Endodontic Practice US Winter 2020 Vol 13 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

ENDODONTICS Company profile U.S. Endo Partners

Former nuclear weapons engineer’s gift to endodontics Carolyn Primus, BS, MS, PhD

Improving endodontic success through coronal leakage prevention — part 1

Learn more on page 10.

EXCELLENCE

endos and counting.

PROMOTING

Don’t miss your opportunity to join the growing community of endo practices.

Winter 2020 – Vol 13 No 4 • endopracticeus.com

Dr. Gregori M. Kurtzman

Treatment of mandibular first molars with atypical anatomy: a case report Drs. Yurii Riznyk and Svitlana Riznyk

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

A look ahead to what’s new

here’s a certain sweet spot that influences whether a technology or solution becomes a new standard of care in endodontic practices. As specialists who care deeply for our patients, we find the greatest value in those advancements that conjoin better clinical outcomes with improved patient experiences. We work with technology and systems every day, but at heart, we’re here to help people. That’s why I’m excited about the many emerging developments I see making a difference in my own practice — and in a growing number of endodontic practices and residency programs across the nation. After swiftly responding to the pandemic and navigating unforeseen challenges, it’s nice to look ahead and focus on positive opportunities for pursuing Steven L. Frost, DDS better together. A shift to high-tech irrigation Traditional needle irrigation can pose a challenge in today’s move toward minimally invasive protocols designed to retain more tooth structure. New multisonic irrigation technology allows your irrigation solution to reach smaller canal intricacies such as lateral canals or isthmuses. A better clean is a better outcome. But I’m equally excited about how this technology improves patient experiences. In addition to a reduction in reported pain, it allows us to go from two-visit endo to one visit. If you were to ask patients if they prefer a procedure that takes two visits or one, we already know the answer. The continued rise of CBCT imaging Watch for growing access to cone beam computed tomographic (CBCT) imaging. Its 3D images provide unprecedented information from missed canals or a fractured root to complexities of the sinuses. I have a saying in my practice: “Great information makes for even better decisions.” By having this information available to us, we’re able to produce better outcomes. Dynamic navigation for preserving tooth structure While magnification and illumination have supported more conservative freehand endodontic access, dynamic navigation is a giant leap for minimally invasive procedures. The computer-guided technology uses real-time feedback to increase accuracy and spare coronal tooth structure, even in the most challenging cases including calcified canals. More endodontists joining together Emerging tech isn’t the only thing changing endodontic practices. One of the biggest shifts we’re seeing is a trend toward group practices and specialty services partnerships (SSPs). While this trend has already impacted general dentistry, endodontists have been slower to move from the legacy practice model. For my own career path, I’ve always believed it’s not just about the journey, but who you take with you. As an owner-partner in the nation’s first and fastest growing SSP, I’m part of a collaborative community that enables me to share best practices and truly focus on patient care. As part of U.S. Endo Partners, we are stronger together. Elevated experiences for staff and patients Smart businesses in every sector know that when your staff feels supported and respected, they’ll show the same level of care for customers and guests. Seemingly small details add up to a big impact. Case in point? We recently redesigned our offices with light colors and modern lines to emphasize the cleanliness of our pristine and safe operatories. The experience is further elevated with a fresh, clean aromatherapy scent circulated throughout our space. Team members feel safe and valued, and the positive feelings are passed on to our patients. Not just change, but progress Change is inevitable, as we’ve seen over the last year. It’s exciting to look ahead at new ways to move forward — better and stronger. By focusing on what’s good for our patients, we’ll ultimately serve our specialty as well. Dr. Steven L. Frost

Steven L. Frost, DDS, comes from a family of dentists. He attended dental school at the University of the Pacific in San Francisco and received his endodontic specialty training at Tufts University in Boston, Massachusetts. Dr. Frost is a member of the American Dental Association, American Association of Endodontists, and the Arizona State Dental Association. He established his practice, Red Mountain Endo in 1994 and is a founding partner of U.S. Endo Partners.

ISSN number 2372-6245

Volume 13 Number 4

Endodontic practice 1

INTRODUCTION

Winter 2020 - Volume 13 Number 4

TABLE OF CONTENTS

Publisher’s perspective Looking forward to 2021! Lisa Moler, Founder/CEO, MedMark Media................................ 6

Influencer profile

Former nuclear weapons engineer’s gift to endodontics

Carolyn Primus, BS, MS, PhD, inventor, researcher, manufacturer, teacher, and humanitarian

Case study The association of endodontic treatment and microsurgery in the treatment of an extensive periapical lesion and recurrent fistula Drs. Artur Henrique Cabral, Gabriella Lopes de Rezende Barbosa, Larissa Rodrigues Santiago, Alexia da Mata Galvão, and Maria Antonieta Veloso Carvalho de Oliveira discuss this surgical retreatment as a viable and effective option................................ 12

Company profile U.S. Endo Partners Drs. Mark Young and Eric Young discuss the essential operational, administrative, and marketing support for endodontists

2 Endodontic practice

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TABLE OF CONTENTS

Continuing education Treatment of mandibular first molars with atypical anatomy: a case report Drs. Yurii Riznyk and Svitlana Riznyk present a challenging case demonstrating the importance of locating all root canals.....................28

Product profile

Continuing education Improving endodontic success through coronal leakage prevention — part 1

Dr. Gregori M. Kurtzman discusses a major determinant of endodontic success or failure

Advanced endodontics with Fotona’s new SkyPulse® Laser Dr. Valerie Kanter discusses a clinically effective photoacoustic effect for endodontic treatment...................... 34

Service profile Next-level strategies to protect your dental practice Bre Cohen discusses preparing your practice for unforeseen risks............36

Service profile

Small talk

Large Practice Sales (LPS) helps dental professionals of all specialties monetize their life’s work

What do we value? A critical question and a values exercise

Top 10 reasons endodontists choose an Invisible Dental Support Organization (IDSO) partner............. 38

Dr. Joel C. Small shares his core values and guiding principles ............................................................. 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 4

THE REVOLUTION IN BIOCERAMICS HAS BEGUN

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PUBLISHER’S PERSPECTIVE

Looking forward to 2021!

hrough all of the challenges and changes of 2020, I look forward to 2021 as a year of renewal and rejuvenation. 2020 changed our perspectives on patient care and the way we run our businesses. Sanitizing and masking have become part of daily routines, and new methods of communicating with patients and sharing information with colleagues have brought new efficiencies to dental practices. 2020 also has taught us that managing our offices efficiently can navigate us through hard times and make the good times even better. This year dentists discovered that teledentistry can keep them clinically connected with patients as well as keeping information flowing. The American TeleDentistry Association Lisa Moler notes that teledentistry can: Founder/Publisher, MedMark Media • Improve dental hygiene of patients • Reduce the cost of care and increase efficiency through reduced travel times, shared professional staffing, and fewer in-person appointments • Be an innovative solution for the mainstream healthcare industry • Improve access to care for patients • Reduce the amount of time patients need to spend away from their offices • Make in-office appointment times more accessible • Make in-office appointment times more accessible to patients who really need them In addition, PPE and aerosol containment policies and other safety precautions will allow you to make future plans to expand your skills and techniques. Endodontic Practice US continues to be a trusted source for introspection, invention, implementation, and innovation for your dental practice. Your strength and dedication to your craft and your teams is truly inspirational. In this issue, we feature a CE by Dr. Gregori M. Kurtzman who focuses on a major determinant of endodontic success or failure — coronal leakage prevention. In their CE, Drs. Yurii Riznyk and Svitlana Riznyk show successful management of a patient with unusual anatomy of the root canal system of the first lower molars. Dr. Eugenia Pilar Consoli Lizzi and colleagues use CBCT to diagnose a multiple C-shaped root canal system in mandibular molars and premolars, and Drs. Artur Henrique Cabral and colleagues treat an extensive periapical lesion and recurrent fistula. This is our last issue for this year, and I think I am joined by all of you in saying that 2021 can’t get here fast enough! We look forward to starting the next year with healing, hope, and vision for a profitable future. As I have said before, stay positive, stay focused, and stay with us as you have over the years. We appreciate and value you, and invite you to contact us regarding submitting articles in 2021. All the best, Lisa Moler Founder/Publisher MedMark Media

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

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6 Endodontic practice

Volume 13 Number 4

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.

* Statements limited to the United States 1 Data on file

INFLUENCER PROFILE

Former nuclear weapons engineer’s gift to endodontics Carolyn Primus, BS, MS, PhD, inventor, researcher, manufacturer, teacher, and humanitarian What can you tell us about your background? I earned a BS degree in Ceramic Engineering, then MS and PhD degrees in Materials Science and Engineering. Before and after getting my degrees, I performed research in national laboratories related first to nuclear weapons and naval defense, and then to consumer products. After that, there I began a 30-year career in dental materials research and development for endodontics, fixed prosthodontics, and orthodontics. I recently retired to write about bioceramics in dentistry.

What originally attracted you to the specialty of endodontics? I was consulting for a leading dental products manufacturer that charged me with developing the manufacturing methods for the original hydraulic bioactive cement formula, commonly known as mineral trioxide aggregate (MTA). In 2002, I invented White ProRoot®* MTA.† Through the process of this work, I learned that hydraulic ceramic cements (MTA) offered immense potential for supporting healing of teeth. From that realization, I began to think of new ideas, and applied to National Institutes of Health/National Institute of Dental and Craniofacial Research (NIH/NIDCR) for a Small Business Innovative Research (SBIR) grant. As part of the grant, I founded Avalon Biomed in 2010 to develop and market MTA Plus®, a line of affordable bioceramic dental medicaments for economical use worldwide. My vision was to develop a bioactive cement that had better properties than existing MTAs, with easier handling, faster

Carolyn Primus, BS, MS, PhD, has received honors in dentistry and materials science, including the University of Illinois Material Science Department Distinguished Alumni (2015), Dr. Edward B. Shils Award (2016), Lucy Hobbs Project Innovator Award (2020), and the first annual Larry L. Hench Lifetime Achievement Award (2020) given by The American Ceramic Society. She has dedicated 30 years to dental materials research and development, having been awarded 13 patents in endodontics and other dental specialties and three other non-dental patents. Dr. Primus has co-authored 27 dental publications, six chapters on dental materials, and other publications in materials science.

8 Endodontic practice

Carolyn Primus, BS, MS, PhD

setting, better color stability, and a price that endodontic, pediatric, and general dentists could afford. Six years later I sold the assets of Avalon Biomed to NuSmile Ltd., the worldwide leader in pediatric esthetic restorative dentistry. Avalon Biomed is now a NuSmile subsidiary focused on endodontics. The past 4 years I have collaborated with NuSmile Ltd. on the innovation of three new products: NeoMTA®2, NeoPUTTY™, and NeoSEALER™ Flo.

What have been your proudest moments in terms of the clinical aspects of your life? It’s a wonderful feeling when products come to fruition with test results and features that meet the needs of dentists and patients. I feel fortunate to have experienced this with several types of materials. I’m especially happy that NeoMTA Plus has been named the Top Bioactive Endodontic cement by DENTAL ADVISOR for the past 6 years. I’ve also had the good fortune of lecturing at dental schools and dental conferences on bioactive ceramics.

What prompted you to develop your newest products? Endodontists have been vocal that the leading bioactive root and pulp products were too expensive, too time-consuming to mix, and prone to premature hardening in their packaging. Based on that information, we spent over 2 years developing three new products. NeoMTA 2 is an improved and economical powder-gel system with higher radiopacity, color stability, smooth consistency, washout resistance, and faster setting times. NeoPUTTY is an affordably priced, premixed, multi-indication pulp and root treatment paste in a syringe that virtually eliminates waste. NeoSEALER Flo is a bioactive bioceramic endodontic sealer in a syringe; its kit includes special tips that avoid waste and allow dispensing directly into a canal.

How challenging was this project? Research and development of new product lines is always challenging, but NuSmile invested the financial and human resources in Avalon Biomed to ensure success. NuSmile doubled the bioceramic Volume 13 Number 4

What has been your biggest challenge in educating endodontists? I have been puzzled about several myths that persist about MTA bioactive cements. Many clinicians continue to assume that all MTA products are costly, slow-setting, “sandy,” and hard to handle. Many dentists remain unaware of how the bioactive bioceramics support healing of pulpal or periapical tissues for many procedures. Several bioactive ceramic cements containing bioactive calcium silicate cement are sporting similar product names and claims that confuse clinicians. The differences among these products — especially regarding cost per dose — are tremendous; dentists need to be smart shoppers! Also, “bioactivity” is loosely used in advertisements for supragingival cements without the histological proof of bioactive hydroxyapatite formation.

What advice would you give to budding endodontists? Read the clinical literature critically. Study the Safety Data Sheets to compare products. Question manufacturers about claims and

INFLUENCER PROFILE

manufacturing area, purchased new capital equipment, and hired two bioengineers dedicated to product development. Expanded resources were applied to seek FDA clearance, Health Canada licenses, and CE certification. After extensive in vitro testing, several dental schools provided professional evaluations, including the College of Dentistry at the University of New England, the Dental College of Georgia at Augusta University, Texas A&M College of Dentistry, and the University of Texas School of Dentistry at Houston. A wide range of cutting-edge endodontists performed our ß-site testing of the products to verify customer satisfaction. Between NuSmile and our professional partners, a powerful team drove these projects to completion.

nomenclature, so you understand the materials or equipment. Many wonderful products are available, but not all products are equally useful; make sure you understand the claims and what you are purchasing. Dental shows are excellent venues to get answers, and I hope they will soon resume.

What is the future of endodontics? Endodontics has a bright future. Regenerative endodontics using bioactive materials will become more common. Instrumentation will remove less root dentin. Equipment and irrigation methods will access the canal anatomy more completely to further improve treatment of pulp necrosis and irreversible pulpitis. Bioactive bioceramic cements and root canal sealers will be central to future improvements. Adult pulpotomies with bioactive bioceramics may become a more viable alternative to conventional root canal therapy.

