with the quality of my system (CS 8100 3D, Carestream Dental). Carestream Dental also offers a free CS 3D Imaging software viewer that I can direct GPs to, so they can view the image accurately back in their own office. This is not only an excellent opportunity to educate the GP community, but also great for building personal business relationships.

Of course, I’ve found that working with GPs who have the same system as I do provides for a much more streamlined experience for everyone. With that in mind, endodontists can provide valuable insight and play an influential role when their referrals ask for recommendations on which new imaging system to invest in. For example, all systems are DICOM-compatible, but using a system that acquires images natively in DICOM and doesn’t need to be converted eliminates an extra step. This makes for easier file sharing between the GPs and endodontists. It’s just a small way endodontists can use their years of experience with 3D imaging systems to guide their GP referrals and help them find success for their mutual patients. Endodontists have more than a decade of experience with CBCT imaging, so it’s important that they lend their years of experience to their peers and referrals regarding the technology. That means helping GPs understand possibly when not to take a scan, how to share a scan if they do, and even when the time is right, to step back and trust the specialists to provide the best care for the GPs’ patients. EP Volume 12 Number 4

PRACTICE MANAGEMENT 20/20 foresight: how to simplify team management and regain control of your practice Paul Edwards, CEO and co-founder of CEDR HR Solutions, offers guidance on building an effective management system

f you’re like the majority of practice owners, your education on how to manage a team was one of trial by fire. Whether you jumped into a leadership role by inheriting or purchasing a practice right out of dental school or you worked your way to ownership as an associate doctor, the end result is almost always the same. Once you step into the role of owner/ manager, it becomes clear very quickly that, although the skills you learned in dental school and beyond might serve to make you a spectacular endodontist, they don’t

prepare you to manage employees or to run your own business. If your practice is or has ever been burdened by employee drama, unengaged or unproductive team members, tedious tasks that suck up your time, payroll issues, high turnover, a lack of clarity on issues such as employee leave, vacation, sick time, travel and educational reimbursements — or any one of the hundreds of issues that are more pertinent to an advanced education in business than a background in the dental sciences — you know firsthand how

Paul Edwards is the CEO and co-founder of CEDR HR Solutions, a leading provider of on-demand HR support for dental practices of all sizes and specialties across the United States. With over 25 years of experience as a manager and business owner, Edwards is well-known throughout the dental community for his expertise in solving HR issues that impact dental practice owners and managers. He specializes in helping dentists successfully handle employee issues and safely navigate the complex and ever-changing employment law landscape through his company’s customized employee handbooks and support center. Edwards is the author of HR Base Camp, a blog and podcast channel for dentists and healthcare providers. He is also a featured writer for The Profitable Dentist, Dentistry IQ, and Dentaltown. He is a contributor to the ADA‘s GPS program and regularly speaks at dental seminars, conferences, and CE courses across the country, including the Greater New York Dental Meeting, Yankee Dental Conference, DOCS Education, AADOM, and more.

Volume 12 Number 4

management issues can affect your bottom line. Let 2020 be the year in which your practice finally starts running the way you always thought (or hoped) it would. Here’s how you get there.

1. Review and revise your company policies First, make sure you have an employee handbook in place for your practice. A professionally written employee handbook will serve as the cornerstone of your office’s team management strategy. Your handbook needs to be customized to reflect your priorities, your company culture, and the laws that apply to your business based on its location and the number of people you employ. Good employee handbooks make expectations clear for your employees. They provide information about the standard workweek, holiday office closures, paid and unpaid time off, how to request a leave of Endodontic practice 45

PRACTICE MANAGEMENT absence, how to dress at work, etc. Handbooks should also outline the protocol for addressing problems in the office and who to go to when an issue arises. Make sure that your policies are in line with all relevant federal, state, and local laws that apply to your business (I HIGHLY recommend working with an HR professional to make sure you get that portion right), and that they are clear and easy to understand. If you or your office manager has trouble interpreting or explaining a policy, it’s going to be unclear to your employees too. Finally, make sure all of your employees have easy access to your handbook. Have them read the entire handbook cover-tocover (preferably during their first day on the job) and sign the last page to acknowledge that they have read and understood all of the policies inside. (This can protect you against claims of ignorance should you ever need to reprimand an employee for violating a policy; and trust me, at some point you will.)

