Endodontic Practice US Fall 2020 Vol 13 No 3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Fall 2020 – Vol 13 No 3 • endopracticeus.com

ENDODONTICS

Identification, diagnosis, and management of cracks Dr. John Rhodes

Evaluation of postoperative pain after single visit root canal treatment associated with three rotary systems Drs. O.A. Hafez, A.H. Diab, and H.A. El Asfouri

Treating infected roots Dr. Jason Bedford

Telemedicine marketing checklist: 10 things endodontists should do Rachael Sauceman

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PROMOTING

See Page 29

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This has been a

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STACY HILL, VP OF MARKETING & RON HILL, DDS, MSD GentleWave® Doctor since 2018

THE GENTLEWAVE® SYSTEM: PEER PROVEN. PATIENT APPROVED. Sonendo® is invested in delivering better results—for your patients and your practice. We measure our success in this endeavor by the growing community of GentleWave® Doctors championing our technology and the satisfied patients expressing appreciation for their RCT experience.

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TOOTH #13 POST-GENTLEWAVE® PROCEDURE†

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† Photo and images courtesy of Ron Hill, DDS, MSD © 2020 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo and SAVING TEETH THROUGH SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: www.sonendo.com/intellectualproperty. MM-1120 Rev 02

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 2020. 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.

Leveraging the pandemic to renew practice growth

ur practices are composed of all the little things we do, but the whole is definitely greater than a sum of its parts. How everything is done, and how details are sequenced, synchronized, and optimized make a huge difference. There is a difference between the execution of tasks and efficient implementation of systems that drive success. Likewise, not every detail or task is created with equal significance. Some things have an outsized relation to practice success. Other things, no less essential from an operational perspective, hardly influence practice success at all. For example, improving your scheduling strategy can greatly influence productivity and success, but even the most perfect system for opening the mail Albert (Ace) Goerig, DDS, MS will not make a noticeable difference. Thousands of mundane details in our practices need to run on autopilot. A much smaller set of vital factors need regular re-examination and continual effort to improve them. Where you draw the line between the mundane and the vital defines how entrenched you are in a comfort zone. However, as business author Jim Collins taught the world 20 years ago in his landmark book, Good to Great, good is the enemy of great. A good comfort zone creates complacency, perpetuates habits that have outlived their effectiveness, and resists change that leads to great performance. More often than not, doctors persist with their practices on autopilot until they start developing pain points — for example, frustration with financial limitations, daily stress, lack of growth, an unmotivated team, or a generalized loss of energy and enthusiasm. These indicators, even if you feel just a shadow of them right now, are the clearest signs that it is time to let go of your comfort zone. Where do you turn? The answer is education for yourself and your team, but not just education that neatly aligns and reinforces what you are doing now. Instead, dive into something that opens your mind to new possibilities, focuses on growth, and challenges your assumptions from a 360-degree perspective. It’s the perfect time because the pandemic is forcing us to change anyway. Later in this issue, my article “What Coronavirus Taught Me About Clinical Efficiency” shares how the pandemic prompted me to re-examine some of my scheduling and clinical care factors to adapt to today’s reality. Sometimes we need that kind of external pressure to signal us that we’ve been coasting, and we need to get motivated about positive change. These changes have reduced my stress, allowed me to have some of my most productive and enjoyable days ever, and over the past 2 months, my team and I have had the 2 most productive months ever in my practice. See how we did it. Dr. Albert (Ace) Goerig Owner and Co-Founder, Endo Mastery

Albert 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 is the author of more than 60 published articles and a contributing author to numerous endodontic textbooks. Dr. Goerig has a private endodontic practice in Olympia, Washington, in the top 1% nationwide for practice profitability. He has coached over 1,000 endodontists during the past 23 years.

ISSN number 2372-6245

Volume 13 Number 3

Endodontic practice 1

INTRODUCTION

Fall 2020 - Volume 13 Number 3

TABLE OF CONTENTS

Endodontic perspective Interdisciplinary endodontics

Publisherâ&#x20AC;&#x2122;s perspective Thoughts of business health, optimism, clarity, and prosperity Lisa Moler, Founder/CEO, MedMark Media................................ 6

Dr. John West discusses saving endodontically diseased teeth with consensus diagnosis, interdisciplinary treatment planning, and sequencing

Continuing education Identification, diagnosis, and management of cracks

Clinical research

Dr. John Rhodes presents another interactive, practical, and problemsolving solution in endodontics. In this issue, he looks at the identification, diagnosis, and management of cracked teeth...................................21

ON THE COVER Inset image on cover courtesy of Dr. John Rhodes. See article on page 21.

Volume 13 Number 3

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TABLE OF CONTENTS

Practice management What coronavirus taught me about clinical efficiency Dr. Albert (Ace) Goerig discusses how to achieve the same or better daily productivity and case completions post-COVID-19...............................28

Product profiles Why I choose handheld for my endodontic X-ray needs

Continuing education Treating infected roots

Dr. Jason Bedford shows how a new hydroxyapatite root repair material benefits the apical closure and healing of a large periradicular radiolucency

Dr. Steve L. Frost discusses a unique, personalized patient experience in imaging........................................... 30

Manta™ Cordless Endodontic Handpiece — SS White Dental® ....................................................... 31

Service profile Silent partners are still investing in great endodontic practices

Marketing momentum Telemedicine marketing checklist: 10 things endodontists should do Marketer Rachael Sauceman discusses safe and effective marketing evolving after the COVID-19 crisis .......................................................34

Chip Fichtner discusses how to create new opportunity in uncertain economic times...............................................32

Ready, set, present! In this article, Jackie Raulerson discusses how to share your practice and treatment successes with an effective presentation....................... 37

Small talk Peak performance Drs. Joel C. Small and Edwin McDonald discuss reaching your maximum practice potential.............. 40

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

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

4 Endodontic practice

Volume 13 Number 3

Courtesy of Allen Ali Nasseh, DDS, MMSc

BY YOUR SIDE

Visit our website at BrasselerUSA.com To order call 800.841.4522 or fax 888.610.1937. In Canada call 800.363.3838. Invoice or statement prices may reflect or be subjected to a bundled discount or rebate pursuant to purchase offer, promotion, or discount program. You must fully and accurately report to Medicare, Medicaid, Tricare and/or any other federal or State program, upon request by such program, the discounted price(s) or net price(s) for each invoiced item, after giving effect to any applicable discounts or rebates, which price(s) may differ from the extended prices set forth on your invoice. Accordingly, you should retain your invoice and all relevant information for your records. It is your responsibility to review any agreements or other documents, including offers or promotions, applicable to the invoiced products/prices to determine if your purchase(s) are subject to a bundled discount or rebate. Any such discounts must be calculated pursuant to the terms of the applicable purchase offer, promotion, or discount program. Participation in a promotional discount program is only permissible in accordance with discount program rules. By participation in such program, you agree that, to your knowledge, your practice complies with the discount program requirements.

B-5178-EP-03.20

PUBLISHER’S PERSPECTIVE

Thoughts of business health, optimism, clarity, and prosperity

s I write this message, COVID-19 is still driving many of the operational aspects of the dental office, and dentists are trying to navigate the challenges and restrictions related to maintaining safety and health. Recently, I attended the ADA’s press conference on reopening — a meeting that gathered dental leaders to discuss CDC guidelines, dentists’ concerns, and the ADA’s direction on how to navigate with “cautious optimism” out of this crisis. Seeing these visionaries of the dental community all working to provide information and guidance to their peers empowered us at MedMark Media as well to work even harder to be an advocate for the dental community. In these times, when it seems we are reinventing dentistry Lisa Moler Founder/Publisher, MedMark Media to accommodate new and evolving needs, we need to call upon the strengths and creativity that have navigated us out of other very difficult times in our lives and our careers. As different types of information swirl around us on the news, on social media, and in our own social circles, it is important to keep the team informed and involved in the decisions that will affect their health and safety. Keep those team meetings ongoing, so the team is aware of your consistent support. Formulate and be proactive on what steps will be taken if a team member is exposed to the virus, or if a patient with COVID-19 has entered your office. Now is the time to use your social media to show patients your dedication to a safe environment for them and your staff. Keep them apprised of your technologies that will offer them the most comprehensive care, even after COVID-19 abates and life returns to the “new normal.” Take a look at all of the telehealth options that are possible for the dental practice. This tool can be useful for prescreening patients as well as scheduling and check-in to reduce the amount of people at your front desk or in your waiting rooms. Make sure that you have clear instructions on your online presence as well as in the waiting area and any area that requires social distancing or face masks. And be clear on when face masks are required in your office (such as removing the mask in the operatory and putting it back on when leaving the room or in the presence of others). In this issue, we continue to provide articles on subjects that can expand your endodontic practice far into the future. In a CE, Dr. Jason Bedford discusses treating infected roots after traumatic incidents. Dr. Bedford notes, “Managing these cases is not straightforward, and the results can be unpredictable.” In his CE, Dr. John Rhodes also examines cracked teeth — their identification, diagnosis, and management. Drs. O.A. Hafez, et al., evaluate postoperative pain after single-visit root canal treatment with several different file systems. Since telemedicine is a growing and necessary part of practice life since COVID-19, marketer Rachael Sauceman offers safe and effective marketing solutions to keep your patients close and cared for. During COVID-19 and after, we strive to keep bringing you ideas and information for clinical and business aspects of your practice. Wishing you and your business health, optimism, clarity, and prosperity in these everchanging moments we are all facing.

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER - CLIENT SERVICES/SALES Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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

To your best success! Lisa Moler Founder/Publisher MedMark Media

6 Endodontic practice

SUBSCRIPTION RATES 1 year (4 issues) $149 3 years (12 issues) $399 Subscribe at www.medmarksubscriptions.com

Volume 13 Number 3

90% of patients agree that sterilization is one of their top concerns related to visiting a dental office post-COVID19. 1

Dentsply Sirona provides the largest range of pre-sterile endodontic instruments in the United States.* As patients return to your practice, safety and performance are critical. Our pre-sterile packaging meets todayâ&#x20AC;&#x2122;s new patient expectations. The time is NOW to educate your patients on how safe and effective Endodontic therapy is in restoring tooth function and ultimately achieving healthy smiles. For more information, contact your Dentsply Sirona Endodontics representative or visit dentsplysirona.com/endo.

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ENDODONTIC PERSPECTIVE

Interdisciplinary endodontics Dr. John West discusses saving endodontically diseased teeth with consensus diagnosis, interdisciplinary treatment planning, and sequencing Introduction Endodontically treated teeth can be the weakest link in the esthetic/restorative diagnosis and treatment plan. They can also be the missing link between success and failure of the interdisciplinary treatment plan. In this, the second decade of the 21st century, we are born out of the humblest biologic stance: When the cause of a disease is removed, the disease itself disappears. The former disease cannot produce continued pathology because, quite simply, it is gone!1 And not only is the disease gone, but the results of the disease are no longer sustainable without the cause. It’s that simple. We, as dentists, are the caretakers of this biologic tenet. And yet, we sometimes forget. We forget because it is easy. We forget because it is hard. We forget because we may be thinking of ourselves and not the patient. We forget because it is convenient. We forget because we failed to do the right thing.

Doing the right thing I chose these five predictable, long-term interdisciplinary endodontic patient presentations as examples of doing the right thing. All patients’ continued care records are from 18 to 26 years posttreatment. They may not have been the safest, the easiest, or the most clinically productive, but they were the right treatment plans for their times. Today, the narrative trend is to “remove and replace” endodontically diseased teeth when in doubt.2 My goal is for these five examples to serve as a reminder that the “always” answer in interdisciplinary endodontic treatment

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 is in private endodontic practice in Tacoma. Dr. West can be reached at johnwest@ centerforendodontics.com. Disclosure: Dr. West reports no disclosures.

8 Endodontic practice

planning is easily found in the answer to the 8-word question “What would I do if it were me?” I am convinced that after reviewing these five patients’ options and considering that endodontic techniques can be mastered by any dentist who wants to learn endodontic skills, the reader will have a new appreciation for the long-term capacity of healing or preventing lesions of endodontic origin. And I submit that if the reader were the patient in these five patient examples, he or she would have chosen the same right thing for him or herself. The interdisciplinary endodontic treatment planning that was chosen by each patient was the right thing for that patient, for the dentist, and for dentistry. Making these choices, to me, is the hallmark of a true caregiver.3,4 The interdisciplinary endodontic treatment planning for each of the five example patients was based on three considerations: 1) biology, 2) structure, and 3) esthetics. Specifically, can the root canal system portals of exit (POEs) be predictably cleaned and sealed either nonsurgically or surgically? Is the periodontal condition healthy, or can it be

made so? Structurally, is there sufficient ferrule width and ferrule height? Is there at least 4.0 mm from height of bone to height of ferrule? Esthetically, does the endodontically involved tooth enhance the dental esthetics, and if not, can it be made to do so?