What would you have become, had you not become a dental materials researcher? Early in my career, I aspired to be an astronaut, but I eventually decided I wanted to develop materials for use in healthcare. I’ve greatly enjoyed being part of the dental community, even though I believe dentistry is underappreciated for its contributions to public health. I feel honored to have been able to interact with the best endodontists and dentists in the world.

What are your hobbies, and what do you do in your spare time? I’m an enthusiastic birder. Even in retirement, I serve as chair of the ADA and ISO committees on endodontic materials. EP

PROROOT®, DENTSPLY® and DENTSPLY SIRONA® are registered trademarks of DENTSPLY SIRONA Inc. † Patented under US Patent No. 7,892,342 assigned to DENTSPLY International Inc.

2002

2010

2014-2016

2020

Invented White ProRoot®* MTA†. 2002 - 2010: Invented improvements for MTA (tricalcium silicate-type) materials.

Received NIH grants on endodontic bioceramics. Founded Avalon Biomed Inc. to commercialize improved bioactive cements.

Invented and commercialized NeoMTA® Plus in 2014. Elected Chair of ADA & ISO Standards committees for endodontic materials.

Invented NeoMTA®2 NeoPUTTY™ and NeoSEALER™ Flo bioceramics.

Volume 13 Number 4

Endodontic practice 9

COMPANY PROFILE

U.S. Endo Partners Drs. Mark Young and Eric Young discuss the essential operational, administrative, and marketing support for endodontists

s practicing clinical endodontists, our foremost goal is to provide the highest standard of patient care. We’ve spent countless nights studying in undergraduate colleges, schools of dentistry, and residencies to prepare us for this mission. Indeed, the standards to become any type of medical or dental specialist are stricter, take longer to learn, and require more time to ensure the excellence patients deserve and our specialty requires. Providing a higher level of care every single day is integral to everything endodontists do for their patients. As practitioners, it is incumbent upon us to anticipate any challenges that may impede us in our duty of excellent patient care. What are those

Mark Young, DDS, received his dental degree from the University of the Pacific and then continued his studies at Harvard University’s School of Dental Medicine, where he received a postgraduate certificate in Endodontics and a master’s degree in Medical Science. Dr. Young considers it a great honor to treat each of his patients and does so with the highest degree of care and compassion. Eric Young, DDS, graduated from the University of the Pacific School of Dentistry in 2007. He continued his education while serving our country in the United States Army. In 2008, he completed an Advanced General Dentistry residency and went on to serve tours in Egypt and Afghanistan with the 3rd Special Forces Group. Dr. Young finished his dental education at Harvard University’s School of Dental Medicine, where he received a postgraduate certificate in Endodontics.

10 Endodontic practice

challenges today, and what challenges are we likely to face tomorrow? How do we overcome those obstacles? The reality many endodontists face in running a clinical practice is already difficult and getting harder. What if there was a better way? U.S. Endo Partners supports fellow endodontists by providing valuable practice resources, so our partner-clinicians can spend more time doing what they love — providing excellent patient care. We provide essential operational, administrative, and marketing support. If endodontists — or for that matter, any specialists — worked together from within a group of like-minded peers, they could create a better future for themselves. Together, as partner-clinicians, we can keep better control of group pricing. We can resist overreach from insurance companies. We can cover for each other and go on vacation without fear of losing referrals. We can benefit from peer-topeer mentoring in a supportive community. Endodontists are stronger together. Perhaps most importantly, our partnerclinicians have more opportunities to provide the highest standard of patient care while increasing their own quality of life. When this cooperative spirit is amplified with investment partners, the enterprise value of this specialty group becomes exponentially increased. We always knew cooperating with other endodontists would lead to a better future. Our initial growth and results are evidence of that belief. This growth makes a better life for partner-clinicians, creates more opportunities for associates, and ensures the best outcomes for our patients. As these results continue to speak for our specialty services

“Being part of an endodontic community creates more freedom, more money, and less stress.” – Dr. Mark Young, DDS

partnership, the number of partner-clinicians across the country increases. As a prospective endodontist considering joining a specialty services partnership, the advantages for U.S. Endo Partners’ model are numerous. We are backed by experienced investment partners with a proven track record of following through on equity events with other specialties. A realistic chance to multiply equity exponentially is remarkable for any partnership. We were the first to market with the largest network and the strongest margins among its partner practices. We possess the proven ability to increase the value of our equity, the momentum to achieve it, and a culture that promotes the welfare of the endodontist and patient. Joining U.S. Endo Partners gives you access to a network of mentors ready to guide you through your journey of becoming a partner. The proven success of U.S. Endo Partners is a testament to the enormous value of endodontists working together. U.S. Endo Partners strives to change the status quo for the improvement of its member endodontists, their families, and their patients. Through favorable market dynamics and enterprise value, we have the opportunity to increase our worth together more than separately. This opportunity allows current and future associates to truly advance into partnership while reaping the rewards of future equity events with a proven team. In a riskbenefit analysis, there are far more benefits to this model than the solo practitioner who assumes all the risk on their own. Explore your options. When you are ready to partner with the first and foremost in endodontic-led specialty services partnerships, please contact us. EP Volume 13 Number 4

70+ Strength in numbers.

endos and counting.

Join the growing community of like-minded endodontists and pursue better â&#x20AC;&#x201C; together. www.USEndoPartners.com/WhatIf

CASE STUDY

The association of endodontic treatment and microsurgery in the treatment of an extensive periapical lesion and recurrent fistula Drs. Artur Henrique Cabral, Gabriella Lopes de Rezende Barbosa, Larissa Rodrigues Santiago, Alexia da Mata Galv達o, and Maria Antonieta Veloso Carvalho de Oliveira discuss this surgical retreatment as a viable and effective option Abstract This article reports the association of endodontic treatment and microsurgery as the treatment choice for an extensive periapical lesion and a recurrent fistula in tooth No. 22 of a 44-year-old female patient. Clinical examinations and periapical radiographs revealed the presence of a palatal fistula and extensive periapical lesion. After biomechanical preparation and 2 months of intracanal medication with calcium hydroxide, the fistula regressed, and the tooth was filled. One month later the fistula reappeared. Then the tooth was reevaluated using cone beam computed tomography, and surgery was performed to remove the lesion, conduct an apicectomy, and retrofill the tooth with mineral trioxide aggregate (MTA). The histopathological diagnosis of the lesion was periapical granuloma. Surgical retreatment is a viable and effective option for treating infection and repairing periapical tissue in teeth with persistent fistulas and extensive periapical lesions.

Introduction The main objective of endodontic treatment is to reduce microorganisms and consequent infections in the root canal.1 This is achieved by cleaning and sealing the root

Artur Henrique Cabral is a Graduate student at School of Dentistry of Federal University of Uberlandia, Brazil. Gabriella Lopes de Rezende Barbosa is a Professor at the Department of Oral Diagnosis, School of Dentistry, Federal University of Uberlandia, Brazil. Larissa Rodrigues Santiago is a third-year resident of surgery and traumatology, Federal University of Uberlandia, Brazil. Alexia da Mata Galv達o is a PhD student at School of Dentistry of Federal University of Uberlandia, Brazil. Maria Antonieta Veloso Carvalho de Oliveira is a Professor at the Department of Endodontics, School of Dentistry, Federal University of Uberlandia, Brazil.

12 Endodontic practice

Figures 1A-1C: Periapical radiographs: 1A. Initial; 1B. Fistulous path; 1C. Final

canal to prevent reinfection and to recover or return functional and esthetic aspects of the tooth.2 The success of cleaning and modeling the root canal system has improved due to various technical, scientific, and biological developments. Nevertheless, endodontic treatments are still prone to failures, accidents, and various other complications.3 Given the risks, and especially those related to maintenance or new bacterial infections, nonsurgical retreatment is always the first choice.4 However, endodontic surgery is an excellent alternative for treatment or retreatment of periapical infections that are persistent, chronic, and extensive.5 This paper reports a case of conventional endodontic treatment followed by endodontic microsurgery in a patient with an extensive periapical lesion and recurrent fistula associated with an upper left lateral incisor.

Case report A 44-year-old female patient presented at the clinic of the School of Dentistry of the Federal University of Uberlandia, Brazil. Six years earlier at the Dental Emergency Room of the same institution, the patient reported

a history of facial trauma, pain, and swelling that was treated by draining an abscess and opening the crown of tooth No. 22. The patient remained free of pain and swelling for 2 years after the procedure. An intraoral clinical examination of tooth No. 22 showed coronary darkening, unsatisfactory resin restorations in proximal teeth, a coronary opening without provisional sealing, and palatal fistula. A periapical radiography showed a broad root canal and a large welldefined unilocular radiolucent lesion associated with the root of tooth No. 22, which suggested a periapical lesion (Figure 1A). The path of the fistula was determined by placing a No. 25 gutta-percha cone (Dentsply Maillefer, Ballaigues, Switzerland) in the fistula and then acquiring a new periapical image. This procedure traced the sinus tract and revealed the origin in the apical region of tooth No. 22 (Figure 1B). Vertical and horizontal percussion tests, and a thermal sensitivity test (Endo Ice速 Spray, Hygenic速) showed absence of pain. The suggested clinical/radiographic diagnosis was chronic apical periodontitis. The root canal instrumentation was performed using the crown-down technique Volume 13 Number 4

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CASE STUDY and Hedströen Nos. 15 to 25 hand files (Dentsply Maillefer, Ballaigues, Switzerland) on the cervical and middle thirds and Kerr files on the apical third (Dentsply Maillefer, Ballaigues, Switzerland). A No. 50 K-File was used with a working length of 21 mm. Foraminal debridement was performed with a No. 15 K-File (Dentsply Maillefer, Ballaigues, Switzerland). Progressive neutralization was carried out throughout by abundant irrigation using a 1% sodium hypochlorite and saline solution, applied with a 25 x 4 hypodermic needle (Ultradent). After instrumentation, the canal was filled with intracanal calcium hydroxide (Ultradent) and sealed with temporary glass ionomer cement (FMG Dental Products, Joinville, Brazil). The intracanal calcium hydroxide medication was replaced 3 times at 15-day intervals. The canal was filled via the lateral and vertical condensation technique using guttapercha cones (Dentsply Maillefer, Ballaigues, Switzerland) and bioceramic endodontic cement (MTA Fillapex, Ângelus, Londrina, Brazil). The tooth was then sealed with glass ionomer cement (FMG Dental Products, Joinville, Brazil) (Figure 1C). Thirty days after these procedures, the fistula reappeared in the palatal region. A cone beam computed tomography (CBCT) was acquired (Gendex CB-500 CBCT unit, Gendex Dental Systems) and showed rupturing of the palatal bone. A 3D reconstruction was performed using Mimics software (Materialise, Leuven, Belgium) in order to calculate the volume of the lesion for further comparison. The initial volume was 666.65 mm3 (Figure 2). Prior to surgery, antibiotic prophylaxis, antisepsis, oral cavity asepsis, and local anesthesia were performed. Then a flap was opened using a No. 15 scalpel (Advantive Wuxi Xinda Medical Device Co., Ltd., Jiangsu, China) to create a horizontal incision with small curves in the gingiva 3.0 mm from the gingival sulcus and complemented by two vertical incisions above the left upper incisors (Ochsenbein – Luebke flap).5 The tissue was broken down and the flap removed using a Molt periosteal elevator (SS White Duflex, Rio de Janeiro, Brazil). The osteotomy used to access the apex of tooth No. 22 was performed with a 6-blade surgical carbide bur No. 702 (KaVo Kerr, Joinville, Brazil) at high rotation and with abundant saline solution irrigation (Figure 3A). After the osteotomy, the lesion was removed using a Lucas Curette (SS White Duflex, Rio de Janeiro, Brazil) (Figure 3B) and stored in a closed container with 1% formaldehyde. 14 Endodontic practice

Figures 2A-2C: Tomographic sections of the lesion and tooth: 2A. Axial; 2B. Coronal; 2C. Sagittal. 3D reconstruction of the tooth with frontal (2D) and lateral views (2E) of the lesion

Figures 3A-3C: 3A. Osteotomy; 3B. Lesion removal; 3C. Clinical aspect of the lesion

Figures 4A-4C: Clinical aspect of the root post apicectomy: 4A. frontal view; 4B. inverted image through dental mirror showing the root canal filling; 4C. After MTA retrofilling

Subsequent histopathological examinations identified the lesion as a periapical granuloma (Figures 3C and 4). The apicectomy was performed by removing 3.0 mm from the apical portion of the root using a 6-blade surgical carbide bur no. 702 (KaVo Kerr, Chapecó Saguaçu – Joinville, Brazil) at high rotation and at a 45° angle (Figure 5).

The retrofill was performed with a mineral trioxide aggregate (MTA) cement (Ângelus Indústria de Produtos Odontológicos S/A, Paraná, Brazil) and an applicator (MTA) (Ângelus Indústria de Produtos Odontológicos S/A, Londrina, Brazil). The opening was sutured with 5.0 absorbable thread (ETHICON - Johnson & Johnson). Periapical digital radiographs were acquired Volume 13 Number 4

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CASE STUDY before (Figure 6A) and after surgery (Figure 6B). The canal entrance was restored with glass ionomer (FMG Dental products, Joinville, SC, Brazil), while the coronary chamber was restored with A3 composite resin (3M). After 24 months, the patient was reevaluated via clinical exams, radiographs, CBCT, and a new 3D reconstruction (Figure 7). The results of these evaluations were satisfactory and showed an absence of fistulous lesion pain and a significant decrease in lesion volume from 666.65 mmÂł to 46.94 mmÂł, suggesting periapical tissue repair.