2. Establish an effective feedback loop There are three basic types of power that managers have over their employees. From the most effective to least effective, these are relational power, expertise power, and position power. You might be able to get an employee to complete a task for you by asserting your position as their superior (position power), but that alone won’t be enough to motivate them to put their best effort into the project. If that employee trusts you as an expert at the task or project in question, that might be enough to make sure the job is done well (expertise power), but the best way to ensure that your employees are putting their best effort into their work is to develop and maintain their trust (relational power). People are more excited and more willing to do things for people they like and respect than they are to execute tasks simply because they were ordered to. Provide regular feedback to your employees, both positive and negative (we call this “coaching”). Have regular one-onone meetings, and make an effort to get to know your employees. Make their goals and expectations clear, and make sure those goals are realistic, measurable, and achievable. When you ask an employee to improve a process, give them a clear path to success and acknowledge their efforts, their victories, and their shortcomings. You’ll also want to document all of the formal conversations you 46 Endodontic practice

Whether you have been in business for 20 years or you have yet to open your doors, it’s never too late (or too early) to build a management system that supports you, your managers, and your employees.

have with your employees — that paper trail will serve as evidence that you did all you could to enable their success should you ever have to terminate. Your success as a manager ultimately comes down to this: Employees who feel as though their work matters to their employers are happier, more engaged, and more productive. And, though relationship building will cost you a little bit of time upfront, you’ll ultimately make up for that effort by decreasing your turnover and increasing productivity and revenue for your practice.

3. Take a good look at your systems The processes, protocols, and software you use at your business should support your company culture, policies, and coaching efforts. Essentially, these tools should make life easier for yourself and your managers. Do the programs you use to manage your team streamline your processes or make them more complicated? Is there a better way to do tasks than by the methods you are currently using? Online document storage and sharing systems such as CEDR’s HR Vault eliminate the need for outdated paper systems and make it easy for employees to read, sign, and reference important documents such as your employee handbook on their own. This empowers employees to find solutions

to most problems by themselves (we call this “employee self-service”), freeing up managers to focus on more important tasks (or clock-out early). Digital timekeeping systems are another great timesaving management tool that all practices can benefit from. If you’re still using paper timesheets or Excel to track hours and manage payroll, consider upgrading to a timekeeping system that automatically tracks time off for your employees as it accrues and allows you to pull payroll reports in seconds. Doing so can save you and your managers at least 2 hours a week, which can add up to full calendar days over the course of a year. Whether you have been in business for 20 years or you have yet to open your doors, it’s never too late (or too early) to build a management system that supports you, your managers, and your employees. Hindsight may be 20/20, but instituting a great management strategy is a visionary move. Give it a try, and I know you’ll be shocked to see what even a little forward thinking can do to provide a boost for your business, both in terms of employee morale and income for your practice. Ready to implement a winning management strategy for 2020? Start with a free strategy call with an HR expert by visiting cedrsolutions.com/healthcare/freehr-consultation. EP This information was provided by CEDR HR Solutions.

Volume 12 Number 4

FINDING GOOD PEOPLE IS HARD. OUR HR EXPERTS MAKE IT EASIER. CEDRâ&#x20AC;&#x2122;s Solution Center is staffed with credentialed and experienced HR and employment law experts. Experience the difference professional one-on-one guidance can make for you and your offce manager with a FREE One-Time HR Problem Solving Session.

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SMALL TALK

The abundant leader Drs. Joel C. Small and Edwin McDonald love the idea of abundance and promote this concept with their clients

“People with a scarcity mentality tend to see everything in terms of win-lose. There is only so much;