Patient reports Patient 1 A patient had a residual sinus tract tracing to the lateral wall of the maxillary right central incisor after a third, and finally esthetic bridge attempt. Biologic considerations: What is the multiple abutment pulpal status? Can the underfilled anatomy of tooth No. 8 be treated surgically and still seal all POEs that could be inaccessible? Can the post be removed nonsurgically, and could underfilled anatomy be successfully discovered, cleaned, and obturated? Is the periodontal condition healthy? Structure considerations: Can the FPD be removed without breaking teeth or damaging the FPD? Note that the FPD was luted in (not bonded) with zinc phosphate

Figures 1A-1F: 1A. The patient’s smile 8 years prior to his car accident when he lost tooth No. 9. 1B. The sinus tract tracer appeared 1 year after the third bridge placement. 1C. Radiograph of gutta-percha cone tracing the sinus tract to the mesial midroot of tooth No. 8. 1D. Periapical radiograph of abutment Nos. 10 and 11; No. 10’s pulp tested nonvital. 1E. CORONAflex™ (KaVo) crown and bridge remover. 1F. The bridge was removed with CORONAflex. Floss was tied to bridge for removal safety Volume 13 Number 3

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ENDODONTIC PERSPECTIVE

Figures 1G-1N: 1G. Previously prepared teeth. 1H. A downpack with visually obturated lateral and apical portals of exit (POEs). 1I. Sealer extruded from the sinus tract; surplus subsequently removed with a 2 x 2 gauze. 1J. Posttreatment radiograph. 1K. A 22-year posttreatment image showing healed lateral and apical LEOs of No. 8. 1L. The healed No. 10 LEO. 1M. Healed sinus tract facial to No. 8. 1N. Final (Case by endodontist Dr. John West, Tacoma, Washington)

cement. Can the post be removed without affecting the ferrule? Esthetic considerations: If endodontic surgery were chosen, could scarring or black triangles be risk factors? With a high smile line, however, surgery was not contraindicated. If surgery is done for tooth No. 8, what about for the nonvital pulp in tooth No. 10? The need to access through FPD or remove FPD already exists. What about removal and implants? The patient loved the bridge, as it was the third attempt to get his smile right again after his car accident. He had no interest in another bridge or implants and understood a nonsurgical interdisciplinary treatment plan was the most predictable but not without possible peril. Interdisciplinary treatment planning and sequencing: The plan was to successfully remove the bridge, and for nonsurgical endodontic retreatment of tooth No. 8, and nonsurgical endodontic treatment of tooth No. 10. The bridge would be permanently cemented after evidence of sinus tract healing (Figure 1). Patient 2 The patient had previously experienced multiple accidents to her maxillary anterior teeth and presented with a sinus tract in tooth No. 8. Biologic considerations: Is nonsurgical or surgical endodontic treatment more predictable given that a lateral POE could 10 Endodontic practice

Figures 2A-2I: 2A. Smiling patient before treatment. 2B. Uneven gingival levels. 2C. Periapical image of a sinus tract tracer to the distal lateral portion of the root canal system. 2D. The No. 6 endodontic file was placed. 2E. The rubber dam was retracted, revealing the file penetrating through the gingiva. 2F. Posttreatment nonsurgical endodontic treatment. 2G. The 23-year posttreatment of tooth No. 8, and later tooth No. 10. 2H. Present-day restorative. 2I. The patient was pleased with her smile, and improved self-esteem gave her new confidence (Case collaboration by endodontist Dr. John West; orthodontist Dr. Vince Kokich Jr, Tacoma; and prosthodontist Dr. Gregg Kinzer, Seattle.) Volume 13 Number 3

Even today, the art of saving compromised teeth, particularly endodontically treated teeth, may seem to have been lost. However, in proper hands and with interdisciplinary planning and consensus diagnosis, the art and science are alive and well. Endodontic interdisciplinary treatment planning gives patients their best path, their right path. She also wanted to remove the “black area between the tooth and gingiva.” Her dentist thought that he could cover the dark halo with a new crown, but he requested internal bleach in order to eliminate the possibility of a dark reflection into the gingiva even with new crown. Biologic considerations: A persistent radicular LEO due to probable coronal leakage and seal breakdown of the silver cone and sealer obturation were present.

Patient 3 The patient presented with percussion and palpation sensitivity in tooth No. 8.

Structure considerations: Shape the endodontic preparation while preserving root width and ferrule. Esthetic considerations: Internal bleaching, followed by a new crown once endodontic symptoms were absent. Interdisciplinary planning and sequencing: Successful nonsurgical endodontic retreatment and safe internal bleaching were done, and a new crown was placed (Figure 3).

Figures 3A-3O: 3A. Pretreatment radiograph of the maxillary right central incisor. 3B. Preoperative photo showing a dark gingival area. 3C. Close-up of the dark gingival area. The patient wanted to improve the crown shape. 3D. The crown was removed. 3E. Close-up of the probable sealer, silver cone, and post staining. 3F. The post was removed. 3G. The silver cone was removed. 3H. The shaping rotary confirmed restrictive flow preparation. 3I. The cleaned root canal system. 3J. The conefit. 3K. Posttreatment and placement of a “safe bleach” barrier. 3L. Improved gingival root color after bleaching. 3M. Close-up of the gingival crown color. 3N. Post-endodontic treatment. 3O. The final, long-term 18-plus-year posttreatment (Case collaboration by endodontist Dr. John West and restorative dentist Dr. Karl Smith, Tacoma.) N. Volume 13 Number 3

O. Endodontic practice 11

ENDODONTIC PERSPECTIVE

not be only lateral but also toward the palatal, making it surgically inaccessible for preparation and obturation? The patient wanted to consider modeling someday and did not want to risk surgical scarring of any kind. Structure considerations: Can a nonsurgical approach preserve the ferrule? Esthetic considerations: An uneven gingival smile line was present that the patient wanted corrected. The orthodontist and prosthodontist agreed to sequencing their treatments once the endodontic status of her maxillary right central incisor was known. Interdisciplinary planning and sequencing: After nonsurgical endodontic retreatment of tooth No. 8, orthodontic treatment to align teeth and correct tooth No. 8’s gingival levels was done. Esthetic restorative dentistry was done as needed (Figure 2).

ENDODONTIC PERSPECTIVE Patient 4 A dentist accidentally created a mesial perforation during endodontic access. The dentist and patient needed an interdisciplinary evaluation. Since implants were not yet mainstream when this patient presented 27 years ago, the choices were to extract and place an FPD or attempt to save the tooth. While the orthodontic evaluation suggested the possible removal of tooth No. 12 followed by orthodontic alignment, the patient absolutely did not want full orthodontics. He wanted “this tooth fixed.” Biologic considerations: Seal the root canal system nonsurgically. Periodontal

pocket correction with osseous recontouring was followed by forced orthodontic eruption in order to create 4 mm from height of bone to height of ferrule. Proper final restoration shape was needed to allow easy plaque control. Structure considerations: None with nonsurgical endodontics. Esthetic considerations: The emergence profile must look natural enough. Interdisciplinary planning and sequencing: Successful nonsurgical endodontics, forced orthodontic eruption, osseous recontouring, and restorative dentistry (Figure 4).

Closing comments

Patient 5 The patient presented with a sinus tract and receding gingival tissue in tooth No. 8. Biologic considerations: Can nonsurgical endodontics be predictably successful if the silver cone is removed and if the apical tooth segment and silver cone section remain without pathology? Structure considerations: None if the third, third, third rule can be achieved (i.e., the maximum-shaped canal should not exceed one-third the width of the root at any level). Esthetic considerations: Can gingival levels be corrected through a connective tissue graft once the sinus tract is healed? Interdisciplinary planning and sequencing: Nonsurgical endodontic treatment in the coronal section of tooth No. 8. After proof of sinus tract healing, a connective tissue graft was done to correct tissue levels (Figure 5).

Figures 4A-4F: 4A. Pretreatment radiograph. 4B. Deep probing into the base of the mesial access perforation. 4C. Forced orthodontic eruption. 4D. Periodontal osseous recontouring. 4E. Finished endodontics and restorative. 4F. At the 26-year posttreatment appointment (Case collaboration by endodontist Dr. John West; orthodontist Dr. Vince Kokich Sr., Tacoma; periodontist Dr. Dave Mathews, Tacoma; and restorative dentist Dr. Ralph O’Connor, Tacoma.)

Would we choose these same five endodontic interdisciplinary treatment plans today? The answer is yes, given that implants were only becoming mainstream when these patients were treated. Nonetheless, even today, the art of saving compromised teeth, particularly endodontically treated teeth, may seem to have been lost. However, in proper hands and with interdisciplinary planning and consensus diagnosis, the art and science are alive and well. Endodontic interdisciplinary treatment planning gives patients their best path, their right path. It’s the right thing! The following quote by author M.H. McKee perhaps best summarizes the lesson of this article: “Wisdom is knowing the right path to take … integrity is taking it.” EP

References

1. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2):269-296. 2. West J. Implants versus endodontics: “As the pendulum swings.” Dent Today. 2014;33:10-12. 3. 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. 4. West J. Endodontic update 2006. J Esthet Restor Dent. 2006;18(5):280-300.

This article was reprinted with permission from Dentistry Today.

Figures 5A-5F: 5A. Pretreatment photo, showing the sinus tract tracer toward the root end. 5B. Probing WNL, but gingival recession is present. 5C. Posttreatment image. 5D. Posttreatment periapical area. 5E. At 19 years’ posttreatment. 5F. The esthetic gingival levels were restored (Case collaboration by endodontist Dr. John West and periodontist Dr. Jim Janakievski, Tacoma.) 12 Endodontic practice

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CLINICAL RESEARCH

Evaluation of postoperative pain after single visit root canal treatment associated with the three rotary systems: ONE ENDO, F6 SkyTaper™, and ProTaper® Universal (randomized controlled clinical trial) Drs. O.A. Hafez, A.H. Diab, and H.A. El Asfouri explore file systems and postoperative pain Summary Objective To compare the intensity of postoperative pain after a single visit endodontic treatment using ProTaper® Universal multiple file system (Dentsply Sirona, Charlotte, North Carolina) and the single file rotary systems — ONE ENDO (NanoEndo LLC, Chattanooga, Tennessee) and F6 SkyTaper™ (Komet Dental, Lemgo, Germany). Methodology Fifty-eight patients aged between 20-50 years old were diagnosed with symptomatic irreversible pulpitis of one maxillary or mandibular premolar. Teeth were randomly assigned to three groups according to the root canal shaping system: ONE ENDO (Group A), F6 SkyTaper™ (Group B), and Rotary ProTaper® Universal (PTU) as a control (Group C). The comparison mainly focused on discovering whether single-file systems are causing the same or different levels of postoperative pain as traditionally used multiple-file systems. The PTU system was the most commonly used system with previous study reports of its performance and, therefore, was selected as a control group for the present study. All treatments were completed in a single visit. The severity of the postoperative pain was assessed by the verbal rating scale (VRS) after 24, 48, and 72 hours. Data was analyzed using the Kruskal-Wallis and Mann-Whitney U tests. O.A. Hafez is the main investigator, MD student at Endodontic Department, Faculty of Dentistry, Cairo University, Egypt. A.H. Diab is Chief Supervisor, Professor of Endodontics, Faculty of Dentistry, Cairo University, Egypt. H.A. El Asfouri is Assistant Supervisor, Lecturer of Endodontics, Faculty of Dentistry, Cairo University, Egypt. Disclosure: The authors have stated explicitly that there is no conflict of interests in connection with this article.

14 Endodontic practice

Results After 24 hours: There was no statistically significant difference between the three studied groups (p = 0.126). After 48 hours: Group A showed the lowest pain levels with statistically significant difference with both groups B (p = 0.003) and C (p = 0.036). However, there was no statistically significant difference between the intervention group B and the control group C (p = 0.407). After 72 hours: Group A showed the highest levels of total pain relief with statistically significant difference with group B (p = 0.011) but without significant difference with group C (p = 0.073). Pain scores for both groups B and C were almost similar (p = 0.459). Conclusion The number of instruments had no impact on postoperative pain. The theory supporting why a clinician would expect different pain levels posttreatment based on a file system is that the number of files as well as file design can extrude different amounts of debris beyond the apex with/without significant effect on postoperative pain.

Introduction Chemo-mechanical preparation of the root canal system is one of the prerequisites of endodontic treatment. The procedure involves canal shaping and using intracanal irrigants to provide optimal cleaning and disinfection within the root canal system. Although various methodologies have been introduced, one of the problems related to all root canal shaping and cleaning procedures is the extrusion of intracanal debris and irrigants into the peri-radicular tissues.1 Debris extrusion during root canal instrumentation is an undesirable side effect of treatment.2 Clinical and biological relevance of apical extrusion of debris is the interappointment or postoperative pain and flare-ups.1 Many studies mentioned

that endodontic patients reported various degrees of pain after endodontic treatment.3 The prevalence of post-endodontic pain was estimated to be 3:58%. With the introduction of single-file systems, a single instrument is used for the entire procedure, which means that the same total amount of debris has to be contained within a single set of flutes.2 Therefore, the efficiency of single-file systems may be accompanied by drawbacks, at least regarding apical extrusion of debris and especially in infected cases where these systems may cause more interappointment emergencies.4 Recent studies have shown that the treatment protocols of new reciprocating systems can also produce extrusion of debris in the apical region, which could be related to postoperative pain when compared with other traditional instrumentation techniques.5 The highest incidence occurs during the first 24-48 hours and gradually decreases over the following days.6 It is one of the major tasks of the endodontist to avoid or minimize, as much as possible, the irritation of the periapical tissues during root canal treatment.6 Apical extrusion of debris has been associated with all types of instruments and instrumentation techniques, even when preparation is maintained short of the apical terminus with some instrumentation techniques extruding less material than others.7 Debris extruded beyond the apical foramen may result in periapical inflammation and postoperative pain. To date, no root canal preparation method has been developed that extrudes no periapical debris. The number of instruments and the kinematics of movement may contribute to debris extrusion during root canal preparation.2 ProTaper® Universal system is a wellknown, engine-driven multiple-file system with continuous rotational movement. It has been the topic of many investigations concerned with apical extrusion of debris Volume 13 Number 3

CLINICAL RESEARCH as well as its association with postoperative pain. Although it was proved in some studies8-15 to extrude debris more than many other systems, associated postoperative pain was associated with controversy.4,16-20 The newer single-file NiTi systems such as ONE ENDO21 and F6 SkyTaper22 are designed to completely prepare root canals with only one instrument. Both systems are used in a continuous rotation motion. The ONE ENDO is a new type of file design: deltatype; featuring two unequal tapers side by side within the same instrument (Figure 1). The F6 SkyTaper system is a 0.06 taper, which is a newer modification of the 0.04 taper rotary system — F36022 (Figure 2). Presently, no previous study has evaluated the effect of the newer single-file rotary systems, ONE ENDO and F6 SkyTaper, on postoperative pain. The null hypothesis for this study stated that there is no difference in postoperative pain between the three groups.