Discussion Unsuccessful endodontic treatment is evidenced by a persistence of signs and symptoms that are caused by microorganisms. These may become resistant to chemical-mechanical processes and intracanal medication, thereby persisting, spreading to the canal and periapical tissue, and perpetuating infection.4,6 Endodontic bacteria cause apical periodontitis, which is characterized by inflammation of periapical tissue, and triggers acute or chronic pathologies, resorption of periapical bone, and affects root surfaces.7-10 Resistant apical periodontitis reduces treatment predictability and indicates that the permanence of bacteria in intraradicular and periapical tissues may cause refractory or recurrent infections.11 The presence of a periapical lesion that is caused by resistant microorganisms in the periapical region and attendant symptoms are fundamental indicators of treatment failure and characterize the need for new management strategies.3,12 Conventional retreatment is the first choice for dealing with unsuccessful endodontic treatments. However, when microorganisms in apical and periapical areas cannot be contained via coronary access, endodontic microsurgery can be used as a complementary therapy.5 The goal of endodontic surgery is to isolate the root canal and prevent bacterial contamination of apical and periapical tissues, thereby stimulating healing. This surgery is recommended for teeth that show persistent failure after treatment and endodontic retreatment.13 In the present clinical case, surgery was chosen due to persistent infection after satisfactory endodontic treatment as well as the persistent fistula associated with extraradicular infection and adhesion of apical microorganisms and bacteria to the root surface and within the inflammatory 16 Endodontic practice

Figure 5: Histopathological aspect of the lesion with hematoxylin and eosin-staining, showing dense unmodified connective tissue permeated by mononuclear inflammatory cells (detail: panoramic aspect of the lesion)

Figures 6A and 6B: Periapical radiographs 6A. Presurgery; 6B. Postsurgery

lesion.14,15 Failure in endodontic treatments are caused by not only technical issues but also microbiological ones since extraradicular colonies may persist even after root canal cleaning.15 Planning endodontic surgery depends on quality complementary exams that precisely show the size and extent of an apical lesion, its relationship with adjacent anatomical roots and structures, and the degree of bone involvement.16,17 Periapical radiographs are of limited value in diagnosing periapical pathologies since they offer only two-dimensional images of three-dimensional structures.18 CBCT, however, shows three-dimensional relationships among structures and provides accurate images of bone and dental tissues

that can be used to diagnose alterations and pathologies in three planes: axial, coronal, and sagittal.18.19 CBCT was used in the present case to evaluate the relationship of the periapical lesion to adjacent structures and tooth No. 22, to show the extent and volume of the lesion, and to demonstrate that the lesion had already caused the lingual rupture of the cortical bone. In the subsequent surgery, enucleation of the lesion and apicectomy were performed due to the extent and recurrence of the fistulous lesion. Enucleation was proposed to eliminate microbial agents that would have been inaccessible to conventional endodontic therapy. The goal of the Volume 13 Number 4

1. Türker SA, Uzunoğlu E, Aslan MH. Evaluation of apically extruded bacteria associated with different nickel-titanium systems. J Endod. 2015;41(6):953-955. 2. Lacerda MFLS, Marceliano-Alves MF, Pérez AR, et al. Cleaning and Shaping Oval Canals with 3 Instrumentation Systems: A Correlative Micro-computed Tomographic and Histologic Study. J Endod. 2017;43(11):1878-1884. 3. Chércoles-Ruiz A, Sánchez-Torres A, Gay-Escoda C. Endodontics, Endodontic Retreatment, and Apical Surgery Versus Tooth Extraction and Implant Placement: A Systematic Review. J Endod. 2017;43(5):679-686. 4. Kang M, In Jung H, Song M, Kim SY, Kim HC, Kim E. Outcome of nonsurgical retreatment and endodontic microsurgery: a meta-analysis. Clin Oral Investig. 2015;19(3):569-582. 5. Del Fabbro M, Corbella S, Sequeira-Byron P, et al. Endodontic procedures for retreatment of periapical lesions. Cochrane Database Syst Rev. 2016;10(10):CD005511. 6. George R. Nonsurgical retreatment vs. endodontic microsurgery: assessing success. Evid Based Dent. 2015;16(3):82-83. 7. Zehnder M, Rechenberg DK, Thurnheer T, Lüthi-Schaller H, Belibasakis GN. FISHing for gutta-percha-adhered biofilms in purulent post-treatment apical periodontitis. Mol Oral Microbiol. 2017;32(3):226-235. 8. De Rossi A, Rocha LB, Rossi MA. Interferon-gamma, interleukin-10, Intercellular adhesion molecule-1, and chemokine receptor 5, but not interleukin-4, attenuate the development of periapical lesions. J Endod. 2008;34(1):31-38. 9. Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39(4):249-281.

Figures 7A-7E: Tomographic sections of the lesion and tooth, shown in 7A. Axial; 7B. Coronal; 7C. Sagittal sections. 3D reconstruction of the tooth 24 months after the procedure, showing the lesion in frontal (7D) and lateral (7E) views

Endodontic surgery with apicectomy and retrofilling procedures combined with endodontic therapy is a viable and effective option for treating a tooth with extensive and chronic periapical lesion. apicectomy was to remove bacteria and other irritating factors from the apical region and to block microorganisms in the periapical tissues from reentering the canal, thereby stimulating healing.20 The success rate of preparing, surgically removing, and sealing the apex ranges from 88% to 94%.21 A histopathological examination showed that the lesion was composed of dense, unmodified, moderately cellularized, and vascularized connective tissue permeated by mononuclear inflammatory cells (lymphohistio-plasmacytes). No epithelial (cystic) lining or other significant histopathological elements were found. These findings and the clinical radiographic information from the case led to a diagnosis of periapical granuloma. A periapical granuloma results from the transformation of periapical tissues into granulation tissue due to chronic inflammation. Imaging exams show this tissue as a delimited, but not completely and welldefined radiolucent lesion. The pathology Volume 13 Number 4

10. Aw V. Discuss the role of microorganisms in the aetiology and pathogenesis of periapical disease. Aust Endod J. 2016;42(2):53-59. 11. Siqueira JF, Rôças IN, Debelian GJ, et al. Profiling of root canal bacterial communities associated with chronic apical periodontitis from Brazilian and Norwegian subjects. J Endod. 2008;34(12):1457-1461. 12. Kamburoğlu K, Yılmaz F, Gulsahi K, Gulen O, Gulsahi A. Change in Periapical Lesion and Adjacent Mucosal Thickening Dimensions One Year after Endodontic Treatment: Volumetric Cone-beam Computed Tomography Assessment. J Endod. 2017;43(2):218-24. 13. Comparin D, Moreira EJL, Souza EM, et al. Postoperative Pain after Endodontic Retreatment Using Rotary or Reciprocating Instruments: A Randomized Clinical Trial. J Endod. 2017;43(7):1084-1088. 14. Ricucci D, Siqueira JF, Lopes WS, Vieira AR, Rôças IN. Extraradicular infection as the cause of persistent symptoms: a case series. J Endod. 2015;41(2):265-273. 15. Sousa BC, Gomes FA, Ferreira CM, et al. Persistent extraradicular bacterial biofilm in endodontically treated human teeth: scanning electron microscopy analysis after apical surgery. Microsc Res Tech. 2017;80(6):662-667.

develops from the body’s initial attempt to promote scarring and healing.22 The tooth was retrofilled with MTA, which is biocompatible and can induce dentinogenesis, cementogenesis, and osteogenesis. MTA is also alkaline, which increases its antimicrobial potential and promotes effective marginal sealing that in turn prevents infiltration.23 A follow-up clinical exam showed absence of pain, swelling, and fistula, indicating elimination of the infection and repair of the periapical tissue. Despite the success of the procedure, a small radiolucent area may remain, which, like an “apical scar,” is asymptomatic and not pathological.24

Conclusion We found that endodontic surgery with apicectomy and retrofilling procedures combined with endodontic therapy is a viable and effective option for treating a tooth with extensive and chronic periapical lesion. EP

16. Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J. 2007;40(10):818-830. 17. Tsurumachi T, Honda K. A new cone beam computerized tomography system for use in endodontic surgery. Int Endod J. 2007;40(3):224-232. 18. Verner FS, D’Addazio PS, Campos CN, et al. Influence of Cone-Beam Computed Tomography filters on diagnosis of simulated endodontic complications. Int Endod J. 2017;50(11):1089-1096. 19. Estrela C, Bueno MR, Azevedo BC, Azevedo JR, Pécora JD. A new periapical index based on cone beam computed tomography. J Endod. 2008;34(11):1325-1331. 20. Wang J, Jiang Y, Chen W, Zhu C, Liang J. Bacterial flora and extraradicular biofilm associated with the apical segment of teeth with post-treatment apical periodontitis. J Endod. 2012;38(7):954-959. 21. Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature—Part 2: Comparison of endodontic microsurgical techniques with and without the use of higher magnification. J Endod. 2012;38(1):1-10. 22. Holland R, Filho JA, de Souza V, et al. Mineral trioxide aggregate repair of lateral root perforations. J Endod. 2001;27(4):281-284. 23. Juerchott A, Pfefferle T, Flechtenmacher C, Mente J, Bendszus M, Heiland S, et al. Differentiation of periapical granulomas and cysts by using dental MRI: a pilot study. Int J Oral Sci. 2018;10(2):17. 24. Schulz M, von Arx T, Altermatt HJ, Bosshardt D. Histology of periapical lesions obtained during apical surgery. J Endod. 2009;35(5):634-642.

Endodontic practice 17

CASE STUDY

REFERENCES

CASE STUDY

Multiple C-shaped root canal system in mandibular molars and premolars diagnosed by cone beam computed tomography: a case report Drs. Eugenia Pilar Consoli Lizzi, Romina Chaintiou Piorno, and Pablo Alejandro Rodríguez focus on a case showing the distinctive anatomy of C-shaped canals Abstract Aim The aim of this report is to present a rare case report in which multiple C-shaped canals were diagnosed in an adolescent male. Case report A healthy 16-year-old Argentine male, with no significant associated factors, was diagnosed to have six mandibular teeth with C-shaped canals by means of CBCT imaging. C-shaped canals were observed in the following teeth — mandibular right second molar, mandibular right first molar, mandibular right second premolar, mandibular left first premolar, mandibular left first molar, and mandibular left second molar Eugenia Pilar Consoli Lizzi, DDS, graduated from the School of Dentistry of the University of La Plata in 2013. Four years later in 2017, she received a Specialization in Endodontics from the University of Buenos Aires. Currently, Dr. Consoli Lizzi serves as an Assistant Professor in the Department of Endodontics, School of Dentistry, University of Buenos Aires, Argentine Republic. Romina Chaintiou Piorno, DDS, graduated from the School of Dentistry of the University of Buenos Aires in 2012. Two years later in 2014, she received a Specialization in Endodontics from the University of Buenos Aires. Currently, Dr. Chaintiou Piorno serves as an Assistant Professor in the Department of Endodontics, School of Dentistry, University of Buenos Aires, Argentine Republic. Pablo Alejandro Rodríguez, DDS, PhD, earned his degree in dentistry from the University of Buenos Aires in 1991. He later graduated with both a Specialization in Endodontics in 2007 and a Specialization in Prosthodontics. Dr. Rodríguez completed his PhD in 2016. Currently, he serves as the Head Professor of the Department of Endodontics and the Director of the Specialization in Endodontics. Dr. Rodríguez is also Professor of Prosthodontics in the School of Dentistry of the University of Buenos Aires. He is the actual Dean of the School of Dentistry of the University of Buenos Aires in the Argentine Republic. Disclosure: The authors deny any conflicts of interest related to this study.

18 Endodontic practice

— and were classified according to Fan et al. classifications. We present this report as the first published documented case of a conebeam image diagnosed patient, exhibiting six C-shaped canals in the same jaw. Clinical implications Clinicians must consider the C-shaped canal anatomy in multiple presentations as a possibility in the clinical practice. Recognition and classification of C-shaped canals lead to a safer endodontic treatment and predictable outcomes.

Introduction The main anatomical feature of the C-shaped roots is the presence of a fin or web connecting the individual canals. In molars, the canal orifice is ribbon shaped describing an arc of 180º or larger, instead of having the typical pulp chamber form with three root canals. The isthmus laying between the canals can develop difficulties when performing the canal debridement and obturation. The prevalence of C-shaped root canals is high in the mandibular second molars1; they may also appear in the mandibular first molars,2 mandibular first premolars,3,4 mandibular second premolars,5,6 maxillary molars,7 and even in maxillary lateral incisors.8 Ingle reported that mandibular firstpremolar canal morphology is generally oval in the coronal third, round or oval in the middle third, and round in the apical third.9 On the other hand, Lu et al. stated that a circumferential or an oval canal, or two canals, could be encountered coronally, and the C-shaped cross section could be found at the apical 3 mm to 6 mm.3 The maxillary second premolar is typically described in textbooks as a single-rooted tooth with a main canal. Usually, the ovoid-shaped root cross section displays development grooves or depressions at the mesial and the distal surfaces.10 Typically, the mandibular molars

exhibit two distinct roots. The mesial root feature is a flattened mesiodistal surface and a wider buccolingual surface. The distal root is mainly straight with an oval canal or two round canals.11 The C-shaped canals are more frequently observed in the mandibular second molars.12 In different research studies, Fan et al. assessed and classified the C-shaped canals (axial sections) by microcomputed tomography, and proposed two classifications. Fan et al. classifications for mandibular second molars.13 C1: form of an uninterrupted C, with no separation or division. C2: semicolon-shaped, C interrupted C3c: three separate canals and C3d: two separate canals C4: single round or oval canal C5: absence of a root canal lumen, only seen close to the apex. Fan et al. classification for mandibular first premolars14: C1: form of an uninterrupted C C2: semicolon-shaped, C interrupted C3: two separate round-, oval-, or ribbon-shaped canals C4: single round-, oval-, or ribbonshaped subdivided according to Wu et al.15 (in C4a, round; C4b, oval; and C4c, ribbon-shaped) C5: three or more separate canals C6: absence of a root canal lumen, localized close to the apex As a possibility, consider finding canal morphology variations before starting the treatment. Although the preoperatory radiographies provide a two-dimensional image of a three-dimensional configuration, the interpretations made by the Clark method16 could help, but would not offer detailed images in the case of complex anatomies. In contrast, the cone-beam computed tomography (CBCT) scan is a 3D-noninvasive method, which enables an accurate morphological analysis with reconstruction of dental tissues. Volume 13 Number 4

CASE STUDY

Figure 1: CBCT scan axial sections showing the C-shaped anatomy in multiple teeth (white arrows). 1A. Radicular coronal third. 1B. Radicular middle third. 1C. Radicular apical third

This study reveals outer and inner anatomic details and variations, suggesting the presence of additional roots and root canals. In comparison with some other digital techniques, it offers a means for a better identification of teeth with multiple canals, such as the mandibular first premolars and the maxillary first molars.17,18 The aim of this article is to present a case report of a male patient exhibiting multiple C-shaped canals in the mandibular arch, diagnosed by CBCT imaging, and to assess and classify its morphology.