e see the concept of abundance as both a philosophy and lifestyle. People who lead an abundant lifestyle see their universe as infinite. They demand win-win scenarios in their personal and professional lives. In their world, it is not just acceptable for everyone to succeed; it is an imperative. In our dental communities, abundant leaders do not see other doctors as competition; they consider them colleagues, and a colleague is honored and respected as a friend. Compare this to a lifestyle of scarcity, or what some call a zero-sum philosophy, in which the universe is viewed as finite. This philosophy requires that for every winner there must be a loser. Colleagues become competitors from which we must protect ourselves. We believe that somehow they will gain an advantage by taking what is rightfully ours, never considering the possibility that there is enough for all. The same is true in our own practices. A scarcity or zero-sum philosophy is not compatible with effective leadership because effective leaders are committed to assuring that everyone they lead is given the opportunity and resources to succeed. To an abundant and effective leader, realizing one’s dreams is a universal goal. Scarcity-based leaders commonly believe that their role is to identify and judge others by their weaknesses rather than their strengths. This is a classic lose-lose scenario, which seldom creates a positive result for either party. Drs. Joel Small and Edwin (Mac) McDonald have a total of over 75 years of dental practice experience. Both doctors are trained and certified Executive Leadership Coaches. They have joined forces to create Line of Sight Coaching, a business dedicated to helping their fellow dentists discover a better and more enjoyable way to create and lead a highly productive clinical dental practice. Through their work, clients experience a better work/ life balance, find more joy in their work, and develop a strong practice culture and brand that positively impact their bottom line. To receive their free ebook, 7 Surprising Steps to Grow Your Practice Through Leadership, go to www.lineofsightcoaching.com.

48 Endodontic practice

Imagine what it would be like working in an office culture based on a scarcity philosophy, an office in which recognition is coveted by the doctor and seldom shared with the members of the team. This is an office in which the doctor has an emotional need for control or an environment lacking spontaneity, creativity, or the opportunity for personal development. Recent studies have shown that burnout is most likely to occur not only when people work long hours, but also when their long hours offer no opportunity for personal development. These are offices in decline, and they will continue their downhill spiral because the burdens created by the doctor’s zero-sum attitude cannot be supported by the weakened cultural infrastructure he/she have created.

Abundance-based leaders are the antithesis of scarcity-based leaders. Abundance-based leaders understand that everyone has weaknesses, but they choose to judge others by their strengths. Their dental practices are always more productive because they utilize individual strengths by positioning their people so they can further develop these strengths while benefiting the practice to the best of their ability. Research has proven that people who routinely utilize their most significant strengths in their daily work are among the most personally satisfied and productive team members. We have also observed in organizational cultures that stress abundance and the development of individual strengths, there is a tendency for individual team weaknesses to spontaneously disappear. It is our belief that this unique phenomenon can occur only when failure is viewed as a learning experience and prerequisite for success, thus giving team members the ability and confidence to openly explore solutions for overcoming weakness without the fear of reprisal Now imagine working in an environment in which the doctor attributes achievements to his/her staff and is the first to accept the

and if someone else has it, that means there will be less for me. The more principle-centered we become, the more we develop an abundance mentality, the more we are genuinely happy for the successes, well-being, achievements, recognition, and good fortune of other people. We believe their success adds to ... rather than detracts from ... our lives.” — Stephen R. Covey

blame for failures. What would it be like to work in an organization in which the leader was fully committed and engaged in assuring that all staff members reach their full potential and realize their individual dreams? This is an organization that will continually thrive. Abundant cultures are participative as well as being creative and adaptive. They can tap into their vital stream of human potential which is a prerequisite for a highly productive and culturally mature organization. They promote self-development and self-direction. Such organizations are the icons of their industries. Herb Kelleher, the untraditional CEO of Southwest Airlines, said this about his organization’s culture: “A financial analyst once asked me if I was afraid of losing control of our organization. I told him I’ve never had control, and I never wanted it. If you create an environment where the people truly participate, you don’t need control. They know what needs to be done, and they do it. And the more that people will devote themselves to your cause on a voluntary basis, a willing basis, the fewer hierarchs and control mechanisms you need.” Is it any wonder that numerous studies have proven that organizations that create cultures based in abundance are significantly more profitable than those organizations whose culture is scarcity-based? EP Volume 12 Number 4

Experiencing the power of digital communication. ZEISS EXTARO 300

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The integrated HD camera of the EXTARO® 300 from ZEISS records wirelessly to the ZEISS Connect App — empowering patient interaction and informed decisions with images and videos directly transferred to your local network. • Benefit from a digital workflow • Easily educate your patients • Demonstrate the value of your work

Attending the Yankee Dental Congress or CDS Midwinter Meeting? Tour the advanced technology of ZEISS EXTARO 300. Yankee Dental Congress, January 30 - February 1, 2020 | ZEISS Booth 517 CDS Midwinter Meeting, February 20 - 22, 2020 | ZEISS Booth 1338 SUR.11393 Rev C © Carl Zeiss Meditec, Inc., 2019. All rights reserved.

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