Participants and methods Study design and sampling This study was a single-blinded, controlled, parallel-grouped, randomized clinical trial. All the procedures were done according to the Declaration of Helsinki (version 2008) and approved by the Research Ethics Committee, Faculty Dentistry, Cairo University, Egypt, with the approval number 16821. The trial was registered on www.ClinicalTrials.gov with the identifier: NCT03065777. All the participants signed an informed consent after understanding the treatment procedure and accepting the possible risks. Eligibility criteria Outpatients in the clinic of Endodontics at the Faculty of Dentistry, Cairo University, Egypt, were recruited to participate in the study according to the following eligibility criteria: A. Inclusion criteria All adults (20-50 years old), medicallyfree patients (males or females) having maxillary or mandibular premolar teeth with symptomatic irreversible pulpitis and indicated for conventional endodontic treatment who accept to enroll in the study. B. Exclusion criteria Those cases that fulfilled any of the following criteria were excluded: nonvital teeth; teeth with apical periodontitis; teeth requiring endodontic retreatment; root resorption; immature/open apex; root canals with radiographic evidence of calcification in 16 Endodontic practice

Figure 1: ONE ENDO file

which patency of the apical foramen could not be established; presence of more than one symptomatic tooth in the same quadrant; pregnancy, medically compromised patients, or patients receiving medication for chronic pain; patients who have taken analgesics in the last 12 hours before treatment; teeth that have initial apical size more than 20; and teeth that could not be treated in a single session. If any evidence of extrusion of root filling material was noticed radiographically, the case was excluded. To confirm symptomatic irreversible pulpitis, the patients should have experienced moderate to severe pain as well as prolonged response to cold testing by Endo-Ice® (Coltene/Whaledent, Inc., Mahwah, New Jersey). Bleeding on access cavity preparation should be present. There should be no periapical radiolucency except for widening periodontal ligaments present radiographically. Randomization In order to randomly assign the patients, a random sequence generated by www. random.org for patients’ numbers was used to assign the patients in the three groups: A, B, or C.

Clinical procedures Root canal treatment was completed in a single visit by an endodontic master’s degree student. All patients received local anesthetic administration with 1.8 ml Mepivacaine HCl 2%-Levonordefrin 1:20000 (Alexandria company for pharmaceuticals and Chemical industries, Egypt). Levonordefrin was used as a vasoconstrictor similar to epinephrine but more stable. The affected tooth was isolated with a rubber dam; then access cavity preparation was done with round carbide and Endo-Z™ burs (Dentsply Maillefer, Tulsa, Oklahoma), using an air turbine handpiece and underwater coolant. Working length was determined with a Root ZX® apex locator (J. Morita, Tokyo, Japan) (J. Morita USA Inc., Irvine, California) and confirmed radiographically. A size 10 K-File (Mani, Utsunomiya, Japan) was used as a patency file. Initial apical size was confirmed to be 20 before introducing the rotary files.

Figure 2: F6 SKYTaper file

For the ONE ENDO group, coronal flaring was done using an OP10L19 orifice opener (Komet Dental, Lemgo, Germany) at speed 300 rpm and 2.8 Ncm. Then a size 30/0.06 ONE ENDO file (NanoEndo LLC, Chattanooga, Tennessee) at 500 rpm was used at WL with a gentle picking motion. For the F6 SkyTaper group, coronal flaring was done using a OP10L19 orifice opener. Then a size 30/0.06 F6 SkyTaper file (Komet Dental, Lemgo, Germany) at 300 rpm and 2.2 Ncm torque was used at WL with gentle picking motion. For the ProTaper Universal (PTU) group, the following sequence was used: SX, S1, S2, F1, F2, and F3 files according to the manufacturer’s instructions for speed and torque of each file. All the three rotary systems were mounted on 16:1 reduction handpiece operated by the X-Smart® Endo Motor (Dentsply Maillefer, Ballaigues, Switzerland) (Dentsply Maillefer, Tulsa, Oklahoma), and introduced into the canal with EDTA gel (MD-Chelcream, META BIOMED CO., LTD, Korea) as a lubricant. The root canals were abundantly irrigated with 2 ml of 5.25% sodium hypochlorite (NaOCl) after each instrument exchange using the 30-guage needle up to 1 mm short of the working length. The amount of final irrigating solution was 10 ml NaOCl and 2 ml EDTA 17% (Master-Dent® EDTA solution; Dentonics, Charlotte, North Carolina) for each canal. Prior to obturation, the root canals were completely dried using 95% ethyl alcohol and sterile absorbent paper points compatible with the root canal diameters. According to Stevens, et al.,23 drying of the canals using 95% ethyl alcohol leads to better uniform adherence of the sealer to dentin surface and penetration of sealer into dentinal tubules. The gutta-percha master cone, compatible with the root canal instrumentation, was then inserted into the root canal, and the first 5 mm was coated with ADSEAL resin sealer (META BIOMED CO., LTD, Korea). Obturation of the root canal system was performed by the single cone or modified single cone techniques. Upon Volume 13 Number 3

CLINICAL RESEARCH

completion of the obturation, the tooth was filled with temporary filling material (Tfil; AHL, Ltd, Kent, UK), and then occlusal adjustment was done (completely taken out of occlusion). Patients were informed that they could experience pain in the days following treatment and asked to fill out a verbal rating scale (VRS)24 defined as follows: 0. No pain. 1. Mild pain: any discomfort of any duration that does not require analgesics. 2. Moderate pain: pain that requires and is relieved with analgesics. 3. Severe pain: any pain that is not relieved with analgesics. To assess postoperative pain, a scale of pain intensity was applied 24 hours, 48 hours, and 72 hours after endodontic treatment after telephoning the research individuals. The recommended medication for pain was ibuprofen (400 mg) when needed.

Statistical analysis Data was analyzed using IBM SPSS advanced statistics (Statistical Package for Social Sciences), version 21 (SPSS Inc., Chicago, Illinois). Numerical data was described as mean and standard deviation or median and range. Data was explored for normality using the Kolmogrov-Smirnov test and Shapiro-Wilk test. Comparisons between study groups for normally distributed numeric variables were done using the ANOVA, followed by Bonferoni post hoc test. Non-normally distributed numeric variables were done by Kruskal-Wallis test, and pairwise comparisons were done by Mann Whitney test. Comparisons between categorical variables were performed using the chi-square test. A p-value less than or equal to 0.05 was considered statistically significant. All tests were two-tailed.

Results A total of 72 patients was assessed to enroll in this study. Fourteen patients were excluded due to expressing one or more of the exclusion criteria. Fifty-eight patients were enrolled to participate in one of the three groups. There was failure to contact with four patients (i.e., one patient in group A, two patients in group B, and one patient in group C). Statistical analysis was performed on the remaining 54 participants. The flow chart of the patients through the study followed the CONSORT flow diagram (Chart 1). Table 1 summarizes the demographic data and general characteristics of the study groups. There were no significant differences Volume 13 Number 3

Chart 1: CONSORT flow diagram

Table 1: Baseline characteristics of the study participants Variable

ONE ENDO (n = 19)

F6 SKYTaper (n = 20)

PTU (n = 19)

P-Value

Mean age (years) ±SD

38.11 ± 9.18

40.00 ± 10.6

36.21 ± 7.0

0.158

Male

6 (31.58%)

2 (10%)

3 (15.79%)

0.233

Female

13 (68.42%)

18 (90%)

16 (84.21%)

Tooth type Mandibular Maxillary

7 (36.8%) 12 (63.2%)

9 (45.0%) 11 (55.0%)

9 (47.4%) 10 (52.6%)

0.789

in age, gender, type of teeth, or the number of canals between the three groups (p > 0.05).

Outcome Table 2 describes pain scores for each group at the three studied periods. Group A: There was significant decrease of pain levels after 48 hours (p = 0.012). However, there was no significant difference after 72 hours (p = 0.080). Group B: There was no significant decrease in pain levels in the first 2 days (p = 0.359) but there were significant lower pain scores after 72 hours (p = 0.004). Group C: Results were similar to group B as there was no significant decrease of pain scores at the first 2 days (p = 0.405), and the lowest pain scores were significantly expressed after 72 hours (p = 0.010).

Table 3 illustrates the comparison of postoperative pain scores between the three groups at different follow-up periods. After 24 hours: There was no statistically significant difference between the three studied groups (p = 0.126). After 48 hours: Group A showed the lowest pain levels with statistically significant difference with both groups B (p = 0.003) and C (p = 0.036). However, there was no statistically significant difference between group B and group C (p = 0.407). After 72 hours: Group A showed the highest levels of total pain relief (i.e.: pain score 0) with statistically significant difference with group B (p = 0.011) but without significant difference with group C (p = 0.073). Pain scores for both groups B and C were almost similar (p = 0.459). Endodontic practice 17

CLINICAL RESEARCH Discussion The aim of this clinical trial was to compare the effect of using single file rotary systems; ONE ENDO and F6 SkyTaper with the conventional multi-file rotary ProTaper Universal system on postoperative pain in cases diagnosed with symptomatic irreversible pulpitis. The results showed that after 24 hours, the highest incidence of moderate pain was in cases treated by the F6 SkyTaper system although the difference was not significant among the assessed instrumentation systems. After 48 hours, significantly lower pain scores were noticed in the ONE ENDO group than the F6 SkyTaper and ProTaper Universal groups, while higher pain levels were associated with the F6 SkyTaper system but without significant difference when compared to the control group. After 72 hours, 16 patients treated by the ONE ENDO system reported total relief of pain with significant difference to the other two groups. Nine and 11 patients in F6 SkyTaper and ProTaper Universal groups, respectively, reported absence of pain without significant difference between them. Regarding the ONE ENDO system, the null hypothesis was rejected while we failed to reject the hypothesis for the F6 SkyTaper system. For the present study, the highest pain scores in all the three groups occurred in the first 24 hours, with gradual reduction in pain levels at the following follow-up periods of 48 hours and 72 hours. Similar findings were reported in a systematic review by Pak, et al.,25 in which pain incidence in the first 24 hours was 40%, declining sharply thereafter, particularly over the first 2 days, and reaching levels of 11% at 7 days. Kherlakian, et al.,26 and Mollashahi, et al.,27 mentioned similar results when using one of the instrumentation systems ProTaper Next, WaveOne® (Dentsply Sirona) or RECIPROC (VDW, Munich, Germany) in the former study or RECIPROC and One Shape files (Medidenta, Las Vegas, Nevada) in the latter. Lower pain levels reported in the ONE ENDO group may be attributed to the file’s special design. It has a cut-flip tip resembling a thick spoon with a sharpened edge. The tip’s blade effectively forms dentinal chips while its opposite side is a curved surface acting as a self-guiding pilot resulting in a flexible tip that can enlarge canals smaller than its tip size effectively with less stress and less debris extrusion.21 The two unequal tapers, side by side, incorporated in the ONE ENDO file afford it superior flexibility and an improved ability to remove debris.21 While its larger tapered cutting edge engages 18 Endodontic practice

Table 2: Pain scores for each group at the three studied periods Pain Score

Time 24 hours

48 hours

P-Value

72 hours

ONE Endo group (n = 18) 0

2 (11.1%)

10 (55.6%)

16 (88.9%)

8 (44.4)

5 (27.8%)

2 (11.1%)

8 (44.4)

3 (16.7%)

0 (0%)

<0.001*

0 (0%)

p1 = 0.012, p2 < 0.001, p3 = 0.080 *

F6 SkyTaper group (n = 18) 0

0 (0%)

1 (5.6%)

9 (50.0%)

5 (27.8%)

9 (50.0%)

6 (33.3%)

13 (72.2%)

8 (44.4%)

3 (16.7%)

0 (0%)

<0.001*

p1 = 0.359, p2 <0.001,* p3 = 0.004* PTU group (n = 18) 0

1 (5.6%)

4 (22.2%)

11 (61.1%)

9 (50.0%)

7 (38.9%)

5 (27.8%)

8 (44.4%)

7 (38.9%)

2 (11.1%)

0 (0%)

<0.001*

p1 = 0.405, p2 = 0.001*, p3=0.010*

p1: p value for comparing between 24 hours and 48 hours p2: p value for comparing between 24 hours and 72 hours p3: p value for comparing between 48 hours and 72 hours * Statistically significant at p ≤ 0.05

Table 3: Comparison between the three studied groups according to postoperative pain score Postoperative Pain Score

ONE ENDO (group A) (n = 18)

F6 SkyTaper (group B) (n = 18)

PTU (group C) (n = 18)

2 (11.1%)

0 (0.0%)

1 (5.6%)

8 (44.4%)

5 (27.8%)

9 (50.0%)

8 (44.4%)

13 (72.2%)

8 (44.4%)

10 (55.6%)

1 (5.6%)

4 (22.2%)

5 (27.8%)

9 (50.0%)

7 (38.9%)

3 (16.7%)

8 (44.4%)

P-Value

24 hours

0.126

48 hours 0.011*

7 (38.9%)

p1 = 0.003, p2 = 0.036, p3 = 0.407 *

72 hours 0

16 (88.9%)

9 (50.0%)

11 (61.1%)

2 (11.1%)

6 (33.3%)

5 (27.8%)

0 (0.0%)

3 (16.7%)

2 (11.1%)

0.034*

p1 = 0.011, p2 = 0.073, p3 = 0.459 *

p1: p value for comparing between Group A and Group B p2: p value for comparing between Group A and Group C p3: p value for comparing between Group B and Group C * Statistically significant at p ≤ 0.05 Volume 13 Number 3

concave areas do not provide sufficient space for debris accumulation. Using a sequence of files gradually approaching the apex may compensate for this limitation.28 By searching the recent available literature, no clinical studies were published incorporating either the ONE ENDO system or the F6 SkyTaper, although ProTaper Universal was compared to single-file reciprocating systems. Pasqualini et al.,17 and Nekoofar et al.,29 reported significant lower postoperative pain in patients treated by ProTaper Universal system than those who treated by the single file reciprocating system, WaveOne. However, Shokraneh, et al.,19 reported that postoperative pain was significantly lower in patients undergoing root canal instrumentation with the WaveOne file compared with the ProTaper Universal files. Relvas, et al.,4 concluded that the occurrence of postoperative pain was similar between Reciproc system and rotary ProTaper Universal system during the time intervals assessed. Several factors are involved in the sensation of postoperative pain (Table 4). This makes clinical investigations that associate pain incidence with possible causes more challenging.26 Although mild discomfort is generally expected after undergoing endodontic treatment, the incidence of postoperative pain and flare-up is reported to range from 3:58%.5 Mechanical, chemical, or microbial injuries to periapical tissues are the leading causes of acute periapical inflammation.30 Preoperative pain is one of the strongest predictors of postoperative pain.31 Therefore, only teeth with vital pulp diagnosed with symptomatic irreversible pulpitis and indicated for endodontic treatment were selected for the present study. In addition, all the teeth were treated in a single visit to rule out the potential influence of intracanal medication or other factors triggering pain. After access cavity preparation, cervical preflaring was done using the orifice opener OP10L file for both intervention groups.