Case report Patient A 16-year-old Argentine male patient was referred to the School of Dentistry, University of Buenos Aires, in October 2017. A CBCT image of the full mandibular arch was taken, the scan was requested by the professionals’ team in charge of the diagnosis, and resolution of preexisting pathologies that have not been the motive of the following report. Ethical considerations were taken into account. The patient signed the informed consent form, which states that the information and the imaging studies can be utilized for academic or scientific purposes and his identity preserved by the Dentistry School (Resolution (CD) N° 983). Medical and family/social history The patient has no relevant medical background or record of systemic disease. CBCT assessment The image volume has been acquired at the Department of Diagnostic Imaging with a Kodak 9000c 3D tomograph, with 70 kV and 10 mA, exposure time of 32.4 seconds, and a voxel size of 200 µm x 200 µm x 200 µm. The DICOM data was CD recorded for its assessment. CBCT images have been assessed at the Department of Endodontics by two endodontists trained on the observation of tomography slices 20 Endodontic practice

Figure 2: CBCT scan of coronal section of teeth with C-shaped anatomy (white arrows)

Table 1: Mandibular first and second molars — Fan et al. classification (2004) Tooth

Coronal

Middle

Apical

4.7

4.6

C3c

3.7

3.6

C3c

Table 2: Mandibular first and second premolars — Fan et al. classification (2008) Tooth

Coronal

Middle

Apical

4.5

C4b

3.4

C4a

and updated on the knowledge of the inner dental anatomy and the identification of mandibular second molars and mandibular first premolars according to the Fan et al. classifications.13,14 In assessing the full mandibular arch volume, the impacted mandibular canines were observed. The mandibular third molars exhibited incomplete apexification. Likewise, two supernumerary teeth with incomplete apexification were impacted — one in the apical region between the mandibular right first and second premolar, and another between the mandibular right lateral incisor and the mandibular right first premolar. C-shaped canals were observed in the following teeth: mandibular right second molar, mandibular right first molar, mandibular right second premolar, mandibular left first premolar,

mandibular left first molar, and mandibular left second molar (Figures 1 and 2). The assessment was done by thirds — namely, coronal, middle and apical: • coronal, 2 mm apical to the canal/s entrance • apical, 2 mm above the apex • middle, the average distance between coronal and apical No finding has been made in the literature as it concerns the C-shaped canal classification either for mandibular second premolars or for mandibular first molars. For this reason, the four C-shaped mandibular second molars and the two C-shaped mandibular first premolars were classified according to the 2004 and 2008 Fan et al. classifications, respectively.13,14 Tables 1 and 2 show the data obtained. Volume 13 Number 4

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CASE STUDY Discussion Because of the different C-shaped canal prevalence percentages rates shown, it is thought that this case presented is unusual and interesting. Regardless of the extensive literature review, it is estimated that this is the first documented case of a cone-beam image diagnosed patient, exhibiting six C-shaped canals in the same jaw. The prevalence variations of the C-shaped canals can be explained based on the diverse assessment methodologies applied, the different sample sizes, or because of the ethnicity or the geographical region considered. Different studies have assessed mandibular premolar root canal morphology over the years and reported that a quite high percentage of these teeth have more than one canal.4 Lu et al. assessed the mandibular first premolar canal morphology in a Chinese population and reported that 18% of the teeth configuration were C-shaped.3 Baisden et al. studied the cross sections of 106 mandibular first premolars in an American population and found that the C-shaped canal prevalence rate was 14%.4 Sikri and Sikri19 researched the morphology aberrations in the pulp space using the same method and reported that the C-shaped canal prevalence rate in a population of India was 10.7%, while Velmurugan and Sandhya20 noted a 1% prevalence rate. Yang et al.21 encountered only five cases of the 440 first premolars studied (1.14%), and Yu et al.22 found just two cases in 178 first premolars, which is a 1.1% prevalence rate. Having such a scarce number of identified samples, it is difficult to understand the relation of this anatomic condition with some other factors such as sex, localization (right or left side), and bilaterality with the aim of performing a statistical analysis. Martins et al. collected a sample of 2,012 mandibular premolars in a Portuguese population and identified 31 of them having C-shaped canals, the C-shaped configuration prevalence rate being 2.3% and 0.6% of mandibular first and second premolars, respectively.6 This prevalence decreases significantly in mandibular first molars. Some works report an incidence rate ranging from 0.85% in the Turkish23 to 0.6% in the Portuguese.24 Silva et al. observed C-shaped canals in only 12 of 460 first and second molars (2.6%); the C-shaped incidence was 4 of 234 first molars (1.7%) and 8 of 226 second molars (3.5%).25 In mandibular second molars, the highest rates in Northeast Asia were 31.5% in Chinese26 and 32.7% in Koreans,27 and a range of 2.7% to 0.6% variation is described 22 Endodontic practice

Clinicians must consider the C-shaped canal anatomy in multiple presentations as a possibility in the clinical practice. Recognition and classification of C-shaped canals lead to a safer endodontic treatment and predictable outcomes. in the Caucasian population.12,28 Considering the nationality of the patient of this case report, a study made in an Argentine subpopulation evaluating C-shaped canals in mandibular second molars by means of CBCT references an incidence of 20%.29

Conclusion The tomographic finding in this case report is relevant because of the unusual presence of six teeth with C-shaped anatomy in the same jaw. The thorough understanding of the root anatomy complexity helps achieve a better root canal system treatment, optimizing the clinician practice.

Acknowledgments The authors acknowledge the Department of Diagnostic Imaging for providing the CBCT image volume of the present work. EP

REFERENCES 1. Jafarzadeh H, Wu Y-N. The C-shaped root canal configuration: A review. J Endod. 2007;33(5):517-523. 2. Bolger WL, Schindler WG. A mandibular first molar with a C-shaped root configuration. J Endod. 1988;14(10):515-519. 3. Lu TY, Yang SF, Pai SF. Complicated root canal morphology of mandibular first premolar in a Chinese population using the cross section method. J Endod. 2006;32(10):932-936. 4. Baisden MK, Kulild JC, Weller RN. Root canal configuration of the mandibular first premolar. J Endod. 1992;18(10):505-508. 5. Cleghorn BM, Christie WH, Dong CCS. Anomalous mandibular premolars: a mandibular first premolar with three roots and a mandibular second premolar with a C-shaped canal system. Int Endod J. 2008;41(11):1005-1014. 6. Martins JNR, Francisco H, Ordinola-Zapata R. Prevalence of C-shaped configurations in the mandibular first and second premolars: A cone-beam computed tomographic in vivo study. J Endod. 2017;43(6):890-895. 7. Dankner E, Friedman S, Stabholz A. Bilateral C shape configuration in maxillary first molars. J Endod. 1990;16(12):601-603. 8. Bóveda C, Fajardo M, Millan B. Root canal treatment of an invaginated maxillary lateral incisor with a C-shaped canal. Quintessence Int. 1999;30(10):707-711. 9. Ingle JI. Endodontics. 3rd ed. Philadelphia: Lea& Febiger; 1985. 10. Ingle JI, Bakland LK, Baumgartner JC. Ingle’s endodontics 6. 6th ed. Hamilton: BC Decker Inc; 2008. 11. Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular first molar. Oral Surg Oral Med Oral Pathol. 1971;32(5):778-784.

12. Cooke HG, Cox FL. C-shaped canal configurations in mandibular molars. J Am Dent Assoc. 1979;99(5):836-839. 13. Fan B, Cheung G, Fan M, Gutmann J, Bian Z. C-shaped canal system in mandibular second molars: Part I — anatomical features. J Endod. 2004;30(12):899-903. 14. Fan B, Yang J, Gutmann JL, Fan M. Root canal systems in mandibular first premolars with C-shaped root configurations. Part I: Microcomputed tomography mapping of the radicular groove and associated root canal cross sections. J Endod. 2008;34(11):1337-1341. 15. Wu M-K, R’oris A, Barkis D, Wesselink PR. Prevalence and extent of long oval canals in the apical third. Oral Surg Oral Med Oral Pathol, Oral Radiol Endod. 2000;89(6):739-743. 16. Clark CA. A method of ascertaining the relative position of unerupted teeth by means of film radiographs. Proc R Soc Med. 1910;3(Odontol Sect):87-90. 17. Matherne RP, Angelopoulos C, Kulild JC, Tira D. Use of cone-beam computed tomography to identify root canal systems in vitro. J Endod. 2008;34(1):87-89. 18. Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J. 2007;40(10):818-830. 19. Sikri VK, Sikri P. Mandibular premolars: aberrations in pulp space morphology. Indian J Dent Res. 1994;5(1):9-14. 20. Velmurugan N, Sandhya R. Root canal morphology of mandibular first premolars in an Indian population: a laboratory study. Int Endod J. 2009;42(1):54-58. 21. Yang H, Tian C, Li G, Yang L, Han X, Wang Y. A cone-beam computed tomography study of the root canal morphology of mandibular first premolars and the location of root canal orifices and apical foramina in a Chinese subpopulation. J Endod. 2013;39(4):435-438. 22. Yu X, Guo B, Li K-Z, et al. Cone-beam computed tomography study of root and canal morphology of mandibular premolars in a western Chinese population. BMC Med Imag. 2012;12(1):18. 23. Demirbuga S, Sekerci Ae, Dincer An, Cayabatmaz M, Zorba Yo. Use of cone-beam computed tomography to evaluate root and canal morphology of mandibular first and second molars in Turkish individuals. Med Oral Patol Oral Cir Bucal. 2013;18(4):e737-e744. 24. Martins JN, Mata A, Marques D, Caramês J. Prevalence of C-shaped mandibular molars in the Portuguese population evaluated by cone-beam computed tomography. Eur J Dent. 2016;10(3):529-535. 25. Silva EJ, Nejaim Y, Silva AV, Haiter-Neto F, Cohenca N. Evaluation of root canal configuration of mandibular molars in a Brazilian population by using cone-beam computed tomography: an in vivo study. J Endod. 2013;39(7):849-852. 26. von Zuben M, Martins JN, Berti L, et al. Worldwide prevalence of mandibular second molar C-shaped morphologies evaluated by cone-beam computed tomography. J Endod. 2017;43(9):1442-1447. 27. Seo MS, Park DS. C-shaped root canals of mandibular second molars in a Korean population: clinical observation and in vitro analysis. Int Endod J. 2004;37(2):139-144. 28. Weine FS. The C-shaped mandibular second molar: incidence and other considerations. Members of the Arizona Endodontic Association. J Endod. 1998;24(5):372-375. 29. Chaintiou Piorno R, Consoli Lizzi EP, Saiegh J, et al. C-shaped canal system in mandibular second molars evaluated by cone-beam computed tomography in an Argentinean subpopulation. GJMR-J. 2019;19(4):17-23.

Volume 13 Number 4

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CONTINUING EDUCATION

Improving endodontic success through coronal leakage prevention — part 1 Dr. Gregori M. Kurtzman discusses a major determinant of endodontic success or failure Introduction Coronal leakage within the canal system following obturation has been associated with endodontic failure. The literature suggests this is more likely a determinant of clinical success or failure then apical leakage.1-3 Recent advances in obturation materials have shown to provide superior sealing of the canal system. But without addressing the coronal aspect of the tooth following endodontic treatment, endodontic failure still may occur. Studies confirm that a sound coronal seal is of paramount importance to the overall success of root canal treatment.4-7 Regardless of which obturation method or materials used, the best rule is, a properly cleaned, shaped, and obturated tooth should be permanently restored as soon as possible.8 No matter what our intentions are following obturation of the canal system, patients may delay restoration of the tooth that has been endodontically treated. Time and financial constraints often influence when the final restoration may be completed.

Educational aims and objectives

Part 1 of this article aims to show the reader how to mitigate coronal leakage as the major determinant of endodontic success or failure.

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: •

Identify the characteristics of coronal leakage as a major determinant of endodontic success or failure.

•

Identify the predominant bacteria found in endodontically treated teeth undergoing coronal leakage and how this constant source of microorganisms and nutrients can initiate and maintain periradicular inflammation.

•

Recognize that coronal leakage may quickly lead to apical migration of bacteria related to what materials are present in obturating the canal system.

•

Realize that the importance of perfectly sealing coronal restorations (both temporary and permanent) during and following treatment.

•

Realize that when significant coronal breakdown is present or replaced by a previously placed non-adhesively bonded direct restoration, a bonded core placed prior to instrumentation/disinfection and obturation of the canal system can greatly diminish the leakage potential both during and after endodontic therapy.

Additionally, between appointments, an adhesive material will prevent leakage and subsequent contamination of the canal system.

Coronal leakage Dr. Gregori M. Kurtzman, DDS, MAGD, FAAIP, FPFA, FACD, FADI, DICOI, DADIA, is in private general dental practice in Silver Spring, Maryland. He is a former Assistant Clinical Professor at University of Maryland in the department of Restorative Dentistry and Endodontics and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. Dr. Kurtzman has lectured internationally on the topics of restorative dentistry, endodontics and implant surgery and prosthetics, removable and fixed prosthetics, and periodontics. Dr. Kurtzman has published over 700 articles globally, several ebooks, and textbook chapters. He has earned Fellowship in the AGD, American College of Dentists (ACD), International Congress of Oral Implantology (ICOI), Pierre Fauchard, ADI, Mastership in the AGD and ICOI and Diplomat status in the ICOI, American Dental Implant Association (ADIA), and International Dental Implant Association (IDIA). Dr. Kurtzman is a consultant and evaluator for multiple dental companies. He has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006 and was featured on their June 2012 cover. Dr. Kurtzman can be reached at: jdr_ kurtzman@maryland-implants.com Disclosure: Dr. Kurtzman has reported no conflicts of interest with the companies mentioned in this article.

24 Endodontic practice

The literature indicates coronal leakage as the major determinant of endodontic success or failure. No matter what is placed into the canals, if the coronal portion of the tooth is not sealed with materials that are adhesive to tooth structure and are resistant to dissolution by oral fluids, over time, endodontic failure may be inevitable. It is common to have a patient present with marginal decay of a crown that the underlying tooth had prior endodontic treatment. Because the tooth was treated endodontically, sensitivity that may indicate a problem under the crown will not alert the patient to the need to seek dental treatment on that particular tooth. Coronal leakage may quickly lead to apical migration of bacteria even when of short duration, related to what materials are present obturating the canal system and in the coronal aspect of the tooth. When the patient does present,

coronal leakage may have been ongoing for an extended period of time, complicating treatment or rendering the tooth non-restorable necessitating extraction. Significant coronal dye and bacterial leakage following exposure of sealed canal system to artificial and natural saliva leading to complete bacterial leakage may occur within 2 days.9,10 Dye leakage can occur in as little as 3 days as reported in an in vitro study.11-13 It has been suggested that gutta percha does not offer an effective barrier to crown-down leakage when exposed to the oral environment.14-16 Additional studies using gutta percha and various sealers indicate that gutta percha will allow bacterial leakage. Yet, the use of an adhesive sealer may significantly slow or stop coronal-apical bacterial migration related to adhesion of the sealer to the gutta percha cone(s) in the obturation.17 The predominant bacteria found in endodontically treated teeth undergoing coronal leakage with persistent apical periodontitis is Staphylococcus, a gram-positive facultative anaerobe. This is followed by Streptococcus and Enterococcus, all normal salivary flora.18,19 Thus, coronal leakage Volume 13 Number 4

sealers when compared after 45 days exposure to the oral cavity, none of the sealers was capable of preventing leakage and coronal dye penetration.25 So we can see that the quality of both the coronal restoration and obturation material are essential to periapical health as none of the present-day root canal sealers may hermetically seal “the root canal wall — gutta-percha obturation interface.” The importance of perfectly sealing coronal restorations (both temporary and permanent) needs to be emphasized and considered during and following treatment.26

Pre-endodontic therapy buildups (canal projection) Coronal leakage is a major contributor to endodontic failure.27,28 When significant coronal breakdown is present or replaced by a previously placed non-adhesively bonded direct restoration, a bonded core placed prior to instrumentation/disinfection and obturation of the canal system can greatly diminish the leakage potential both during and after endodontic therapy. Isolation of the pulp chamber can be a challenging task when minimal coronal structure remains, and endodontic treatment is required as part of the oral rehabilitation (Figure 1). Coronal reinforcement has traditionally been addressed following the endodontic phase.29 Yet a coronal bonded buildup can simplify the endodontic phase, strengthening the remaining tooth structure. This can decrease the possibility of further damage to the tooth due to dam-clamp placement or functioning on the tooth before

Figures 1 and 2: 1. Severe coronal breakdown of a lower molar requiring endodontic therapy. 2. A Canal Projector placed upon a hand file Volume 13 Number 4

a full coverage restoration can be placed. The Canal Projector core allows isolation of the individual canals by adhesively surrounding them with a resin buildup. Sealing the pulpal floor to the outer periphery of the tooth and surrounding the canal orifices will decrease coronal leakage potential during and following endodontic treatment. Following identification of the canal orifices and caries removal prior to instrumentation of the canals, a Canal Projector cone (CJM Engineering, Santa Barbara, California; www.cjmengineering.com) is placed on a hand file and inserted into each canal. (Figure 2) The Canal Projector cone is pressed into intimate contact with the coronal aspect of the canal orifice with cotton pliers pressed apically on the cone sitting on the file in the canal. A dentin adhesive is placed on all exposed surfaces with a microbrush and light-cured. Addition of a dual-cure activator that matches the dentin bonding agent can be added (following manufacturer’s instructions) should the practitioner chose to ensure complete curing of the adhesive on the deeper aspects of the coronal portion of the endodontic access preparation. Next, a dualcure buildup material is injected around the projector cones, backfilling from the pulpal floor coronally. The placed buildup material is light-cured and then allowed to complete self-cure in the deeper aspects for 3-4 minutes. When the buildup material setting has been completed, the hand files and projectors can be removed leaving straightline access into each individual canal (Figure 3). Visualization of the orifice is elevated to

Figure 3: Coronal pre-endodontic buildup achieved with Canal Projectors providing individual straight-line access into each canal Endodontic practice 25

CONTINUING EDUCATION

provides a constant source of microorganisms and nutrients that can initiate and maintain periradicular inflammation and may well be the largest cause of failure in endodontic therapy.20 Endodontic obturation materials do not prevent coronal microleakage for an indefinite period of time.21 One study reported on a sample of 937 obturated teeth, which had not received restorative treatment during the previous year. The data reported that the technical standard of both coronal restoration and root filling were essential to periapical health.22 It is not uncommon following root canal treatment for coronal leakage as a result of the presence of a deficient composite resin fillings and secondary caries under restorations to occur.23 Yet the endodontic materials utilized over the past 50 years when challenged have shown that they do not prevent coronal leakage. Another study reported on 45 teeth that were cleaned, shaped, and then obturated using a lateral condensation technique with gutta percha and a root canal sealer. The coronal portions of the obturation materials were placed in contact with Staphylococcus epidermidis and Proteus vulgaris. The number of days required for these bacteria to penetrate the entire root canals was determined, with over 50% of the root canals becoming completely contaminated after a 19-day exposure to S. epidermidis. Fifty percent of the root canals were also totally contaminated when the coronal surfaces of their fillings were exposed to P. vulgaris for 42 days.24 AH-26® and other commonly used

CONTINUING EDUCATION

Figure 4: Canal Projectors have been shortened at the coronal aspect back into the pre-endodontic buildup when the endodontic treatment will require more than one appointment

the occlusal plane instead of deep within the tooth, and a bonded seal coronally around each orifice is achieved. When endodontic treatment cannot be completed at the initial visit, following calcium hydroxide (CaOH) placement as a medicament into each canal, the projectors are shortened at the coronal aspect of the cone by 2 mm and are reinserted into the projected canal (Figure 4). A provisional temporary material is then placed over the shortened cone to seal each projected orifice (Figure 5). At the subsequent appointment, the temporary filling material is removed from atop the projector cone, and the cone is removed by threading a hand file into it and tugging it out. When restoring the tooth, if the practitioner wishes to place posts into the tooth, post space preparation is simplified, and misdirection of the post preparation is minimized.

Conclusion Coronal leakage prevention needs to be implemented when endodontic treatment is initiated to maximize the long-term results and prevent reinfection of the canal system after obturation. Frequently, patients may delay restoration of the endodontically treated tooth due to financial reasons, and the old saying “out of pain, out of mind” rings true. Once the pain in the tooth is alleviated, patients are not well motivated to get the tooth restored in some cases. This may lead to coronal leakage at the restorative material placed to temporarily seal the access over the canal system obturation. 26 Endodontic practice

Figure 5: Temporary filling material has been placed over the shortened Canal Projectors placed back into the pre-endodontic buildup to seal the canals between appointments to complete the endodontic treatment

So, with that in mind, engineering the tooth prior to and during the endodontic phase of treatment can aid in coronal leakage prevention until a definitive final restoration can be placed. Part 2 will appear in the Spring 2021 issue. EP

13. Shah S, De R, Kishan KV, et al. Comparative evaluation of sealing ability of calcium sulfate with self-etch adhesive, mineral trioxide aggregate plus, and bone cement as furcal perforation repair materials: An In vitro dye extraction study. Indian J Dent Res. 2019;30(4):573-578. 14. Cohen S, Burns R. Pathways to the Pulp. 8th ed. CV Mosby, New York; 2001. 15. Lone MM, Khan FR, Lone MA. Evaluation of Microleakage in Single-Rooted Teeth Obturated with Thermoplasticized Gutta-Percha Using Various Endodontic Sealers: An In-Vitro Study. J Coll Physicians Surg Pak. 2018;28(5):339-343. 16. Lone MM, Khan FR. Evaluation Of Micro Leakage Of Root Canals Filled With Different Obturation Techniques: An In Vitro Study. J Ayub Med Coll Abbottabad. 2018;30(1):35-39.

REFERENCES 1. Sritharan A. Discuss that the coronal seal is more important than the apical seal for endodontic success. Aust Endod J. 2002;28(3):112-115. 2. Veríssimo DM, do Vale MS. Methodologies for assessment of apical and coronal leakage of endodontic filling materials: a critical review. J Oral Sci. 2006;48(3):93-98. 3. Gillen BM, Looney SW, Gu LS, et al. Impact of the quality of coronal restoration versus the quality of root canal fillings on success of root canal treatment: a systematic review and meta-analysis. J Endod. 2011;37(7):895-902. 4. Begotka BA, Hartwell GR.: The importance of the coronal seal following root canal treatment. Va Dent J. 1996;73(4):8-10. 5. Siqueira JF Jr, Rocas IN, Favieri A, et al. Bacterial leakage in coronally unsealed root canals obturated with 3 different techniques. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(5):647-650 6. Mohajerfar M, Nadizadeh K, Hooshmand T, et al. Coronal Microleakage of Teeth Restored with Cast Posts and Cores Cemented with Four Different Luting Agents after Thermocycling. J Prosthodont. 2019;28(1):e332-e336. 7. Almohareb T. Sealing Ability of Esthetic Post and Core Systems. J Contemp Dent Pract. 2017;18(7):627-632. 8. Pommel L, Camps J. In vitro apical leakage of system B compared with other filling techniques. J Endod. 2001;27(7):449-551. 9. Khayat A, Lee SJ, Torabinejad M. Human saliva penetration of coronally unsealed obturated root canals. J Endod. 1993;19(9):458-461. 10. Balaji S, Kumar K, Venkatesan R, Krishnamoorthy S, Manoharan V, Marimuthu S. Assessment of Coronal Leakage with Two Intracanal Medicaments After Exposure to Human Saliva-An In Vitro Study. Int J Clin Pediatr Dent. 2018;11(5):406-411. 11. Swanson K, Madison S. An evaluation of coronal microleakage in endodontically treated teeth. Part I. Time periods. J Endod. 1987;13(2):56-59. 12. Tabassum S, Khan FR. Failure of endodontic treatment: The usual suspects. Eur J Dent. 2016;10(1):144-147.

17. Britto LR, Grimaudo NJ, Vertucci FJ. Coronal microleakage assessed by polymicrobial markers. J Contemp Dent Pract. 2003;4(3):1-10. 18. Adib V, Spratt D, Ng YL, Gulabivala K. Cultivable microbial flora associated with persistent periapical disease and coronal leakage after root canal treatment: a preliminary study. Int Endod J. 2004;37(8):542-551. 19. Dioguardi M, Di Gioia G, Illuzzi G, et al. Inspection of the Microbiota in Endodontic Lesions. Dent J (Basel). 2019;7(2):47. 20. Leonard JE; Gutmann JL, Guo IY. Apical and coronal seal of roots obturated with a dentine bonding agent and resin. Inter Endod J. 1996; 29(2)76-83. 21. Pisano D, DiFiore P, McClanahan S, Lautenschlager E, Duncan J. Intraorific Sealing of Gutta-Percha Obturated Root Canal to Prevent Coronal Microleakage. J Endod. 1998;24:659-662 22. Parekh B, Irani RS, Sathe S, Hegde V. Intraorifice sealing ability of different materials in endodontically treated teeth: An in vitro study. J Conserv Dent. 2014;17(3):234-237. 23. De Moor R, Coppens C, Hommez G. Coronal leakage reconsidered. Rev Belge Med Dent. 2002;57(3):161-185. 24. Chong BS. Coronal leakage and treatment failure. J Endod. 1995;21(3):159-60. 25. Torabinejad M, Ung B, Kettering JD. In vitro bacterial penetration of coronally unsealed endodontically treated teeth. J Endod. 1990;16(12):566-569. 26. Kopper PM, Figueiredo JA, Della Bona A, et al. Comparative in vivo analysis of the sealing ability of three endodontic sealers in post-prepared root canals. Int Endod J. 2003;36(12):857-863. 27. De Moor R, Coppens C, Hommez G. Coronal. leakage reconsidered. Rev Belge Med Dent. 2002;57(3):161-85. 28. De Moor R, Hommez G. The importance of apical and coronal leakage in the success or failure of endodontic treatment, Rev Belge Med Dent. 2000;55(4):334-44. 29. Kurtzman GM. Restoring Teeth with Severe Coronal Breakdown as a Prelude to Endodontic Therapy. Endodontic Therapy; 2004.