Borges, et al.,32 reported that cervical preflaring was associated with significantly lesser amount of apically extruded debris when used with different instrumentation systems. All rotary files were introduced into the canals with EDTA gel to reduce heat generated by the rotating instrument against dentinal walls as well as removal of the smear layer. According to the conditions established for this study, there were no statistically significant differences regarding the gender and age between the three studied groups. These results are in agreement with Watkins, et al.,33 Segura-Egea, et al.,34 and Sadaf, et al.,35 who reported that males and females reported the same level of pain. On the other hand, contrary to the results of the present study, Watkins, et al.33 and Segura-Egea, et al.,34 reported that younger people experienced significantly higher pain levels. With regards to the tooth type whether maxillary or mandibular premolars, results of the present study go with conclusions reported by Watkins, et al.,33 Segura-Egea, et al.,34 and Harrison, et al.,36 as there was no significant difference between maxillary and mandibular premolar teeth.

Conclusion Within the limitations of the present study, it could be concluded that the number of root canal shaping files may not have a significant effect on the postoperative pain. EP

Table 4: Factors affecting postoperative pain a. Patient related Age and gender Genetics Physiological measures Preoperative medication

b. Tooth related Type and location Pulpal status Preoperative pain

c. Treatment procedure related Type of administered anesthesia Number of treatment visits Instrumentation technique Foraminal enlargement Irrigation method Obturation technique

Figure 3: ONE ENDO file Volume 13 Number 3

Figure 4: F6 SKYTaper file

Occlusal reduction

Endodontic practice 19

CLINICAL RESEARCH

the canal wall, provides superior strength, and superior cutting efficiency, its opposing smaller tapered edge provides additional space for breaking down and removing debris. Furthermore, the ONE ENDO file features fewer spirals at the tip to resist screwing-in forces21 (Figure 3). F6 SkyTaper file has S-shaped a crosssectional design, which gives the instrument small core diameter with two sharp cutting blades and deep flutes creating a space for debris accumulation (Figure 4). However, this cross section is the same through the whole length of the file (i.e., fixed cross section); and besides its constant 0.06 taper, this design may render the system of better cutting efficiency and higher tendency to screw-in and push internal canal debris beyond the apex.22 Clinically, this was reflected in the present study through higher expression of pain 2 and 3 days postoperatively with significant difference to the ONE ENDO group. On the other hand, no significant difference was noticed at any time interval between the F6 SkyTaper system and the ProTaper Universal system. The ProTaper Universal system, which served as control group for the present study, is a more conventionally used full-sequence rotary system. It provides a slower mechanical enlargement and gradual approach to the apex. Recent studies were more concerned with investigating the single-file reciprocating systems than continuously rotating ones. That is why the present study aimed to compare the multi-file system with the newly introduced single-file rotating ones regarding their influence on postoperative pain. The convex triangular cross section of the ProTaper Universal shaping files and finishing files F1 and F2 provides greater mass to the instrumentsâ&#x20AC;&#x2122; core, making them more rigid, reducing the depth of flutes, and therefore limiting its ability to allow coronal removal of debris. The cross section of larger finishing files was modified to be concave triangular to make them more flexible; however, these

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10. Surakanti JR, Venkata RCP, Vemisetty HK, et al. Comparative evaluation of apically extruded debris during root canal preparation using ProTaperTM, HyflexTM and WaveoneTM rotary systems. J Conserv Dent. 2014;17(2):129-132.

34. Segura-Egea JJ, Cisneros-Cabello R, Llamas-Carreras JM, Velasco-Ortega E. Pain associated with root canal treatment. Int Endod J. 2009;42(7):614-620. 35. Sadaf D, Ahmad MZ. Factors associated with postoperative pain in endodontic therapy. Int J Biomed Sci. 2014;10(4):243-247.

21. NanoEndo. https://nanoendo.com/index.php#. Accessed on February 19, 2020. 22. Dagna A, Gastaldo G, Beltrami R, Chiesa M, Poggio C. F360 and F6 Skytaper: SEM evaluation of cleaning efficiency. Ann Stomatol (Roma). 2016;6(1):69-74.

11. Capar ID, Arslan H, Akcay M, Ertas H. An in vitro comparison of apically extruded debris and instrumentation times with ProTaper Universal, ProTaper Next, Twisted File Adaptive, and HyFlex instruments. J Endod. 2014;40(10):1638-1641.

36. Harrison JW, Baumgartner JC, Svec TA. Incidence of pain associated with clinical factors during and after root canal therapy. Part 2. Postobturation pain. J Endod. 1983;9(10):434-438.

23. Stevens RW, Strother JM, McClanahan SB. Leakage and

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Volume 13 Number 3

-EP-07

.15

Dr. John Rhodes presents another interactive, practical, and problem-solving solution in endodontics. In this issue, he looks at the identification, diagnosis, and management of cracked teeth

he survival rate of root-filled teeth at 5 years can be as high as 99%, but presence of a crack could reduce the likely survival rate by up to 10% (Sim, et al., 2016). Optimal management of cracked teeth will enhance the likelihood of long-term survival and success.

Educational aims and objectives

This clinical article aims to give protocols for the identification, diagnosis, and management of cracked teeth.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 23 or take the quiz online at endopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can:

Introduction

•

Obtain an 8-point plan for tackling cracks.

Cracks may result from increased occlusal forces, bruxist habits, or occlusal interferences. Heavily filled teeth are weakened by the loss of tooth volume and will be more susceptible. Post-crown restorations in anterior teeth with reduced or no ferrule will have a higher risk of root fracture. Teeth can also fracture as the result of trauma, the most common presentation being an oblique fracture in anterior teeth. Cracks can be created iatrogenically during restorative procedures, for example, when removing a post or drilling with insufficient water coolant. Cracks can also be induced during apical surgery when using an ultrasonic tip with insufficient coolant or at too high power. A crack may present while the tooth is still vital with the patient complaining of discomfort when chewing, and this is frequently accompanied by sharp pain on release. This can be accompanied by increased sensitivity to cold as the pulp becomes reversibly pulpitic. Often an individual cusp is fractured and flexing; detection can be made by careful examination using good illumination, magnification, and a simple bite test with a bite stick on the individual cusps to isolate the culprit. Patients may present with a lost restoration or tooth that feels mobile. Post-retained anterior crowns that have de-cemented can often be associated with vertical root fracture. A lack of ferrule results in excessive stress on the root. If it fractures and flexes with occlusal forces, the cement lutes fails, and the crown becomes loose.

•

Realize some reasons for occurrence of cracks.

•

Identify methods of clinical examination and investigation of cracks.

•

Realize some advantages and shortcomings of imaging for detecting cracks.

•

Realize several factors that could affect prognosis of cracks.

John Rhodes, BDS(Lond), FDS RCS(Ed), MSc, MFGDP(UK), MRD RCS(Ed), is a specialist in endodontics, the author of textbooks and numerous papers, and owner of The Endodontic Practice Poole and Dorchester. He lectures and teaches on endodontics nationally.

Volume 13 Number 3

Visual assessment: magnification, illumination, and radiographs Clinical examination should include visual assessment using magnification and illumination, vitality testing, periodontal probing, radiographs, and sometimes CBCT. Disassembly and investigation may be necessary to confirm the diagnosis. Using a microscope with transillumination may highlight a crack, and a dye such as methylene blue may help if it is not visibly stained.

Cracked cusp detection A plastic bite-stick such a Tooth Slooth® II (Professional Results Inc.) or FracFinder™ (Denbur Inc.) can be used to apply force to each individual cusp and may highlight the presence of a cuspal fracture. The patient can also be asked to bite on a cotton-wool roll to flex a crack in the tooth, and on-release pain may be elicited. Many of these teeth are vital or reversibly pulpitic and will react to cold stimuli such as EndoFrost (Roeko).

Periodontal pocketing Periodontal probing can reveal the presence of a root fracture; a deep narrow pocket could be indicative of a root fracture but could also be a sinus tract. Deep narrow pocketing on both sides of a tooth, however, is almost pathognomonic (Figure 1).

Radiographs It is unlikely that a crack will be seen on a radiograph unless the X-ray beam has passed through the line of the crack. Osseous changes can be detected around the root of the root. The classic presentation of a “J”-shaped radiolucency that wraps around the apex of the tooth can be indicative of a crack but can also be the produced by a chronic abscess. There may be crestal or furcal bone loss or widening of the periodontal ligament.

CBCT Cone beam computed tomography is invaluable for assessment of horizontal or

Figure 1: Probing depths are deeper on the mesial and distal aspects of this premolar, which are almost certainly the result of a vertical root fracture Endodontic practice 21

CONTINUING EDUCATION

Identification, diagnosis, and management of cracks

CONTINUING EDUCATION

Figure 3: In this case, the radiograph shows a classic “J”-shaped radiolucency around the MB root and furcal bone loss. The tooth is cracked across the pulp floor and has a hopeless prognosis

Table 1: Management of cracks: a summary 1. Clinical exam and investigation 2. Cracked cusp detection 3. Check radiographs 4. Assess periodontal situation 5. Check CBCT

Figure 2: Occasionally cracks are visible on a CBCT image such as this, but artifacts from metal restorations can obscure detail in many cases

oblique cracks in anterior teeth that have suffered trauma. A CBCT image gives information on the angle and location of a crack that cannot be gleaned from a radiograph. In posterior teeth, CBCT is generally not a reliable method for detecting cracks. There are often large restorations in teeth that are cracked, and these can cause artifacts on the image, obscuring detail. If a crack is significant, it may be visible; but to avoid confusion with artifacts, it is a good idea to look for any sign of radiolucency in the adjacent osseous detail. If there is a change in the periodontal ligament on both sides of a root, then it is likely that a crack is present (Figure 2).

Investigation Carefully removing a restoration and assessing the extent of a crack with magnification and illumination will allow the operator to make a decision on whether a tooth is restorable and the likely prognosis for survival following root canal treatment (Figure 3).

Prognosis There are several factors that could affect prognosis: • Multiple cracks • Terminal teeth

6. Treatment 7. Manage posttreatment restorative options

• Preoperative periodontal pocketing • Cracks across the pulp floor or down a root canal Terminal teeth have greater occlusal stress placed on them as they are nearer to the axis of the TMJ, and those that act as abutments for fixed or removable prosthetics may also be placed under increased stress. Post-crown restorations, for example, have a lower survival rate when used as abutments. Teeth that are bounded by others appear to have some protection offered by the teeth either side (Tan, et al., 2006). Preoperative periodontal pocketing may indicate the presence of a crack. Sometimes this can be seen using the operating microscope by gently retracting the gingival with a flat plastic and looking directly at the root surface. Cracks that extend across the pulp floor or down a root canal are associated with a lower survival rate in root-filled teeth (Sim, et al., 2016), and so could determine that the tooth would be better extracted and replaced (Figure 4).

Restoration post-endodontics

restored with loss of marginal ridges should be restored with a cusp coverage restoration. When there is significant loss of tooth volume, a full-coverage restoration may be required. In anterior teeth restored with post crowns, a ferrule of at least 1.5 mm - 2.0 mm will provide an increased bracing effect and reduce the risk of fracture (Sorensen and Engelman, 1990). EP

To reduce the risk of fracture after root canal treatment, molar teeth that are heavily

REFERENCES

Find out more To see how these steps are applied, visit https://youtu.be/RErqBWyGyXI, or search YouTube for john rhodes endo identification diagnosis and management of cracks. The author is happy to answer questions directly via YouTube @john rhodes endo.

22 Endodontic practice

Figure 4: In this case, the restoration has been removed, and an access cavity created. Staining with methylene blue and visualization under the microscope highlighted a crack extending across the pulp floor. The tooth was extracted

1. Sim IG, Lim TS, Krishnaswamy G, Chen NN. Decision Making for Retention of Endodontically Treated Posterior Cracked Teeth: A 5-year Follow-up Study. J Endod. 2016;42(2):225-229. 2. Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent. 1990;(63)5:529-536. 3. Tan L, Chen NN, Poon CY, Wong HB. Survival of root filled cracked teeth in a tertiary institution. Int Endod J. 2006; 39(11):886-889.