Volume 13 Number 4

REF: EP V13.4 KURTZMAN

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Improving endodontic success through coronal leakage prevention — part 1 KURTZMAN

1. No matter what is placed into the canals, if the coronal portion of the tooth is not sealed with materials that are _______, over time, endodontic failure may be inevitable. a. adhesive to tooth structure b. resistant to dissolution by oral fluids c. dissolvable by oral fluids d. both a and b 2. Significant coronal dye and bacterial leakage following exposure of sealed canal system to artificial and natural saliva leading to complete bacterial leakage may occur within _______. a. 2 days b. 4 days c. 1 week d. 12 days 3. It has been suggested that gutta percha ________ to crown-down leakage when exposed to the oral environment. a. offers an effective barrier b. does not offer an effective barrier c. offers the best possible barrier d. is the preferred preventative

8. 5. (In the study cited in Chong BS, Coronal Leakage and Treatment Failure)The number of days required for these bacteria to penetrate the entire root canals was determined, with over _____ of the root canals becoming completely contaminated after a 19-day exposure to S. epidermidis. a. 25% b. 50% c. 65% d. 70% 6. The quality of ________ is/are essential to periapical health as none of the present-day root canal sealers may hermetically seal “the root canal wall — guttapercha obturation interface.” a. the coronal restoration b. obturation material c. patient’s oral hygiene d. both a and b 7.

4. The predominant bacteria found in endodontically treated teeth undergoing coronal leakage with persistent apical periodontitis is ________. a. Staphylococcus

Volume 13 Number 4

c. can be a challenging task d. is impossible

b. Streptococcus c. Enterococcus d. Pneumococcus

Isolation of the pulp chamber ________ when minimal coronal structure remains, and endodontic treatment is required as part of the oral rehabilitation. a. is a simple task b. should not be considered

(After a dual-cure buildup material is injected around the projector cones) The placed buildup material is light-cured and then allowed to complete self-cure in the deeper aspects for ______. a. 1-2 minutes b. 3-4 minutes c. 5-6 minutes d. 7-8 minutes

9. When endodontic treatment cannot be completed at the initial visit, following calcium hydroxide (CaOH) placement as a medicament into each canal, the projectors are shortened at the coronal aspect of the cone by ______ and are reinserted into the projected canal. a. 1 mm b. 2 mm c. 3 mm d. 4 mm 10. At the subsequent appointment, the temporary filling material is removed from atop the projector cone, and the cone is removed by _______ and tugging it out. a. threading a hand file into it b. using a high-speed handpiece c. using a low-speed handpiece d. none of the above

Endodontic practice 27

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Treatment of mandibular first molars with atypical anatomy: a case report Drs. Yurii Riznyk and Svitlana Riznyk present a challenging case demonstrating the importance of locating all root canals

30-year-old female patient presented with symptomatic irreversible pulpitis of both LR6 and LL6 teeth. Cone beam computed tomography (CBCT) of the region revealed a middle mesial canal (MMC) in tooth LR6, and a middle distal canal in tooth LL6. The case was managed with K-Files (Dentsply Maillefer), K-File Nitiflex (Dentsply Maillefer), ProTaper Next® (Dentsply Maillefer), XP-endo® Shaper (FKG), and BT-Race (FKG) under copious irrigation with sodium hypochlorite, ethylenediaminetetraacetic (EDTA) acid, and saline. Premixed bioceramic sealer TotalFill® (FKG) and gutta percha were used for root canal obturation. The access cavities were restored using glass ionomer cement and resin composite. A 12-month review showed that the teeth were functional within normal periodontal parameters. The favorable clinical and radiographic outcome in this case demonstrated that the treatment approach followed is effective in solving complex clinical challenges.

Introduction The main objective of endodontic therapy is a thorough debridement of the root canal space followed by complete obturation (Vertucci, 2005). The latest advances in the instrumentation techniques and equipment have enabled us to solve difficult clinical cases in endodontics (Berutti, et al., 2009). At the same time, regardless of the continuous improvement in technology, the thorough knowledge of the internal anatomy of the pulp chamber and the root canal system is critical to increasing the rate of clinical

Educational aims and objectives

This article aims to show the reader successful management of a case with unusual anatomy of the root canal system of first lower molars.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 33 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: •

Recognize the importance of using a cone beam computed tomography to evaluate the complexity of the morphology of teeth before the endodontic treatment.

•

Identify the characteristics and types of the middle mesial canal (MMC).

•

Recognize that endodontic treatment of mandibular molars requires a high level of knowledge and clinical skills due to their anatomical variations.

•

Realize that missed root canals are a possible cause of failure in previous root canal treatment of first lower molars.

•

Realize that teeth with atypical canal configuration complicate the process of identifying and accessing root canals in the endodontic treatment.

success of endodontic treatment (Fava, 2001; Vertucci, 2005). The failure of the treatment could be the result of failure to recognize any unusual canal configuration, as well as prepare and perform the proper obturation of the missed root canals (Leonardo, 1998; Almeida, et al. 2015). This assertion may be confirmed by the research of Song, et al. (2011), who reported that 30% of possible causes of failure in the previous root canal treatment of first lower molars were missed root canals.

Dr. Yurii Riznyk is assistant of the restorative dentistry department at Danylo Halytsky Lviv National Medical University, Lviv, Ukraine. In 2012, he was co-winner of the Ukrainian Endodontic Association competition “Art of Endodontic Treatment.” Dr. Svitlana Riznyk works in the therapeutic dentistry department of Lviv Medical Institute, Lviv, Ukraine.

Figure 1 28 Endodontic practice

In most of the cases, the first mandibular molar has two roots with two root canals in the mesial root and one canal in the distal root (Vertucci, et al., 2006; de Pablo, et al., 2010). In the endodontic treatment of the first mandibular molar, the main difficulty is the mesial root, which may have an additional middle root canal — middle mesial canal (MMC), located in the developmental groove between the mesiolingual (ML) and the mesiobuccal (MB) canals. According to studies, the third canal in the mesial root can be found up to 18% of cases (Pomerantz, et al., 1981; Navarro, et al., 2007; de Pablo, et al., 2010; Versiani, et al., 2016). The MMC is categorized into three types: Fin, independent, and confluent (Pomerantz, et al., 1981): 1. Fin type lacks a separate orifice. It is usually a small linear extension of MB or ML canal. 2. A separate orifice and separate apex are specific to this independent type. 3. The confluent type is characterized by a separate orifice, but it merges with either the MB or the ML canal. The research found that confluent configuration is the most prevalent anatomic configuration (Versiani, et al., 2016). Most of Volume 13 Number 4

investigations for sinus tract and periodontal involvement were negative. The preoperative sagittal section of CBCT (Figure 1) revealed radiolucency on the occlusal surface of the crown approaching the pulp space in the LR6. The coronal sections of CBCT of the mesial (Figure 2) and distal roots (Figure 3) revealed two root canals in each of them. The axial section (Figure 4) confirmed MMC in the tooth LR6. A diagnosis of symptomatic irreversible pulpitis was made, based on the clinical and radiographic examination, and we recommended conservative endodontic treatment. The patient declined alternative treatment methods. After administration of conductive anesthesia (Ubistesin™ 4% 1:100000; 3M Oral Care) and rubber dam isolation of the operative area, we performed access to the pulp

chamber using long neck drills and ultrasonic tips. The pulp chamber was rinsed with 6% sodium hypochlorite (NaOCl). We used staining with methylene blue dye and MicroOpener 15.04 (Dentsply Maillefer) under the optical magnification to examine the pulp chamber floor. After access preparation and a careful analysis of the floor, we found two root canals in the mesial roots and two root canals in distal ones. The orifice of the MMC was found after the developmental groove preparation by the ultrasonic tip in the mesial root between the previously identified ML and MB canals. It is necessary to remember that diameter of the MMC canal is smaller in comparison with the ML and MB canals, and due to the anatomical danger zones, it requires more careful preparation (De-Deus, et al., 2019; Keles, et al., 2020).

Figures 2-4

Case report A 30-year-old female patient was referred to the clinic with the chief complaint of spontaneous pain in the lower right region of the jaw for 3 days previous. The patient’s medical and family history was non-contributory. On clinical examination, a deep carious lesion was seen in tooth LR6. Thermal testing of the right mandibular first molar caused intense lingering pain. Percussion and palpation in the region of this tooth were painless, and Volume 13 Number 4

Figure 5 Endodontic practice 29

CONTINUING EDUCATION

the MMC orifices are at the cementoenamel junction (CEJ) level; however, it may also be detected at 1 mm and 2 mm depths from the CEJ and even deeper (Keleş & Keskin, 2017), and may need an additional groove preparation. There are also reports of the presence of three root canals in the distal root, with the incidence of 0.2%-3% (Kottoor, et al., 2010). Analyzing the morphology of the mesial root, Type IV, according to Vertucci classification, was most often identified — 52.3%, and Type II in 35% of cases (de Pablo, et al., 2010). In the distal root, the most often identified type was Type I — 62.7%, and Type II — 14.5% (de Pablo, et al., 2010). The usage of the intraoral radiographs, a dental operating microscope, a sharp explorer, and staining with methylene blue dye are commonly accepted principles for primary endodontic treatment (de Carvalho and Zuolo, 2000; Chavda and Garg, 2016). However, radiographs provide a very simple two-dimensional image, hiding the complex structure of root canals, making the evaluation of the morphological structure of the molars complex and challenging. At the same time, the use of 3D analysis has undeniable advantages in the identification of morphological variations of teeth (Durack and Patel, 2012; de Paula, et al., 2013). Nevertheless, the use of this method is limited for the primary endodontic treatment due to the ALARA principle, which states that every effort should be made by professionals to keep the patient’s exposure to ionizing radiation as low as practically possible (Farman, 2005). In this case report, the preoperative 3D examination and CBCT 1-year after the treatment were not performed for the endodontic treatment of teeth LL6 and LR6, but for the examination, diagnosis, planning, and evaluation of results of surgical treatment on the mandible. The technique enabled to evaluate the complexity of the morphology of lower molars before the endodontic treatment.

CONTINUING EDUCATION

Figures 6-9

We negotiated canals, and established patency at working length with 10 K-File (Dentsply Maillefer) using an iPex apex locator (NSK, Japan) and confirmed with radiographs. A size 15 K-File Nitiflex (Dentsply Maillefer) was used to perform the glide path. Then we conducted the shaping of the root canals using the ProTaper Next X1 (Dentsply Maillefer) instrument, followed by the XP-endo Shaper (FKG), and 35/.04 BT-Race (FKG). At each change of the endodontic instrument, we irrigated the canals with a 6% NaOCl. For better purification of the isthmus, the Micro-Debriders (Dentsply Maillefer) were used. At the end of preparation, we applied 17% ethylenediaminetetraacetic acid (EDTA) for 1 minute to remove the smear layer and performed the irrigation with a copious volume of 6% NaOCl. XP-endo finisher (FKG) was used within 15 seconds to activate all of the solutions, applying slow, gentle longitudinal movements of 7 mm-8 mm to cover the entire length of the canal. Before the obturation, we rinsed all canals with saline. All master cones were

processed antiseptically, fitted, and set on a working length. The canals were partially dried with paper points and obturated by cold hydrodynamic obturation technique of gutta percha and premixed bioceramic sealer Totalfill (FKG). We cleaned the pulp chamber in order to remove the excess of gutta percha and bioceramic sealer, temporarily restored the tooth with resin composite, and made the posttreatment radiograph of tooth LR6 (Figure 5). Then we referred the patient for the permanent restoration of tooth LR6. We were able to evaluate the complexity of the morphology of tooth LR6 and its obturation, with the CBCT (Planmeca ProMaxÂŽ, Finland) of the mandible 1 year after the treatment (Figures 6-9). In the medial system, the pulp space separates into three canals, and two of them join into one during its course to exit as two root canals (Figure 7), which are the 3-2 type according to the classification of the root canal morphology (Gulabivala, et al., 2001; Sert and Bayirli, 2004; Bansal, et al., 2018). In the distal system (Figure 8), two canals run separately from orifice to apex, which

corresponds to the Type 2-2 classification of root canals morphology (Vertucci, 1984; Weine, et al., 1988; Bansal, et al., 2018). Axial CBCT slice of tooth LR6 confirmed three root canals in the medial and two root canals in distal roots (Figure 9). In a short while, the same patient was referred to the clinic with the chief complaint of intermittent moderate pain in the lowerleft region of the jaw. On clinical examination, we could see a deep carious lesion in tooth LL6. Pulp thermal testing caused intense, extended pain. The percussion test of the tooth LL6 was negative. The tooth was apically painless to palpation. The periodontal probing near LL6 was within the physiological norm. A preoperative sagittal section of CBCT (Figure 10) revealed radiolucency on the occlusal surface of the crown, approaching the pulp space in the LL6. The coronal sections of CBCT showed two root canals of the medial root (Figure 11) and two main canals in the distal root (Figure 12). The axial sections (Figure 13) confirmed MDC in the tooth LL6.

Figures 10-13 30 Endodontic practice

Volume 13 Number 4

CONTINUING EDUCATION

Figures 14-15

All clinical signs indicated the symptomatic irreversible pulpitis, and conservative endodontic treatment was recommended. The patient declined alternative treatment methods, so we carried out the treatment of tooth LL6 according to the same main principle as mentioned above. After anesthesia (Ubistesin 4% 1:100000; 3M Oral Care) and rubber dam isolation of the operative area, we gained access to the pulp chamber. Then we investigated the bottom of the pulp chamber with MicroOpener 15.04 (Dentsply Maillefer) under the optical magnification. The pulp chamber was antiseptically processed. As in the previous case, during the examination of the bottom of the pulp chamber, we found two root canals in the mesial roots and two root canals in distal ones. Based on the CBCT data, we made the preparation of the developmental groove in the distal root between the identified DL and DB canals, and the orifice of the MDC was found approximately 3 mm below the CEJ. Afterward, we negotiated canals, and established patency at working length with 10 K-File (Dentsply Maillefer) using an iPex apex locator (NSK, Japan) and confirmed with radiographs. A size 15 K-File Nitiflex (Dentsply Maillefer) was used to perform the glide path. The mechanical instrumentation of the root canals was performed using the 10/.06 BT-Race (FKG) instrument followed the XP-endo Shaper (FKG), and 35/.04 BT-Race (FKG) with isthmus cleaning with the Micro-Debriders (Dentsply Maillefer). At each change of instrument, we irrigated the canals with a 6% NaOCl. At the final stage of Volume 13 Number 4

Figures 16-18

biomechanical preparation, 17% EDTA was applied for one minute succeeded by the copious amount of 6% NaOCl. To activate the solutions we used the XP-endo Finisher (FKG). Before the obturation, all canals were rinsed with saline. We processed all master cones antiseptically, then fitted and set them on a working length. The canals were partially dried with paper points, and we carried out the cold hydrodynamic obturation technique of gutta-percha and bioceramic sealer TotalFill (FKG) to obturate them. The cleaning of the pulp chamber was performed, and glass-ionomer cement and resin composite were applied to temporarily restore the tooth. We made the posttreatment radiograph of tooth LL6 (Figure 14). Then the patient was referred for the permanent restoration of tooth LL6.

The patient was recalled at 6 and 12 months postoperatively. At follow-up appointments, the LL6 and LR6 teeth were asymptomatic and functional. We used the same CBCT (Planmeca ProMax, Finland) of the mandible to evaluate the complexity of the morphology of tooth LL6 and its obturation, 1 year after the treatment (Figures 15-18). In the mesial system, two separate root canals with separate orifices and two separate apexes (Figure 16) correspond to the Type 2-2 morphology of root canals system (Vertucci, 1984; Weine et al., 1988; Bansal et al., 2018). Distal root canals correspond Type 2-3-1: two canals divide into three and then during its course unite into one (Sert and Bayirli, 2004; Al-Qudah and Awawdeh, 2009; Bansal, et al., 2018). Root canals overlap one another on the postoperative radiograph Endodontic practice 31

CONTINUING EDUCATION (Figure 14). Axial slice of CBCT tooth LL6 confirmed two root canals in mesial and three root canals in the distal roots (Figure 18).

Discussion Endodontic treatment of mandibular molars requires a high level of knowledge and clinical skills due to their anatomical variations. One of the studies claimed that middle mesial canal can be the sequelae of instrumenting the isthmus between the mesiobuccal and mesiolingual canals rather than an extra canal (Mortman and Ahn, 2003). However, according to the more recent studies, the true third canal in the mesial root of the mandibular first molar was found up to 18% (Navarro, et al., 2007; de Pablo, et al., 2010; Versiani, et al., 2016), and 0.2-3% in the distal root (Kottoor, et al., 2010). Teeth with atypical canal configuration complicate the process of identifying and accessing root canals in the endodontic treatment. CBCT has the ability to overcome the limitations of conventional radiography such as three-dimensional evaluation of the complex canal anatomy during endodontic treatment (Durack and Patel, 2012; de Paula, et al., 2013), but it is necessary to remember that in usual practice, a posttreatment CBCT must be confirmed by appropriate indications and meet with current guidelines regarding ALARA. The dental operating microscope is necessary for the detection of accessory canals in mandibular molars (de Carvalho and Zuolo, 2000; Karapinar-Kazandag, et al., 2010). At the present stage of the development of endodontics, it is impossible to carry out a complete cleaning of the root canal system. When flat or curved root canals with oval cross sections are considered, the most current rotary nickel-titanium file systems will not adequately clean and shape the canal with favorable results (Metzger, et al., 2010). Therefore, an endodontic file should be used that adapts to the natural morphology of the root canals and efficiently cleans it. Appropriate shaping and cleaning of the root canal system with the XP-endo Shaper and XP-endo Finisher instruments used for this clinical case have the potential to improve root canal system cleaning (Azim, et al., 2016; Azim, et al., 2017).

Conclusion Professionals should always consider morphological variations of the root canal 32 Endodontic practice

The latest advances in the instrumentation techniques and equipment have enabled us to solve difficult clinical cases in endodontics. At the same time, regardless of the continuous improvement in technology, the thorough knowledge of the internal anatomy of the pulp chamber and the root canal system is critical to increasing the rate of clinical success of endodontic treatment.

system before the beginning of treatment. This case report reinforces the importance of using cone beam computed tomography to evaluate the complexity of the morphology of teeth before the endodontic treatment. The favorable clinical and radiographic outcome in this case demonstrated that the treatment approach followed in the present case is effective in solving complex clinical challenges. EP

14. Fava LRG. Root canal treatment in an unusual maxillary first molar: a s case report. Int Endod J. 2001;34(8):649-653.

REFERENCES

19. Kottoor J, Sudha R, Velmurugan N. Middle distal canal of the mandibular first molar: a case report and literature review. Int Endod J. 2010;43(8):714-722.

1. Almeida G, Machado R, Sanches Cunha R, Vansan LP, Neelakantan P. Maxillary first molar with 8 root canals detected by CBCT scanning. Gen Dent. 2015;63(2):68-70. 2. Al-Qudah AA, Awawdeh LA. Root and canal morphology of mandibular first and second molar teeth in a Jordanian population. Int Endod J. 2009;42(9):775–784.

15. Gulabivala K, Aung TH, Alavi A, Ng YL. Root and canal morphology of Burmese mandibular molars. Int Endod J. 2001;34(5):359-370. 16. Karapinar-Kazandag M, Basrani BR, Friedman S. The operating microscope enhances detection and negotiation of accessory mesial canals in mandibular molars. J Endod. 2010; 36(8):1289-1294. 17. Keleş A, Keskin C. Detectability of middle mesial root canal orifices by troughing technique in mandibular molars: a micro–computed tomographic study. J Endod. 2017;43(8):1329-1331. 18. Keleş A, Keskin C, Alqawasmi R, Versiani M. Evaluation of dentine thickness of middle mesial canals of mandibular molars prepared with rotary instruments: a micro-CT study. Int Endod J. 2020;53(4):519-528.

20. Leonardo MR. Aspectos anatomicos da cavidade pulpar: relacoes com o tratamento de canais radiculares. In: Leonardo MR, Leal JM eds. Endodontia: tratamento de canais radiculares. 3rd ed. São Paulo: Panamericana; 1998.

3. Azim AA, Aksel H, Zhuang T, et al. Efficacy of 4 irrigation protocols in killing bacteria colonized in dentinal tubules examined by novel confocal laser scanning microscope analysis. J Endod. 2016;42(6): 928-934.

21. Metzger Z, Zary R, Cohen R, Teperovich E, Paque F. The quality of root canal preparation and root canal obturation in canals treated with rotary versus self-adjusting files: a three-dimensional micro-computed tomographic study. J Endod. 2010;36(9):1569-1573.

4. Azim AA, Plasecki L, da Silva Neto UX, Cruz ATG, Azim KA. XP-Shaper, a novel adaptive core rotary instrument: Microcomputed tomographic analysis of its shaping abilities. J Endod. 2017;43(9):1532-1538.

22. Mortman RE, Ahn S. Mandibular first molars with three mesial canals. Gen Dent. 2003;51(6):549-551.

5. Bansal R, Hegde S, Astekar MS. Classification of root canal configurations: A review and a new proposal of nomenclature system for root canal configuration. Journal of Clinical and Diagnostic Research. 2018;12(5):1-5. 6. Berutti E, Cantatore G, Castellucci A, et al. Use of nickeltitanium rotary PathFile to create the glide path: comparison with manual preflaring in simulated root canals. J Endod. 2009;35(3):408–412. 7. Chavda SM, Garg SA. Advanced methods for identification of middle mesial canal in mandibular molars; an in vitro study. Endodontology. 2016;28(2):92-96. 8. de Carvalho MC, Zuolo ML. Orifice locating with a microscope. J Endod. 2000;26(9):532-534. 9. De-Deus G, Rodrigues EA, Belladonna FG, et al. Anatomical danger zone reconsidered: a micro-CT study on dentine thickness in mandibular molars. Int Endod J. 2019;52(10):1501-1507 10. de Pablo OV, Estevez R, Péix Sánchez M, Heilborn C, Cohenca N. Root anatomy and canal configuration of the permanent mandibular first molar: a systematic review. J Endod. 2010;36(12):1919-1931. 11. de Paula AF, Brito-Júnior M, Quintino AC, et al. Three independent mesial canals in a mandibular molar: Four-year follow-up of a case using cone beam computed tomography. Case Rep Dent. 2013. 12. Durack C, Patel S. Cone beam computed tomography in endodontics. Br Dent J. 2012;23(3):179-191. 13. Farman AG. ALARA still applies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100(4): 395-397.

23. Navarro LF, Luzi A, Garcia AA, Garcia AH. Third canal in the mesial root of permanent mandibular first molars: review of the literature and presentation of three clinical reports and two in vitro studies. Med Oral Patol Oral Cir Bucal. 2007;12(8):605-609. 24. Pomerantz HH, Eidelman DL, Goldberg MG. Treatment considerations of the middle mesial canal of mandibular first and second molar. J Endod. 1981;7(12):565-568. 25. Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod. 2004;30(6):391-398. 26. Song M, Kim HC, Lee W, Kim E. Analysis of the cause of failure in nonsurgical endodontic treatment by microscopic inspection during endodontic microsurgery. J Endod. 2011;37(11):1516-1519. 27. Versiani MA, Ordinola-Zapata R, Keleş A, et al. Middle mesial canals in mandibular first molars: a micro-CT study in different populations. Arch Oral Biol. 2016;61:130-137. 28. Vertucci F. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol. 1984; 58(5):589-599. 29. Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics. 2005;10:3-29. 30. Vertucci FJ, Haddix JE, Britto LR. Tooth morphology and access cavity preparation. In: Cohen S, Hargreaves KM, eds. Pathways of the pulp. 9th ed. St. Louis MO: Mosby; 2006. 31. Weine FS, Pasiewicz RA, Rice RT. Canal configuration of the mandibular second molar using a clinically oriented in vitro method. J Endod. 1988;14(5):207-213.

Volume 13 Number 4

REF: EP V13.4 RIZNYK

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TELEPHONE/FAX

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

Treatment of mandibular first molars with atypical anatomy: a case report RIZNYK

1. The failure of the (endodontic) treatment could be the result of ________. a. failure to recognize any unusual canal configuration b. failure to prepare for the proper obturation of the root canals c. failure to perform the proper obturation of the missed root canals d. all of the above 2. The research of Song, et al. (2011), reported that ______ of possible causes of failure in the previous root canal treatment of first lower molars were missed root canals. a. 10% b. 30% c. 50% d. 62% 3. According to studies, the third canal in the mesial root can be found up to ______ of cases. a. 18% b. 28% c. 38% d. 48% 4. In the middle mesial canal (MMC), Fin type ____.

Volume 13 Number 4

a. b. c. d.

has a separate orifice is the most prevalent anatomic configuration lacks a separate orifice never needs additional groove preparation

5. In the middle mesial canal (MMC), the independent type has _______. a. a separate orifice b. a separate apex c. an attached orifice d. both a and b

8. The use of this method (3D CBCT imaging) is limited for the primary endodontic treatment due to the ___, which states that every effort should be made by professionals to keep the patientâ&#x20AC;&#x2122;s exposure to ionizing radiation as low as practically possible. a. Justification principle b. Radiation optimization principle c. ALARA principle d. Direct Benefit Principle

6. The usage of the intraoral radiographs, _______ are commonly accepted principles for primary endodontic treatment. a. a dental operating microscope b. a sharp explorer c. staining with methylene blue dye d. all of the above

9. For this patient, before the obturation, all canals were rinsed with _______. a. saline b. ethanol c. citric acid d. spring water

7. The use of 3D analysis has undeniable advantages in ________. a. providing a process with no ionizing radiation b. the identification of morphological variations of teeth c. providing the best 2D image d. being the only type of imaging allowable for endodontic radiography

10. This case report reinforces the importance of using ______ to evaluate the complexity of the morphology of teeth before the endodontic treatment. a. 2D radiography b. cone beam computed tomography c. microscopy d. special dyes

Endodontic practice 33

CE CREDITS

ENDODONTIC PRACTICE CE

PRODUCT PROFILE

Advanced endodontics with Fotona’s new SkyPulse® Laser Dr. Valerie Kanter discusses a clinically effective photoacoustic effect for endodontic treatment

ver 15 million root canal procedures are being performed each year. And for years, dental practitioners have used traditional methods to treat them. But today, research studies are showing that root canal irrigation is more effective and patientfriendly when treated with a laser. With traditional methods, oral infections can happen because microorganisms had not been eliminated from the root canal systems, allowing for recontamination to occur after treatment. In severe cases, studies have shown that oral infections can also affect a

patient’s cardiovascular health. It is for this reason that many dental practitioners are upgrading their practices to include a laser. In my practice, I use the Fotona LightWalker Dental Laser and Fotona’s newest endodontic laser, the SkyPulse®. Having the SkyPulse® laser allows me to offer technology that preserves the integrity of my patients’ teeth, improve healing times, and increases precision during treatment. I added the SkyPulse® to my arsenal of treatment tools because it can produce exceptionally low-energy and short-duration laser pulses optimized to generate a Valerie Kanter, DMD, MS, graduated from the University of Florida College of Dentistry with a specialty in endodontics and then moved to Los Angeles, where she established a reputation for outstanding patient-centered care. She teaches at the UCLA School of Dentistry. Dr. Kanter is a Board-certified endodontist with a passion for providing safe and effective biological treatments that relieve pain, preserve and regenerate natural teeth whenever possible, and improve the health and well-being of her patients.