Volume 13 Number 3

REF: EP V13.3 RHODES

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $129; call 866-579-9496 or visit endopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Go online to endopracticeus.com/ce-articles, click on the article, then click on the take quiz button, and enter your test answers n Mail this completed quiz to: Endodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9, Scottsdale, AZ 85260

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Identification, diagnosis, and management of cracks RHODES

1. The survival rate of root-filled teeth at 5 years can be as high as 99%, but presence of a crack could reduce the likely survival rate by up to _________. a. 10% b. 35% c. 65% d. 75% 2. Cracks may result from increased _______. a. occlusal forces b. bruxist habits c. occlusal interferences d. all of the above 3. ________ are weakened by the loss of tooth volume and will be more susceptible. a. Teeth with veneers b. Heavily filled teeth c. Teeth with small fillings d. Bonded teeth 4. Clinical examination should include visual assessment using magnification and illumination, _______, and sometimes CBCT. a. vitality testing

Volume 13 Number 3

b. periodontal probing c. radiographs d. all of the above 5. Using a/an _______ may highlight a crack, and a dye such as methylene blue may help if it is not visibly stained. a. overhead light b. mouth mirror c microscope with transillumination d. magnifier with light attachment 6. Periodontal probing can reveal the presence of a root fracture; a ________ could be indicative of a root fracture but could also be a sinus tract. a. deep narrow pocket b. shallow narrow pocket c. deep wide pocket d. shallow wide pocket 7. The classic presentation of a ________ radiolucency that wraps around the apex of the tooth can be indicative of a crack but can also be the produced by a chronic abscess. a. “V”-shaped b. “J”-shaped

c. “C”-shaped d. “U”-shaped 8. ________ is invaluable for assessment of horizontal or oblique cracks in anterior teeth that have suffered trauma. a. 2D radiographs b. Transillumination c. Cone beam computed tomography d. Periodontal probing 9. In posterior teeth, CBCT is ________ for detecting cracks. a. the most reliable method b. generally not a reliable method c. as beneficial as any other imaging modality d. none of the above 10. (In restoration post-endodontics) In anterior teeth restored with post crowns, a ferrule of at least _______ will provide an increased bracing effect and reduce the risk of fracture. a. 0.5 mm - 1.0 mm b. 1.5 mm - 2.0 mm c. 2.5 mm - 3.0 mm d. 3.5 mm - 4.0 mm

Endodontic practice 23

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Treating infected roots Dr. Jason Bedford shows how a new hydroxyapatite root repair material benefits the apical closure and healing of a large periradicular radiolucency Introduction Traumatic injuries to the upper central incisors are extremely common. By the age of 20, 23% of males and 13% of females have suffered some degree of traumatic injury to their anterior teeth (Andreasen and Andreasen, 2000). These injuries are likely to take place between the ages of 8 and 10. At this age, many of the teeth injured are therefore immature, which complicates their management and long-term prognosis (Figure 1). Contemporary endodontic techniques revolve around maintaining the vitality of the pulp, to encourage it to develop, and the root and pulp space to mature. In one study, over 50% of patients attending a pediatric dentistry clinic with complex enamel or dentin fractures were successfully treated using simple etch and bonding techniques with no need for root treatment (Cem Gungor, et al., 2007). However, many older patients will not have had the benefit of these contemporary techniques. They will regularly present for treatment decades after the traumatic incident, requesting an esthetic improvement to their aging restorations. Unfortunately, these teeth often have longstanding, commonly asymptomatic endodontic infections, immature root formation, and large posts in situ. It is not unusual for patients to find it difficult to relate their presenting complaints with traumatic incidents that may have occurred decades earlier, of which they have very little recollection. Managing these cases is not straightforward, and the results can be unpredictable. Fortunately though, several options are now available to clinicians and their patients.

Jason Bedford BDS, MDentSci, MFDS RCPSG, is a specialist in endodontics, works in specialist endodontic practices in Nottingham, Stoke and Solihull, and is also a co-founder of D2D Endo Ltd.

24 Endodontic practice

Educational aims and objectives

This clinical article aims to show how a new hydroxyapatite root repair material benefits the apical closure and healing of a large periradicular radiolucency.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 27 or take the quiz online at endopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Consider the potential of iRoot® BP through the success of a case study.

•

Realize some statistics regarding traumatic injuries to the upper incisors.

•

Realize several options for treatment choices, carrying various risks for this patient.

•

Observe the technique for removal of old root filling material for this patient.

•

Observe canal disinfection, canal shaping, and management of the open apex for this patient.

Figure 1: Appearance of anterior teeth on first visit to surgery

Case study A 42-year-old woman was referred by her GDP for the assessment of the prognosis of two endodontically involved failing anterior crowns. The patient was fit and well, with no relevant medical history. Her main complaint was that one of her crowns had recently fractured and was currently replaced with a temporary crown. She was also concerned about discoloration of the tooth and the composite fillings in her other front teeth. The teeth in question had originally been root-filled and crowned soon after they were

damaged in a bicycle accident when the patient was approximately 10 years old. The crowns had been replaced several times over the years, and the current crowns had been in place for 15 years. The patient had not experienced any pain recently, but had been aware of a swelling below her upper lip for as long as she could remember. On examination, the dentition was heavily restored but well cared for. There was a palpable swelling over the apices of the upper left incisor teeth. A small sinus was found adjacent to the upper left lateral incisor. Volume 13 Number 3

It is not unusual for patients to find it difficult to relate their presenting complaints with traumatic incidents that may have occurred decades earlier, of which they have very little recollection. Managing these cases is not straightforward, and the results can be unpredictable. Fortunately though, several options are now available to clinicians and their patients.

of a root fracture UL1 or periradicular cyst were also considered (Figure 2). The treatment choices were: 1. Orthograde revision of the root fillings 2. Apical surgery 3. Extraction followed by implant placement, a denture, or conventional bridge work

Option one: orthograde re-root fillings Orthograde revision of the root fillings was complicated by several things: • the presence of the large metal post in the UL1 — removal of this post was not without risk and could have resulted in a fracture of the root • the extent of the apical lesion • the long duration of the infection • the immature/open apex present UL1 Additionally, even if successful, the end result for the UL1 would be a replacement post crown, of which 61% will last less than 10 years (Peutzfeld, et al., 2007).

Option two: apical surgery One of the key indications for apical surgery is that there should be an adequate root filling in situ. Therefore, apical surgery was not indicated in this case. The patient was advised, however, that should the infection not respond to conventional endodontics, then apical surgery may be required.

Figure 2: Preoperative view Volume 13 Number 3

Figure 3: iRoot BP (VerioDent,Canada)

Option three: extraction and replacement of UL1 and UL2 The opinion of an experienced implantologist was sought. After considering the practical difficulties posed by the large bony defect, the possible need for a bone graft and the cost implications, the patient decided against pursuing the implant option. The use of a bridge to replace the UL1 and UL2 was considered a last option by the patient. As implants were not appropriate, and a bridge could always be placed at a later date if the endodontic treatment failed, the patient asked us to attempt to revise the failing root fillings. Conventional re-root filling is then broken down into several stages, all of which are relatively straightforward, but put together can result in a very long appointment.

Crown and post removal The temporary crown was removed easily and the post removed using a combination of ET25 (Acteon) and CPR post removing ultrasonic tips (Dentsply Sirona).

Removal of old root filling material The original root filling in the UR1 consisted of a single GP cone with sealer. This point was removed using a braiding technique. Three size 15 Hedstrom files are passed down either side of the GP cone. These are then twisted around each other, gripping the GP point. The files are then withdrawn together with the GP point. The root filling material in the UR2 was more densely compacted. This was removed using the gutta-percha removal files — GPR files. These are used in a crowndown manner removing the GP down to the apical third. Often the GP cones will wrap around these files and are rapidly removed in one piece. If this is not the case, then the apical GP is softened with products such as Endodontic practice 25

CONTINUING EDUCATION

The upper left central incisor had been recently restored with a temporary crown. The lateral incisor had an all-ceramic crown, through which an access cavity had been made some years ago. There were several composite restorations on the other anterior teeth that had begun to show their age, and the patient was keen to have replaced. X-rays of the anterior teeth revealed that the upper right central incisor had been root-filled some months before and had been asymptomatic since that time. There was some evidence of an apical radiolucency, which it was decided would be reviewed as it had only recently been completed. The upper left central incisor had been restored with a wide, serrated metal post. The root-filling material had been placed to the correct apical extent, but appeared to be a single cone that did not completely obturate the canal. The tooth appeared to have an immature, open apex. The upper left lateral incisor had been root-filled more recently. It looked well condensed but possibly 1 mm - 2 mm short of the radiographic root terminus. A large, well-circumscribed circular radiolucency, approximately 12 mm in diameter, appeared to be associated with the apices of both upper left incisors. Both teeth had lost the normal periodontal ligament space. An initial diagnosis of failing root fillings UL1, UL2 with chronic periapical periodontitis was made. The alternative diagnoses

CONTINUING EDUCATION

Figure 5: Final restorations (Image courtesy of Dr. Nigel Hammond) Figure 4: Healing after 3 months

orange solvent and removed manually with Hedstrom files.

Canal shaping The UR1 required very little in the way of further canal preparation. The walls of the canal were debrided of residual filling materials using hand files. The apical diameter was gauged at size 80.

Canal disinfection Careful irrigation with warmed 4% sodium hypochlorite solution was carried out throughout the shaping procedure. This was followed by a 1-minute rinse with 17% EDTA solution to remove any further debris and to dissolve the smear layer created during canal preparation. The canal was then irrigated with more sodium hypochlorite, activated with Acteon Irrisafeâ&#x201E;˘ ultrasonic tips (QED UK) (Figure 3). These have been shown to heat the irrigant and enhance its chemical and physical action on the bacterial biofilm present within the canal (Haappsalo, et al., 2010). The canals were then dressed with non-setting calcium hydroxide paste for 2 weeks.

Managing the open apex At the second visit, the buccal swelling that had been present for months had resolved, and the area was much healthier looking. The patient reported that the discomfort had settled almost immediately following the first visit. The root canals were 26 Endodontic practice

re-irrigated and dried using paper points. The apex of the central incisor was gauged to be around a size 80. This is too wide to be predictably obturated using traditional thermoplastic obturation techniques due to the risk of extrusion of the filling material into the apical tissues. In recent years, apical-closure techniques have been described that utilize tricalcium phosphate cements, such as MTA. However, the mixing, manipulation, and placement of these materials can be frustratingly difficult. The use of hydroxyapatite to repair roots has long been established (Alhadainy, et al., 1998). Recently, pre-filled syringes of hydroxyapatite have become available in the form of iRootÂŽ BP (Veriodent Canada) (Figure 3). The premixed material is relatively viscous and can simply be syringed into the canal. These products are considerably less expensive than MTA preparations. The working length is marked on the syringe using a rubber stop and a small amount of the paste placed at the apex of the tooth. The needle is withdrawn as the paste is extruded, and the canal filled to the

required depth. This is usually 4 mm - 5 mm. The rest of the canal can be filled with gutta percha or in this case, a small amount of glass ionomer was place over the IRoot BP and a post space prepared. A temporary post crown was constructed, and the patient referred back to her general dental practitioner for the immediate construction of new anterior crowns.

3-month review stage Although the patient had been asymptomatic, it was considered prudent to take a radiograph in order to assess the healing of the very large apical area at the 3-month stage (Figure 4). A periapical radiograph revealed rapid healing of the apical area. On closer examination, it also appears to show the formation of a hard tissue barrier apical to the hydroxyapatite paste (Figure 5). The use of injectable hydroxyapatite paste such as iRoot BP provides a convenient, cost-effective, and predictable method of sealing canals with large apical diameters. This versatile material can also be used as a replacement for MTA in perforations, apicectomies, and pulp capping. EP

REFERENCES 1. Alhadainy, HA, Himel, VT, Lee WB, Elbaghdady YM. The use of a Hydroxyapatite-based material and calcium sulfate as artificial floors to repair furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86(6):723-729. 2. Andreasen JO, Andreasen FM. Essentials of Traumatic Injuries to the Teeth. 2nd ed. Copenhagen, Denmark: Munksgaard and Mosby; 2000, 3. Cem Gungor H, Uysal S, Altay N. A retrospective evaluation of crown-fractured permanent teeth treated in a pediatric dentistry clinic, Dent Traumatol. 2007;23(4):211-217. 4. Haapasalo M, Shen Ya, Oian W, Gao Y. Irrigation in endodontics. Dent Clin North Am. 2010;54(2):291-312. 5. Peutzfeldt A, Sahafi A, Asmussen E. A survey of failed post-retained restorations. Clin Oral Investig. 2008;12(1):37-44,

Volume 13 Number 3

REF: EP V13.3 BEDFORD

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit endopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Go online to endopracticeus.com/ce-articles, click on the article, then click on the take quiz button, and enter your test answers n Mail this completed quiz to: Endodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9, Scottsdale, AZ 85260

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

Treating infected roots BEDFORD

1. By the age of ______, 23% of males and 13% of females have suffered some degree of traumatic injury to their anterior teeth. a. 10 b. 20 c. 35 d. 40 2. These injuries are likely to take place between the ages of _______. a. 3 and 5 b. 8 and 10 c. 15 and 17 d. 20 and 22 3. In one study, over ______ of patients attending a pediatric dentistry clinic with complex enamel or dentin fractures were successfully treated using simple etch and bonding techniques with no need for root treatment. a. 10% b. 25% c. 50% d. 70% 4.

(When older patients present for treatment requesting treatment for aging restorations) Unfortunately, these teeth often have _______.