34 Endodontic practice

clinically effective photoacoustic effect for endodontic treatment using a method called SWEEPS® (Shock Wave Enhanced Emission Photoacoustic Streaming). It’s equipped with a 2940nm Er:YAG and offers two additional high-performance diode module accessories to provide a wide range of both soft and hard tissue treatment options. In addition to endodontic applications, it has proven success in periodontics, implantology, and soft-tissue surgery applications. For me, having SWEEPS® is essential to my patient root canal treatment plan. SWEEPS® is a revolutionary method for chemically cleaning and debriding the complex root canal system using Er:YAG laser energy at sub-ablative power levels for a more thorough and precise irrigation. The minimally invasive instrumentation preserves more of the natural tooth structure and thereby improves strength and integrity. Using synchronized pairs of ultra-short pulses, an accelerated collapse of laser-induced bubbles is achieved, leading to enhanced shockwave emission inside even the narrowest root canals. The precise waves of energy thoroughly clean the complex root canal system that traditional methods can sometimes miss. The containment of the shockwaves thoroughly streams these solutions through the entire canal system, enhancing their effectiveness. The canals and subcanals are left clean, and the dentinal tubules are free of smear layer.

The effectiveness of SWEEPS® should not be underestimated, as it is not uncommon for me to be able to save a patient’s tooth, even when it was deemed to be a loss with traditional treatment methods. SWEEPS® is equally effective for final water rinsing prior to obturation. After sealing the canal, the restoration can be completed finishing off with 1064nm laser photobiomodulation. What do you want in your practice that benefits a patient’s comfort and decreases pain? In my practice and for my patients, it’s photobiomodulation. Having the 1064nm wavelength there to help stimulate healing after my procedures is profoundly different than anything that I have experienced in dentistry. It helps ensure that my patients are comfortable when they leave the office after a treatment. This laser treatment is far more advanced than traditional irrigation procedure methods because the shockwaves generate cleaning solutions that travel throughout the entire root canal system, disrupt biofilms, and eliminate bacteria that would otherwise be left behind to continue to pose a risk on the health of the tooth and patient as a whole. The powerful combination of Fotona’s SkyPulse® Endo laser and its SWEEPS® treatment represents a unique and highly effective solution for modern endodontics improving irrigation and disinfection. This method represents an entirely new way of thinking about root canal therapy with patients receiving fast, safe, and effective root canal treatments. EP Volume 13 Number 4

AUTHOR GUIDELINES Endodontic Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world. Endodontic Practice US is designed to be read by specialists in Endodontics, Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Endodontic Practice US requires original, unpublished article submissions on endodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Endodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to endodontics. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 13 Number 4

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

Endodontic practice 35

SERVICE PROFILE

Next-level strategies to protect your dental practice Bre Cohen discusses preparing your practice for unforeseen risks

t’s safe to say COVID-19 has hit the dental industry hard. Having to close doors for months can be a big blow to any practice; and while traditional insurance is great, chances are it didn’t cover your business interruption during this pandemic. So, how will you handle the next adverse event? That thought makes many cringe and for good reason. However, entrepreneurial dental practices are finding ways to protect their business risks that fall outside of traditional insurance through Enterprise Risk Management programs like those from Strategic Risk Alternatives. These programs are nothing new; they’ve been utilized by Fortune 500 Companies for decades. Strategic Risk Alternatives saw a need in the market to make these programs available to small-tomidsize companies and did just that. Their Enterprise Risk Management program serves as a lifeline to successful companies going through a difficult time and allows them to be proactive instead of reactive in protecting their practices.

How does it work? Much like a 401(k) helps you use taxadvantaged dollars to prepare for retirement, the Enterprise Risk Management program by Strategic Risk Alternatives helps you use taxadvantaged dollars to prepare for unforeseen risk. It utilizes US Tax Code 831(b), which Bre Cohen is the Business Development and Marketing Manager for Strategic Risk Alternatives.

36 Endodontic practice

The Enterprise Risk Management program serves as a lifeline to successful companies going through a difficult time and allows them to be proactive in protecting their practice instead of reactive. helps businesses set tax-deferred income aside for risks that fall outside of traditional insurance. This includes COVID-19-type disruptions as well as other cash flow disruptions. Examples follow: • Contingent business interruption • Political risk • Supply chain interruption • Key employee loss/critical illness • Payroll protection • and more … Strategic Risk Alternatives serves as 831(b) plan administrators to help you identify risks, create a customized plan, manage transactions, monitor compliance, prepare paperwork, and other ongoing client services to ensure you are prepared for the next unforeseen risk. “When COVID-19 hit, dental practices currently utilizing our program were able to recoup cash flow losses in a matter of days through their 831(b). If you own a successful practice, consider the advantages of setting pre-taxed dollars aside for unforeseen risks — big or small,” says Bill McKernan, President of Business Development at Strategic Risk Alternatives. “Unforeseen risk is real, and it happens every single day. It could be something as big as the next pandemic or as small as being out of work for a short period of time due to a medical issue. With our

program, you’re able to make your practice whole again and rest a little easier at night.”

Other programs for dental practices Strategic Risk Alternatives also offers a Dental Protection Plan program to help practices warranty their work. With a clearly defined warranty, you can increase patient retention and use pre-tax dollars to pay for rework. Strategic Risk Alternatives works with the practice to custom-design a defined warranty program based on their individual practice needs. Through this program, the practice would set aside money from transactions and put it in their 831(b) Dental Protection Plan to fund warranties for their work. Depending on the terms the dentist sets, the warranty may require a patient to come back once a year to check the work and honor the warranty. This creates customer peace of mind, retention, and loyalty. In addition, you are building a war chest to pay for any issues that do arise. Interested in learning more? Contact Strategic Risk Alternatives by visiting their website, strategicriskalternatives.com/DPP, or calling Bill or Ed at (208) 424-2249 for a free assessment and to learn more about protecting what you have worked so hard to build. EP Volume 13 Number 4

SERVICE PROFILE

Large Practice Sales (LPS) helps dental professionals of all specialties monetize their life’s work Top 10 reasons endodontists choose an Invisible Dental Support Organization (IDSO) partner

he opportunities for endodontists to monetize a part of their practice with a silent partner, an Invisible Dental Support Organization (IDSO), have never been greater than today. Thanks to your performance during the COVID-19 era, endodontic practices are now the most valuable of all dental specialists. This may or may not last, but there are at least eight endodontist-only IDSOs that have been formed in the past 2 years. They are eagerly contacting endodontists around the country, attempting to do deals directly with doctors. In addition, the multi-specialty IDSOs also have a renewed interest. The smart doctors will generate a bidding contest among all of the good ones to achieve the highest values with the best partners! In a typical transaction, an IDSO will buy between 60% and 90% of a practice for cash up front. Doctors retain ownership of the balance and continue operating the practice under their brand, team, and strategy. The goal is to use the resources of a larger, silent partner to help the practice grow bigger, faster, and more profitably, benefiting both partners. Doctors also have significant upside potential in the value of their retained ownership. While an IDSO partnership is not a fit for all doctors, it can secure a doctor’s future and provide opportunities for wealth creation far beyond individual practice ownership. In addition, doctors can be relieved of operational headaches.

Top 10 reasons to partner with an IDSO 1. Financial security and asset diversification. Typically, doctors’ largest asset is their practice. Liquifying only

The goal is to use the resources of a larger, silent partner to help the practice grow bigger, faster, and more profitably, benefiting both partners.

a part of the practice can secure most doctors’ financial futures. Reduced administrative headaches and burdens. Doctors can focus on patient care and growth rather than management minutiae. Enhanced patient care. IDSOs can heighten patient-centered care through collaboration and education as a part of a larger group of practices. Improved practice profitability. Bigger is better in the purchasing of equipment, supplies, and team benefits. IDSOs can also have leverage to negotiate higher reimbursement rates from payors. Recruiting of doctors and team members. Many IDSOs have internal recruiting teams to assist their partner practices. More than ever, new doctors today are seeking security and stability. Growth requires recruiting, and IDSOs can offer future ownership to current and future associates. Growth opportunities. Most IDSOs encourage and provide capital for practice expansion through the addition of associates and acquisitions of competitors. IDSOs may also own or acquire interests in potential new patient referral sources.

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.

7. Known exit in the future, but locking in 2020 value levels. When doctors are ready to retire, their IDSO partners purchase their retained ownership on a date certain at a fixed formula tied to future earnings. 8. Security for doctors and team members. COVID-19 has proven that life can change rapidly and in unimagined ways. Size matters in a more complex future. 9. Dramatic value increases. Certain IDSOs, which offer equity participation, may provide upside opportunities far beyond single-practice ownership. In one well-known IDSO, doctors who accepted equity early achieved over 50x returns on their retained equity. 10. Taxes. At some point, you will want to monetize the value of your practice. Federal tax rates on long-term capital gains are today 20%, and soon they could be doubled. Peace of mind is key. All doctors are potentially at risk in a fragile economy. Certainly, endodontists have fared better than most, but there is always risk of change. Cash in the bank along with a resourceful partner is always a welcome security blanket! Every doctor and every IDSO is different. Understanding the potential value of your practice to an IDSO partner is the first step in making an informed decision. Doctors can receive a confidential, no obligation, and no cost analysis of the value of their practice by contacting Large Practice Sales. EP This information was provided by Large Practice Sales.

38 Endodontic practice

Volume 13 Number 4

Silent Partners are Eager to Invest in Large Endodontic Groups With Collections Over $1,500,000 In 2020, LPS will advise larger practices on over $400,000,000 of transactions with Invisible Dental Support Organizations (IDSO). Even with the impact of Covid-19, we are still achieving record values for clients across the country.

Recent Transactions (During Covid-19) 2.0X Collections, Multiple-Doctor Endodontist Group 1.8X Collections, Three-Doctor Endodontist Group Register for one of our upcoming webinars by visiting us at www.FindMyEndoPartner.com

SILENT PARTNERS HELP YOU TO GROW BIGGER, BETTER, FASTER AND MORE PROFITABLY

To schedule a confidential call, and get a FREE practice value analysis, call 877-557-5119 or Email EndoUS@LargePracticeSales.com

SMALL TALK

What do we value? A critical question and a values exercise Dr. Joel C. Small shares his core values and guiding principles

hose of us who have identified our core values and honor these values in our daily lives understand that they serve us as a vital and perpetual reference point. The same is true for our clinical practices. Once we establish, implement, and honor a set of mutually agreed-upon values, a noticeable transformation begins. We begin to notice changes in our team dynamics. There is a stronger sense of unity as well as more selfaccountability and motivation. A different kind of dialogue occurs — one that rejects blame and finger-pointing, adopts a tone of support, and promotes team building. Decision-making becomes much easier because decisions are now referenced against our values, which guide us toward better decisions. We find that there is a noticeable esprit de corps among team members and, with time, they become very protective of the practice environment they have worked so hard to develop. Mutually shared values are also foundational to our practice culture, and it is our unique culture that serves as our brand in the service industry. It is our culture along with the brand that the culture creates that sets us apart and allows us to establish a sustainable competitive advantage in the dental marketplace. Our culture is unique to our practice. It is the only thing that no other practice can copy. My personal coach once said to me that when we embrace our values, we will never feel lost again. I know this to be true. Dr. Joel C. Small is a retired clinical endodontist, Board Certified Executive Leadership Coach, entrepreneur, speaker, and the author of Face to Face: A Leadership Guide For Healthcare Professionals and Entrepreneurs. He also holds the designation of Professional Certified Coach (PCC) with the International Coach Federation. In his coaching practice, Line of Sight Coaching, Dr. Small works with a limited number of motivated healthcare professionals. He received his DDS (Doctor of Dental Surgery) and completed his residency in endodontics at the University of Texas School of Dentistry in Houston, Texas. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas in Dallas, Jindal School of Management, postgraduate program in executive coaching.

40 Endodontic practice

How to identify your core values 1. A core value is something I have chosen freely and with consideration for the consequences of my choice. 2. A core value is something I prize greatly and has a positive influence on my life. 3. A core value is something I want to publicly affirm. 4. A core value is something I am willing to act on. 5. A core value is something I would repeat. If given the circumstances, I would respond in the same way. Core values are guiding principles around which I will make all my business (and personal) decisions. It is what I view as “right and “true.“

Identifying core values: the process Identifying shared values as a group exercise need not be complicated, just thoughtful. I would recommend setting aside at least 2 hours for this exercise. You can provide your team members with the “extensive“ list of values* and ask them to pick their top five using the criteria in the “Identifying core values.”* The values list is only a guide and not intended to limit or exclude other choices. Before you meet with the staff, compile a list of everyone’s top five values, and give the list to each participant. Begin by going around the room asking each person to discuss his/her chosen values and what each of these values means to him/her. On the list of values, write a brief (one sentence) definition of the value so everyone understands and shares the same meaning. You will likely find overlap with chosen values. Some of the chosen values may be the same, or you may find that two different values share the same meaning, in which case you can choose which value is most consistent with the group’s interpretation. Once everyone has had a chance to share their list, review the list again as a group using the criteria in the “Identifying core values“ document. Mark the values that unanimously meet the group’s evaluation using the requested criteria. Debate is encouraged and may prove enlightening. As the list becomes smaller, you will find that very few values meet everyone’s needs. Once there is a consensus on three to five values, you have found your core values. As a final sign of solidarity and commitment, go around the table asking for each person’s verbal assurance that this list represents the guiding values by which the practice will operate. Finally, it is a good idea to collaborate about how team members will be accountable for living these values and how these values can be used as a guideline in decision-making for each team member. From this point on, decision-making and performance feedback will be made with these shared values as guidelines.

To help you begin the process of identifying your practice values, we are providing the above values exercise, which we have our clients perform with their staff.

*The complete list of values is too extensive to include here. If you would like a copy of the list, please contact us at joel@lineof sightcoaching.com. EP Volume 13 Number 4

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