Volume 13 Number 3

a. long-standing, commonly asymptomatic endodontic infections b. immature root formation c. large posts in situ d. all of the above 5. One of the key indications for apical surgery is that there should be ________. a. no aging restorations b. no history of traumatic incident c. an adequate root filling in situ d. no desire for subsequent esthetic improvement 6. (For this patient for canal disinfection) Careful irrigation with _______ solution was carried out throughout the shaping procedure. a. warmed 4% sodium hypochlorite b. cooled 4% sodium hypochlorite c. warmed 25% EDTA d. warmed 2% chlorhexidine 7. (For this patient) This (irrigation) was followed by a _______ rinse with 17% EDTA solution to remove any further debris and to dissolve the smear layer created during canal preparation. a. 1-minute b. 2-minute

c. 3-minute d. 5-minute 8.

(For this patient, after irrigation) The canals were then dressed with non-setting calcium hydroxide paste for _______. a. 5 days b. 10 days c. 2 weeks d. 1 month

9. (For this patient) The apex of the central incisor was gauged to be around a size 80. This is _______ to be predictably obturated using traditional thermoplastic obturation techniques due to the risk of extrusion of the filling material into the apical tissues. a. too wide b. the perfect width for c. too narrow d. an appropriate width for the tooth 10. In recent years, apical-closure techniques have been described that utilize tricalcium phosphate cements, such as MTA. However, the _______ of these materials can be frustratingly difficult. a. mixing b. manipulation c. placement d. all of the above

Endodontic practice 27

CE CREDITS

ENDODONTIC PRACTICE CE

PRACTICE MANAGEMENT

What coronavirus taught me about clinical efficiency Dr. Albert (Ace) Goerig discusses how to achieve the same or better daily productivity and case completions post-COVID-19

or most endodontic practices, the past few months have probably been some of the busiest. As GPs returned from shutdown in May and June, pent-up patient demand and subsequent endo referrals have surged from July onward. Yet the precautions we implemented in our practices have continued, including check-in procedures, limiting contact between patients, enhanced PPE, mitigation of aerosols, and coronavirus disinfection both inside and outside the treatment rooms. In high-productivity practices like mine, keeping up with the surge in patient flow has brought unique challenges, especially given our current reluctance to transition during a patient appointment due to PPE standards and to minimize possibilities for cross-patient exposure. As a result, I took these factors as an opportunity to examine my clinical care approach and evaluate the underlying systems and routines that had previously guided my schedule and delivery of care. My goal was to achieve the same or better daily productivity and case completions as I was able to achieve before the pandemic. I also had the benefit of sharing and learning with endodontic colleagues in my Mastery Circle group as we explored different options through biweekly Zoom meetings. Here is what I found. Initial patient form: All initial patient information, medical history, and consent forms are requested to be completed online and sent to our office before the appointment — 90% of our patients are now doing this. The assistant simply meets the patient at the door, does the COVID-19 screening and temperature check, and brings them directly back to the treatment room. Diagnosis: My assistants are highly trained to interview patients and ask

Albert 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 is the author of more than 60 published articles and a contributing author to numerous endodontic textbooks. Dr. Goerig has a private endodontic practice in Olympia, Washington, in the top 1% nationwide for practice profitability. He has coached over 1,000 endodontists during the past 23 years. For more information, visit www.endomastery.com, email info@ endomastery.com, or call (800) 482-7563.

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assessment questions, plus take CBCT scans and radiographs. My clinical team identified two areas where efficiency could be improved. First was increasing the number of radiographs from the referring doctor in advance. The coronavirus prompted us to improve our language around referrer-sent X-rays and to communicate how patients might avoid a nontreatment evaluation appointment if radiographs can be sent in advance. It would also save our schedule from nontreatment cases. As a result, enough GPs improved their efforts on enough cases that we have an appreciably lower rate of nontreatment cases now. Second in diagnostic efficiency was being meticulous with my team to not duplicate our assessment efforts. My team helped me identify where I routinely ask patients the same questions they have already asked. We also reviewed the imaging needs for various case types to ensure that they took all the diagnostic images I typically want so that time was not wasted once I entered the operatory. Anesthesia: All doctors have a clinical comfort zone — their armamentarium of preferred supplies, equipment, technology, and techniques that underpin their clinical practice and help them achieve consistent case results. One area my Mastery Circle group identified for efficiency improvements was anesthesia, where the waiting time before treatment can be significantly shortened through supplemental anesthesia in addition to regional nerve blocks. Periodontal ligament injections (PDL) can be effective in as little as 30 seconds to 1 minute. This can be effectively done with a standard syringe, lidocaine 1:100,000 epinephrine, and a 30-gauge needle applied buccal and lingual on the distal of lower teeth or mesial and distal of upper teeth after initial blocks or infiltration injections. My preference for vital lower molars is to use intraosseous injections (such as Stabident) mesial or distal to the tooth with mepivicaine without epinephrine.

Transitioning Since anesthesia time can be shortened so significantly with supplemental anesthesia techniques, even without a pandemic, it warrants reconsideration of whether transitioning makes sense. Today with improved diagnostic and anesthesia efficiency, I am completing routine cases in less time than ever, and completing more cases per day. This has

the added benefit of staying focused on one patient at a time, and never feeling as though I have to bounce out of the treatment room. Our patients appreciate us not interacting with other patients during their treatment. It also means that with transitions not occurring, assistants have more time for disinfection and documentation in each operatory before the next patient is seated. They can be very thorough, which saves me even more time at the end of the day as I review treatment notes that are 99% complete in advance.

Sidebook and daily flow One of the things we usually relied on transitions for was sidebook appointments. We have always strived to minimize the number of recalls. For routine cases, we never recall patients automatically and prefer to follow up by phone. If the patient reports atypical post-op symptoms of discomfort, we will assess them by phone first and bring them in only if the symptoms indicate. For evaluations, we are using two strategies: First is to appoint “evals” at the end of treatment slots rather than in a transition slot. Second is to reserve power hours. A power hour would mean booking back-to-back evals, so we can assess patients in a very efficient way — for example, five 12-minute eval appointments or four 15-minute appointments. In fact, the eval fees from a power hour plus the CBCT fees can be just as much as an RCT fee. A final note about improving daily productivity and dealing with the surge (and it is entirely a personal preference): Consider how much time you are taking for lunch. If you need the time for re-energizing, by all means continue to take an hour lunch. However, if you have the energy and you want to maximize your daily productivity, a 10-minute lunch could be worth $1,000 daily, or $15,000 to $20,000 per month, depending on the number of days you work.

The new normal Much has been said about the “new normal” imposed by the pandemic. But in my experience and many Endo Mastery coaching clients, the new normal is a better normal: better flow, better teamwork, better productivity, and less stress. At this point, I wouldn’t want to go back to the way it was. EP Volume 13 Number 3

DR. ACE GOERIG Owner, Endo Mastery

“I PERSONALLY GUARANTEE YOUR PRACTICE WILL GROW!”

TRANSFORM YOUR PRACTICE—TRANSFORM YOUR LIFE! ENDODONTIC PRACTICE COACHING WITH GUARANTEED* RESULTS Grow to new levels and overcome limitations in the economy Improve referrals and optimize productivity and profitability Maximize daily teamwork and eliminate stress Become debt-free and live in financial freedom Love your patients, referrers and team like never before

1-800-482-7563 info@endomastery.com | www.endomastery.com

FREE PRACTICE ANALYSIS! CALL TODAY! * Our straightforward no-risk guarantee is included in every standard practice coaching agreement. Ask us for details.

PRODUCT PROFILE

Why I choose handheld for my endodontic X-ray needs Dr. Steve L. Frost discusses a unique, personalized patient experience in imaging

he implementation of new technologies has helped my practice to stay relevant and patient-focused. I’ve repeatedly seen how having the right equipment gives clinicians an edge and sense of confidence that is easily noticed by their patients, staff, and referring dentists. With that said, at first I was skeptical of the idea of using a handheld radiographic unit. However, once I tried KaVo NOMAD™ Pro 2, I was convinced. It has been exciting to see how such a practical innovation could create a unique, personalized patient experience. NOMAD has been a complete gamechanger in my busy endodontic practice in three key ways. 1. Being able to stay chairside with the patient has eliminated the headache and wasted time associated with dealing with a drifting or malfunctioning wall-mount unit. My assistants love not dealing with the hassle of unnecessary retakes or waiting for a wall-mount unit to become available in our adjoining operatories. And the whole team enjoys being able to stay in the room with the patient to foster a more personalized experience. 2. I get high-quality endodontic radiographic images that give me instantaneous feedback during the entire root canal procedure. I can position the sensor and NOMAD without leaving Steve L. Frost, DDS, is a mentor, clinical educator, father of five boys and one princess, and brother of an identical twin. Dr. Steven L. Frost has been a thought leader, innovator, and implementer of the single-visit root canal therapy for 24 years. He is a graduate of the University of the Pacific School of Dentistry in 1992. He received his Certificate in Endodontics from Tufts School of Dental Medicine in 1994. Dr. Frost founded Red Mountain Endodontics in 1994 and is currently the head of three endodontic offices. Red Mountain Endodontics is one of the co-founding offices of US Endo Partners. He has presented all aspects of endodontics, including dental trauma to large groups of dentists. He also is known in his community for allowing general dentists to be trained one-on-one at his office to assist them in expanding their endodontic skills. Disclosure: Dr. Frost is the Chief Clinical Officer of US Endo Partners.

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KaVo NOMAD™ Pro 2

the patient or operatory, whenever needed. This reduces treatment time by as much as 10-15 minutes per procedure. At the end of the day, streamlining and optimizing the root canal process is crucial. 3. New evolving technology always increases credibility with patients and staff. NOMAD is a great conversation starter with my curious patients, and they are often impressed by the fast, seamless process at my practice. Most importantly, they feel confident during their treatment knowing that I use the best technology with the least amount of chair time

Combined with high-level communication with the patient, referring dentist, and specialist, incorporating handheld X-ray technology is vital for a seamless and pleasant patient experience. This is where my patient reviews have increased exponentially, and I’ve achieved substantial organic growth, especially since my staff and I are able to remain chairside throughout the procedure. We live in a fast-paced world with new technologies all around us to make our lives better, faster, and stronger. We see it in healthcare, communication devices, transportation, and even in our homes. As consumers, we are conditioned to look for the ways our lives can be better, easier, and simpler. Shouldn’t we as dentists always strive to offer our patients new technology to keep pace with their ever-changing world? Join me in implementing handheld X-ray systems when doing modern day root canals. *The opinions and techniques shown here are the recommendation of Dr. Steve L. Frost. KaVo is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own judgment in treating their patients. EP Volume 13 Number 3

chieve your optimal freedom with the SS White Dental® Manta™ Cordless Endodontic Handpiece. The Manta is as incredible as it is compact. At an ultralight weight of just 1.2 ounces, the Manta handpiece has the power you need in a small, ergonomic body that will reduce hand fatigue while fitting comfortably in your pocket. Each Manta handpiece uses a precision processing technology to minimize vibration and features a mini-angle head for the optimal line-of-sight for procedures. You will enjoy all the options and speed necessary to begin treatment or complete retreatment — featuring an easy-read LCD display screen, speed, and torque controls, five memory programs, and full auto-stop and auto-reverse, The Manta Cordless Endodontic Handpiece operates the file at 100-600 rpm with a standard gear ratio of 20:1. That’s a lot of power in a tiny package! The 8.5-hour battery life on a lightning-fast charge of just 140 minutes means that the Manta will be with you all day, operating at maximum efficiency and performance. The most fascinating aspect of the Manta is that it’s one of the lightest endodontic handpieces available today. At roughly the same weight as a slice of sandwich bread, you no longer have to accept hand-andwrist pain as “part of the job.” The Manta allows practitioners to shape and clean the canal in a smooth, flowing motion more efficiently. The cordless Manta handpiece gives you full 360-degree rotation, and at such a minimal weight, you can keep your wrist position neutral and comfortable. With so much power, comfort, and options, the Manta is the ideal companion for today’s busy dental practices. The Manta works efficiently with most major brands of NiTi files. DCTaperH files are an excellent choice for conservative coronal shaping. DCTaperH files mirror the natural shape of the root in a variable “V” decreasing rate of taper from tip to shaft. Endodontists report using only one or two files per case, saving money on the cost of shaping per procedure. With our proprietary heat treatment process, file flexibility allows Volume 13 Number 3

for the successful navigation of the curviest of curves in any canal you treat with no ledging or transportation. The Exact Family (ExactTaper™, ExactFlow™, and Exact Guide™) rotary files are engineered to make the transition from glide path to shaping a seamless procedure while reducing the potential for over preparation. The Exact line files are available in the same sizes and lengths of comparable file systems, requiring no change to your current protocol or technique, so you get predictable results every time. The Manta Endodontic Cordless Handpiece includes five valuable preset programs, and auto-reverse features three working modes — auto-reverse on, auto-stop, autoreverse — for giving you full control to keep your patients safe and comfortable. If too much pressure is applied while operating the unit, it will automatically reverse. This function minimizes the risk of breakage in even the most complex cases. Each handpiece has the look and design of an electric toothbrush. Patients find the design less threatening, greatly improving their experience and outcome. Plus, the electric motor is extremely quiet, which has a mutual benefit to you and your patient. The Manta is ideal for practitioners of all experience levels. Each preset program mode is perfect for the various stages of a root canal procedure. As you use the unit, you will become more accustomed to operation and can create custom settings

Manta™ Endodontic Cordless Handpiece

and programs for ultimate personalization. Whether you’re a general dentist or an endodontist, Manta is the cordless handpiece you need at a price you won’t believe! EP This information was provided by SS White Dental®.

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PRODUCT PROFILE

Manta™ Cordless Endodontic Handpiece — SS White Dental®

SERVICE PROFILE

Silent partners are still investing in great endodontic practices Chip Fichtner discusses how to create new opportunity in uncertain economic times

ne of the unexpected benefits of COVID-19 is an increase in the value of larger endodontic practices to silent partners called Invisible Dental Support Organizations (IDSO). Doctors may have the opportunity to monetize a part of their practice for cash now at favorable 2020 tax rates. Diversifying a doctor’s personal assets by selling a piece of their most valuable “investment” has become very popular in these uncertain economic times.

Cash now plus retained ownership Doctors retain ownership and continue running their practice under their brand, team, and strategy for years or decades, but with the resources of a large, silent partner. Doctors can secure their financial future, and yet continue practicing with additional upside potential via their partial ownership in the practice. And doctors have a known buyer for the remaining ownership when they are ready to retire.

Endodontic practices have increased in value Several dynamics are driving up the values of endodontic practices today. First, many performed better during the national shutdown of March, April, and May than did other specialists and general practice dentists. This resiliency is attractive to riskaverse investors. A second driver of new value levels is the belief that in a recession, patients will still seek pain relief, but opt for a root canal versus the higher cost of an implant procedure. Many investors that back the IDSOs are of the belief that we are only in the first inning of a depressed economy Chip Fichtner, is the founder of Large Practice Sales, which specializes in the transactions of Invisible Dental Service Organizations (IDSOs) for all practices. The company has completed more than $100 million of transactions in the past 6 months. After careers at Merrill Lynch and Bear Stearns, he began buying and selling businesses of all types for his own portfolio. Mr. Fichtner has been the Chairman and/or CEO of multiple publicly traded companies and has presented at conferences on investing and marketing from Hong Kong to Monaco. Learn more at largepracticesales.com.

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Doctors retain ownership and continue running their practice under their brand, team, and strategy for years or decades, but with the resources of a large, silent partner.

and that lower cost options will be attractive to patients. A third driver of values and competitive bidding for great practices is that there are a number of newer IDSOs focused exclusively on investing in endodontic practices. These are in addition to the rekindled interest from a variety of multispecialty IDSOs that have historically been more infatuated with implants than root canals. Attitudes change quickly in the IDSO space, and at the moment, doctors using the right advisor can attract multiple bidders, driving up values to and past 2019 bubble levels. We don’t know how long this anomaly will continue, but at the moment, it is a golden opportunity for liquidity for growing endodontic practices with smart doctors of any age.

IDSOs goal is growth of your practice and its value IDSOs can provide multiple benefits to endodontic practice owners besides millions of dollars in cash up front. The list of available resources and support varies widely by IDSO. Attractive support services provided by a larger partner may include purchasing discounts, better quality/lower-cost team benefits, leverage in payor negotiations, administrative burden reduction, and referral synergies with other owned practices in the area. Each IDSO partner has a different menu of support and growth opportunities.

In addition, a doctor’s retained equity in either the practice and/or the IDSO parent potentially has significant upside potential. It has not been unusual for IDSOs to provide returns to their owner doctors of 2 times, 5 times, and even 20 times the value of their initial equity stake, over time. Certainly, these gains have been inflated due to a 10-year bull market, but dentistry continues to be very attractive to private equity groups, family offices, and SBICs, even during COVID-19.

Young doctors are most attractive One of the interesting changes in these transactions is the average age of interested doctors. Younger doctors view IDSO partners as a mechanism to provide the capital and management to expand through acquisitions or new office starts. Practices can grow rapidly with the doctor benefiting from a risk-free, ongoing ownership stake.

Timing is critical While the overall effects of the COVID-19 disaster are still an unknown, there are new opportunities for great endodontists to achieve liquidity and larger gains if they move quickly. Doctors can learn more about the potential value of their practice in an IDSO transaction through a confidential and no cost practice evaluation. Visit www.Large PracticeSales.com to learn more. EP Volume 13 Number 3

Now is the Time To Monetize Part of Your Practice Value Invisible Dental Support Organizations (IDSO) buy 60% to 90% of your practice for cash up front. You remain as owner, operating under your brand with your team. Stay for five to 20+ years with a known exit. Silent partners provide you with the resources to grow your practice bigger, better, faster, more profitably and compete more effectively.

Recent Transactions

2X Collections, Two-Doctor General Practice, Age 30s, Sold 60%, Retained 40% 2.6X Collections, One-Doctor Periodontist and new partner will start a new office in six months.

Recent (Covid Era) Transactions

2.1X Collections, One-Doctor Oral Surgeon 2.1X Collections, One-Doctor Orthodontist 2.0X Collections, Multiple-Doctor Endodontist

DONâ&#x20AC;&#x2122;T GET CAUGHT IN THE NEXT WAVE ALONE WATCH OUR WEBINAR ON DEMAND: COVID-19 UPDATE Why IDSOs are Accelerating Partnerships With Great Doctors Earn One CE. Lecture by Chip Fichtner, Principal

19 D I V O C

To schedule a confidential call, and get a FREE practice value analysis, call 877-557-5119 or Email EndoUs@LargePracticeSales.com Webinar On Demand at FindMyEndoPartner.com

MARKETING MOMENTUM

Telemedicine marketing checklist: 10 things endodontists should do Marketer Rachael Sauceman discusses safe and effective marketing evolving after the COVID-19 crisis

o say that the COVID-19 pandemic has been a catalyst for change across all industries is an understatement. Earlier this year, dental practices across the nation were struggling to maintain revenue while abiding by state regulations, as well as recommendations set forth by medical associations such as the Centers for Disease Control and Prevention, the American Dental Association, and others. Many states deemed emergency dental care essential — and at this stage, all states have reinstated elective dental care, according to the ADA’s Center for Professional Success.1 Although this reopening is somewhat of a “return to normal” at the surface level, it’s safe to say that dental practices of all types will continue to face challenges as they work to deliver quality care in a way that offers a safe environment for patients, doctors, and staff members. One advancement we’ve seen in this area is the rapid shift toward virtual consultations. Across the entire healthcare vertical, we’re seeing an unprecedented adoption of telemedicine as a way to continue serving patients. Telemedicine has long been a trend as younger generations prefer to access care on their own terms, but red tape from regulations and payers, as well as growing pains from the implementation process, have held back a lot of practices from adopting telemedicine. But in today’s environment, telemedicine is helping many practices and patients weather the storm. Whether you’ve implemented a teledentistry solution already or you’re considering one, ensuring patients are aware of this new offering is just as crucial as implementing

Rachael Sauceman is the Head of Strategic Initiatives for Full Media, a Chattanooga, Tennessee-based digital marketing agency specializing in healthcare. Full Media offers a full spectrum of digital marketing capabilities within the healthcare space, including website design, online advertising, SEO, patient experience optimization, and analytics.

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the technology. This 10-step checklist offers guidance to help market virtual appointments from your endodontic practice.

1. Update your website. Especially during the COVID-19 pandemic, prospective patients are looking for detailed information about your practice’s current operations. And because different patients may consume information differently, it’s important to have your COVID-19 statement and telemedicine offerings accessible in multiple ways. If you already have a COVID-19 statement on your website, be sure to provide information regarding telemedicine options from that page — and while it may seem like a big project if you’re in a hurry to add virtual appointment details to your website, it’s important to have a specific page dedicated to telemedicine offerings. Although your existing patients would probably search for your specific practice, this may also be an opportunity to gain new patients who are uncomfortable returning to in-office appointments. Having a dedicated telemedicine page ensures you can capture both types of searches. We like this example from Aspen Dental.2 The Virtual Care page is linked directly from the homepage in an easy-to-find section. The page addresses cost, scheduling options, and explains how a virtual appointment works.

2. Make sure patients understand what to expect. The more questions you can answer for patients in advance, the more likely they are to be comfortable with a virtual appointment. Some common questions you might be able to address in an FAQ section on your telemedicine page include: • Are you currently seeing existing patients only, or can new patients schedule a virtual appointment? • What types of issues can be addressed with a virtual appointment?

Figure 1: This Facebook post from Dentists of East Brainerd lets patients know about their new service

• What types of endodontic problems are considered to be emergent? • Will my insurance cover this appointment? • How do I schedule a virtual appointment? • What is the process to connect with a provider at the time of my appointment?

3. Contact existing patients. Since existing patients are more familiar with your pre-COVID-19 processes and procedures, they may be unaware that telemedicine is an option. Send an email with details and a link to your new telemedicine page through an existing platform if you have one, or consider reaching out to patients individually with short phone calls.

4. Promote on social media. Although it can’t be your only form of outreach, be sure to notify your followers on social media. Since the average post on a Facebook business page only reaches 6.4% of all the people who like the page,3 it’s a good idea to consider boosting your Facebook posts. If Volume 13 Number 3

Since the average post on a Facebook business page only reaches 6.4% of all the people who like the page,3 it’s a good idea to consider boosting your Facebook posts.

5. Consider Google Search Ads. Search ads offer highly effective marketing because they’re displayed to patients and prospective patients as they’re actually searching for you. As dental offices reopen before some people may feel comfortable with making a trip to a physical office, there’s a good chance that some of those individuals may search for telemedicine consultations. By implementing Google Search Ads for your teledentistry offerings, you’ll have a high likelihood of pulling this type of patient to your website. For example, endodontists can’t target people who are experiencing tooth pain on Facebook. But they can target people who are searching for a virtual appointment for tooth pain on Google Search. If you are rolling out a new virtual appointment offering, we suggest that you take these steps: • Start with branded advertising. Existing patients and those who may already be familiar with your brand will likely search for your practice specifically. Having an ad that references your virtual offerings will ensure those individuals are made aware of this new option. • Create ads to answer FAQs. As an endodontist, the types of problems you may see are fairly specific. Do patients often ask you about specific types of tooth pain? Create ads that target the types of concerns patients may search for. • Implement more general ads. Since some patients may simply search for virtual dental appointments, teledentistry visits, etc., ensure some of your ads focus on these general terms and topics. • Broaden geographic targeting. While advertising for in-office visits should be more targeted, patients from more distant or remote locations may be interested in your virtual consultations. Volume 13 Number 3

Figure 2: Using search ads on Google Ads, you can ensure that your telehealth service shows up exactly when patients are looking for you

Figure 3: Patients are spending more time surfing the web, viewing news and videos, and shopping online at this time

6. Be where your customers are going for information. COVID-19 has changed essentially everything — the way we communicate, the way we work, our purchasing habits, and so on. It has also impacted the way users search for and consume content. Data from WordStream shows that search volume is down, but content consumption on the Google Display Network and YouTube is booming.4 The Google Display Network enables advertisers to show ads on content throughout the web, like local and national news websites, lifestyle blogs, YouTube videos, mobile apps, and games, and may be a good place for your practice to advertise. You may also choose to begin creating video content that you can upload to YouTube

and embed into blogs or relevant pages on your website. Cell phone cameras can record video of decent enough quality without having to invest in high-dollar productions. (Online retailers offer cell phone tripods and/ or light rings that can enhance the quality of your video.) Topics to consider include: • Educating patients about the telemedicine platform you’re using. Walk them through what to expect during a virtual consultation, and be sure to cover topics such as why you chose the particular platform you’re using, as well as patient privacy. Once you’ve uploaded this video to YouTube, be sure to embed it on your teledentistry webpage. • Introducing yourself to prospective new patients (if you’re taking Endodontic practice 35

MARKETING MOMENTUM

you’d like to implement a more sophisticated marketing plan, you may decide to invest in ads on Facebook, Instagram, and Twitter — or whichever platforms currently draw the most engagement. Social media ads not only help your content display to more of your existing followers, but also draw in prospective patients who may not be familiar with your practice.

MARKETING MOMENTUM them). Talk about the immediate needs for telemedicine as it relates to COVID-19, and explain your plans for the future. Offer an overview of the types of services you offer, and let patients know what they can expect during a visit to your practice. • Offering helpful tutorials that can prevent patients from needing emergent care. Do your patients have common symptoms and complaints? Could many of them be solved with better dental hygiene or compliance in their treatment plan? Make videos to address these topics. Even after COVID-19 is no longer a consideration, video content on YouTube can benefit your search rankings.

7. Update your local listings. Did you know that more than 50% of searches result in no clicks whatsoever to a website?5 This means many prospective patients may take action by calling your practice or gaining other pertinent information directly from listings on Google, Bing, Yahoo! Maps, and Google My Business. Be sure to provide information about COVID-19 and virtual appointments in those listings (and keep track of what you’ve updated in a spreadsheet, so you can remove the COVID-19 details when appropriate). Google My Business is also currently allowing providers to add two unique links to local listings: a link to COVID-19 information and another to teledentistry information on your website. If your practice operates in more than one location, you’ll need to add the links to each profile, all of which can be found in your Google My Business dashboard.

Did you know that more than 50% of searches result in no clicks whatsoever to a website?5 This means many prospective patients may take action by calling your practice or gaining other pertinent information directly from listings on Google, Bing, Yahoo! Maps, and Google My Business.

8. Update Meta information on your website. Meta information is the blue link text and descriptive text underneath that appears directly in search results listings. While many websites have default Meta information that is pulled from the site’s page title and content, it can be customized to offer more detail for searchers. Meta information is also crawled by search engines, meaning that it can increase the likelihood of your website appearing to prospective patients. Although you may not need to update every page on your site, be sure key pages like your homepage, provider pages, and location pages make note of virtual appointment offerings.

9. Set up a direct mail campaign. Although it is not as quick to implement as a digital marketing campaign, direct mail often generates good results. Whether you are notifying existing patients about your new offering or trying to reach prospective patients in your community, direct mail can be an effective approach.

10. Let patients know about inperson care.

Figure 4: Google My Business has offered new options to medical practices to ensure that patients can easily access telehealth information on Google Maps

Not all care can be done virtually, especially in endodontics. Many patients will understand that while they may be able to set up a virtual consultation with an endodontist, they will eventually need to come into your office for a procedure.

Consider adding some information to your website that complements your telemedicine services, helping patients understand what precautions you are taking to keep them safe if and when they need to come in for care. Dental365™ in New York has a great example detailing the exact precautions they are taking to ensure that patients are safe.6 This practice has even gone the extra mile by including a video in the actual office showing their staff participating in safety measures. Patients want to know that you are taking steps to protect them from infection and that best practices, like social distancing and mask-wearing, will be enforced by your front-office staff. While you may feel like you can explain these precautions over the phone or in a telemedicine visit, some patients may never even reach out and pay for a telemedicine consultation if they don’t feel like their entire care experience will be safe. By explaining your virtual and in-office services upfront, you can gain a competitive advantage and answer many doubts upfront that may be a deterrent for your patients. EP

REFERENCES 1. ADA Center for Professional Success. COVID-19 State Mandates and Recommendations. https://success.ada. org/en/practice-management/patients/covid-19-statemandates-and-recommendations. Accessed July 8, 2020. 2. Aspen Dental. Virtual Care. https://www.aspendental.com/ virtualcare. Accessed. July 8, 2020. 3. Bain P. 10 Need to Know Facebook Marketing Stats for 2019. Social Media Today. https://www.socialmediatoday. com/news/10-need-to-know-facebook-marketing-statsfor-2019/547488/. Posted February 5, 2019. Accessed July 8, 2020. 4. Irvine M. New Data Reveals PPC Ad Campaigns Are Rebounding. Wordstream. https://www.wordstream.com/ blog/ws/2020/05/04/ppc-rebound-covid-19-data. Updated July 2, 2020. Accessed July 8, 2020.

Figure 5: Dentists of East Brainerd has updated their website’s Meta information and provided a specific page on their website about teledentistry. 36 Endodontic practice

5. Nguyen G. Now, more than 50% of Google searches end without a click to other content, study finds. Search Engine Land. https://searchengineland.com/now-more-50of-google-searches-end-without-a-click-to-other-contentstudy-finds-320574. Posted August 14, 2019. Accessed July 8, 2020. 6. Dental 365. https://www.godental365.com/about-us/whydental-365/. Accessed July 8, 2020.

Volume 13 Number 3

In this article, Jackie Raulerson discusses how to share your practice and treatment successes with an effective presentation

powerful presentation creates curiosity, provokes thought, and puts the focus on you and your valuable information. Like telling any effective story, there are distinct steps to crafting the perfect deck of slides to support your lecture. During my career, I have enjoyed assisting many dentists and other dental professionals in creating or enhancing visual materials for their slide presentations. This article shares some tips and techniques that I’ve learned to produce a meaningful and memorable presentation. Depending upon the type of presentation — a clinical case showing the use of specific products or covering a practice-management technique — different approaches are necessary. The subject matter will determine the formality of the presentation and, in some cases, dictate its visual appearance. Presentations that offer continuing education (CE) credits come with their own set of guidelines and usually are peer-reviewed. Many CE providers specify that the presentation must be noncommercial; therefore, you are required to eliminate any identifying patient information and not show bias to a particular product. They may limit the use of brand names, instead preferring to use the generic type of technology or equipment these products represent. You also may need to include references for any clinical claim you make for any product or fact.

The key to building an effective presentation Your audience wants to focus on you and your information. Any distractions should be eliminated. Whether using PowerPoint®, Keynote™, or another program, the same

Jackie Raulerson, RDH, has been in the dental clinical field for 20 years and in dental development and marketing for 17 years. Working with both manufacturers and dental professionals, she helped to establish a strong editorial and social media presence for several global companies. Jackie now operates her own business to help both dental sectors accomplish their marketing needs. She can be reached at jackie@yourmessagedelivered.net.

Volume 13 Number 3

Figures 1A-1B: On the left, a less wide resolution will present with black bars to each side. A correct size or resolution will cover the screen for full impact. (All clinical images herein courtesy of Diwakar Kinra, DDS, MS)

Figure 2: Due to improper settings, the slides are stretched to fill the monitor’s screen

general “rules” apply. It all boils down to this: Keep it simple in both design and content.

Slide design Slide size or resolution Each venue will have a specific size of TV, monitor, or screen on which your presentation will be displayed. Before building your presentation, verify the specs with the event coordinator. You want your slide to grab the full screen (Figure 1B). If your presentation was built with a different resolution, you can make changes, but you will want to do this ahead of time. Before you present to your audience, run onsite tests to ensure that there is no slide stretching or squeezing and thus visual anatomical distortion (Figure 2).

Your master slide Some associations and companies (if you are speaking on their behalf) have a master slide that you are obligated to use. However, if there are no restrictions, you should create your own master slide that speaks to who you are but not too “loudly.” Your professional information If you want to use your logo, name, and contact information on each slide, the size and combination of these may be too distracting to appear slide after slide. In this case, consider showing the full information in a larger size at the beginning, for instance, on your “bio slide,” and then switch over to a diminutive version on the remaining slides. As seen in Figure 3B, the logo and practice Endodontic practice 37

MARKETING MOMENTUM

Ready, set, present!

MARKETING MOMENTUM name show at the bottom the slide, smaller, and slightly watermarked or faded. Color and/or background When considering slide color and background, keep in mind that “clean” does not equal “boring.” White, black, or neutrals will keep the audience focused on the information on the slide. It is best to be consistent with one color throughout the presentation. For example, Figure 4B slide shown in various background colors within the same presentation can force changes in font color and interfere with image backgrounds. These changes also require the eye and mind to adjust before concentrating on the content. Slide transitions Busy slide transitions are one of the greatest offenders of distraction. Spinning, checkerboarding, or swooping of slides can be jarring — consider a simple fade from one slide to another for a more professional presentation.

Your audience wants to focus on you and your information. Any distractions should be eliminated ... It all boils down to this: Keep it simple in both design and content.

Figures 3A-3B: The left slide shows the initial and full use of your practice information, while the right slide shows name and logo only — much more appropriate for all remaining slides

Presentation content Divide and conquer Sometimes too much information can be overwhelming. Breaking up a subject is the easiest way to conquer a huge amount of information. At some point, you will need to decide what to include and what to delete. This will be driven by your objectives and, of course, the time limit. Start with an outline Creating an outline will help you make editing decisions. An outline will also help you generate a cohesive, organized flow and avoid tangents. Limit the number of cases to those that meet the main statements of your outline. For example, if one of your objectives is to show how the use of aligners has worked in your practice, pick the best few examples. There is no need to show 10 cases when your point can be made with three.

Figures 4A-4B: The slide on the left is a basic (but not boring) background. The slide on the right changes to a blue background and drives a font color change. However, the logo and image are on a white background, which can be distracting unless you take the time to edit

Figures 5A-5B: Follow the 7 x 7 rule for slide text — try to use no more than seven lines of text and no more than seven words per line. Seen here, the right slide is obviously easier to understand than the left slide

Slide content Text We’ve all seen presentations where there are way too many words on the slide (Figure 5A), which forced the presenter to become a “slide reader.” While it may be appropriate for more extensive information to appear on your handouts, the amount of text on a slide should be minimal. Edit text to be clear and concise. Typically, bulleted information is easiest to digest. Each bullet should be short and to the point. If you have more than a few bullets 38 Endodontic practice

on a slide, consider splitting the information into several slides. Select a font, font size, font color, and bulleting style that are simple and easy on the eyes. These should match throughout your presentation. Use color, bold, italics, or underline select words for emphasis —just not all of these at once! 2D clinical photos and X-rays Your presentation will be displayed on a

large screen. This makes image resolution critical for all clinical images. A pixelated or blurry image is not useful. Capture and save clinical photos in high resolution. You can always reduce resolution after capture; you cannot increase it very successfully. Crop out distracting or unimportant information in the photo or image. Additionally, there is no need to heavily notate an image with text if you will discuss the same information in your lecture (Figures 6A-6B). Volume 13 Number 3

Video clips Use a video, especially in 3D technologies and imaging, to show anatomical structures. While you may be familiar with using your 3D program, others may not. I would urge you to plan ahead when recording specific procedures. It may be helpful to mix video with high-quality digital photographs that you take during the procedure. Charts Often there a clean, simple way to show

considerable amounts of information, especially numeric stats. For example, if you have a great deal of data in written form, make it easy for your attendees to see at a glance by using a chart. Programs such as Microsoft® Excel create attractive charts from line items (Figure 7B). Graphics Graphics and other photos can support your presentation and break up slide content to maintain interest. For example, if you want to speak about an increase in your

production, an image can often convey this, as well as or better than text (Figure 8). Give credit where it’s due The Internet offers all kinds of information in text and image form. While these exist in a public domain, someone created it. If you use this information, give credit either on the slide or at the end of your presentation. For copyrighted material, such as articles or a clip from a web series or TV show, request permission to use. Review, review, review Finally, review your presentation for specifics: spelling, consistency in alignment, font, transitions, and length. While it takes more time, it is productive to concentrate on one of these at a time. For length, consider your time limit, and run through your presentation to ensure you can stay within the time frame. Be sure to leave 5-10 minutes at the end for a Q&A with attendees.

Figure 7: The desired statistical information in this article can be placed into a nicely readable chart

Figure 8: Simple graphic that lets you and your information take center stage Volume 13 Number 3

Where to go for help For selecting proper content and creating its flow, my article in the January/February 2020 issue of Orthodontic Practice US should offer some assistance. I’m a big believer in YouTube™ learning. There are many how-to videos on good practices for building presentations, adding supportive visual materials, and even on delivering your information to audiences. By following a few simple slide-building rules, you can effectively share your clinical and professional experiences with your peers. But remember, you are the most important part of your presentation. I hope that this information will give you more confidence in sharing your clinical and professional experiences. You can do this! As in dentistry, it all starts with a plan. EP Endodontic practice 39

MARKETING MOMENTUM

Figures 6A-6B: The slide on the left is a pixelated image with too much text overlay and unnecessary visual information; it is distracting. The slide on the right has a clear image with minimal text and is cropped to show the area of interest

SMALL TALK

Peak performance Drs. Joel C. Small and Edwin McDonald discuss reaching your maximum practice potential

eak performance is a state of optimal function and flow. Some refer to it as “being in the zone” or “hitting on all cylinders.” For athletes, peak performance is the manifestation of their maximum athletic potential. Their peak experience may last only seconds or minutes, yet it represents the culmination of years of hard work and dedication that, like a meticulously made Swiss watch, brings all the working parts into harmony to create something beautiful and special. Like elite athletes, many of us less athletic types aspire to attain peak performance in our lives. For those of us fortunate enough to have a peak experience, whether we be athletes, business executives, or healthcare professionals, the experience leaves an indelible mark on our psyche. Once experienced, we want to remain at our peak forever. This is a challenging but worthy aspiration. Keeping a clinical healthcare practice at peak performance is a daunting task because it is not a solo endeavor. Taking an entire team to peak performance and maintaining this level of performance is a group effort and requires a level of leadership and self-awareness that few realize. The following are three factors that are essential if we are to succeed.

Leadership A clinical healthcare team will never achieve peak performance if the doctor leads by default. … PERIOD. Our commitment to develop and scale our leadership as

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.

40 Endodontic practice

the complexity of our practices increases is, without question, the most significant factor in our practices’ success. Leaders must develop a high degree of self-awareness and emotional intelligence. We must recognize our blind spots and shortcomings as well as our strengths. We must create a psychologically safe culture in which team members can speak freely, offering feedback without the fear of reprisal. We must place our values front and center and make them non-negotiable. Finally, we must believe in the good intentions of the people we lead, and we must lead by example. Those of us who take these issues to heart and lead with purpose will flourish. Peak performance will be within our grasp. Those of us who lead by default will flounder. It is really that simple.

Vision What does peak performance look like? What individual tasks must be performed flawlessly for a team to experience collective peak performance? These are essential questions that require an answer because without a shared image of what peak performance looks like, it is almost impossible to achieve. We must spend time with our staff creating a vision of peak performance. Try making a “Peak Performance Checklist” that details individual tasks, when done flawlessly, will contribute to peak performance. The initial list will serve as a rough draft that will be altered as time and experience dictate. Like any vision, it will fade unless we keep it alive. We must revisit the vision in staff meetings and conversations. Practicerelated decisions and actions should be discussed and referenced regarding their contributions in achieving peak performance. We must impress on our staff that peak performance requires the highest level possible of interdependence between staff members. The front office and clinical staff must function and communicate as a team. As leaders, we must become coaches, as opposed to managers, to help our team function consistently at this high level. More

importantly, we must leave our egos at the door and become one with our team.

Review It is no longer acceptable to allow poor performance to continue because we feel that it is not worth the effort and/or expenditure of emotional capital to correct. Unless all team members (and doctors) are functioning in unison and at a high level, there will be no flow, and peak performance will be unattainable. Here is the good news! These remedial conversations need not be gut-wrenching. If we have created a psychologically safe culture, discussions regarding performance are common and viewed as being necessary if the team is to attain peak performance. Here is the bad news! We have no immunity to similar discussions. Remember, we have parked our ego at the door. Over time, performance discussions, good or bad, will be seen for what they are — a necessary and useful tool. The armed forces utilize a procedure they call an “After Action Review.”At the end of a day or at the completion of a specific task, they review what went well and what could have been performed better. This is done in the interest of achieving peak performance. There is no emotion or ego involved. Team leaders give their impression of the overall team performance, and each individual team member critiques his/her individual performance for the day and focuses on what went well and what could have done better. This is a powerful, growth-oriented tool. There are many other factors that impact peak performance in organizations. For example, leaders must assess their personal needs and requirements that allow them to function at their highest level. These may be different for everyone. In summary, organizational peak performance is aspirational. No one and no organization functions at this level continually, yet it is a worthy goal. There will be days when things just do not go well. We should be kind to ourselves and our team, recognizing that better leaders experience fewer down days and more peak experiences. EP Volume 13 Number 3

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