Endodontic Practice US Spring 2021 Vol 14 No 1 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Spring 2021 – Vol 14 No 1 • endopracticeus.com

PROMOTING

EXCELLENCE

GentleWave® facilitates disinfection and obturation of hidden middle mesial anatomy Drs. Michael W. Ford and Gerald N. Glickman

ENDODONTICS Educator profile Richard Simcock, DDS

Company profile Who we are: 3DISC

Improving endodontic success through coronal leakage prevention: part 2 Dr. Gregori M. Kurtzman

Accuracy of electronic apex locators in single-rooted teeth during endodontic retreatment with chloroform Drs. David Keinan, Aviv Shmuel, Shlomi Ritz, and Iris Slutzky-Goldberg

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

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 © MedMark, LLC 2021. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice US or the publisher.

The times they are a changin’

ob Dylan wrote that song title in 1963, but he could just as well be talking about today. 2020 was a strange year — unavoidable chaos and turmoil from all sides. Everyone was affected. Everyone was off-balance. Having lived through the 1960s, I can say without reservation that 2020 was a bad year, maybe the worst. But life went on. While our overwhelming health worry was a virus, people still got tooth decay. People still got gum disease. People still got toothaches. And in the middle of this chaos, the dental profession figured out how to get treatment to people. Not as efficiently perhaps, or as comprehensively. But treatment nonetheless. We learned, we adapted, and we served the populaEric Herbranson, BS, DDS, MS tion as best we could. Everything changed. The parking lot became the waiting room. We sterilized everything … twice! We wore scrubs on top of our scrubs. We worried about airflow. We bathed in hand sanitizer. The patients’ fears expanded from, “Is this going to hurt?” to adding “Am I going to get sick?” Their expectations expanded. “Did you clean this surface/doorknob/etc.?” “Can I get this done today?” We adapted. Underpinning our efforts was ubiquitous technology helping us along the way. We don’t even notice it most of the time, but it’s there. The patients email in their health history. We retrieve the patients from the automobile “waiting room” with a cellphone. We record their faces with a dot on the side of a little square on the top of our computer monitor. No germinfested money anymore! Just put the end of that little plastic card in this box here, wait for a minute, and we’re good-to-go. Better yet, do it online. This technology help is hitting our clinical lives as well and is changing the way we treat patients. CBCTs allow us to see the anatomy in 3D with a 30-second scan. We can use that scan information to aim our handpiece. We can do routine one appointment endo treatment with exquisite quality now. Technology can help us in this “new normal” we are living. Let me give you an example. A friend recently had a patient who presented with pain and swelling from an upper premolar that had been neglected because of COVID-19 fears. It needed immediate treatment. Rather than a conventional approach, he chose to use Sonendo’s GentleWave® device he’d recently adopted since it was optimized for a single-visit treatment and was virtually aerosol-free. Surprisingly, when he removed the rubber dam at the end of the procedure, the swelling was gone! The negative apical pressure feature of the device had actually drained the pus from the swelling through the tooth during the cycle. The patient was thrilled that the procedure was comfortable and relieved that he was finished and didn’t need to come back. Everyone was happy except the assistant who found a big bolus of pus in the waste receptacle when she was cleaning up the machine! Kind of gross for the assistant, but this case shows how a novel technology advance can help us give quality care in a “new normal” of fear and anxious expectation for the patient. And the advancements keep coming. Sonendo is introducing a new procedure instrument called CrossFire™, which cleans the canal system from the outside of the tooth through just an access cavity. I wonder what the opinion leaders from 1963 would think of that? The chaos of 2020 has forced a fast-forward on what new technology can do for us. These devices are moving from the “nice to have” luxury category to the “need to have” items. Maybe that’s the silver lining of 2020. Dr. Eric Herbranson Eric Herbranson, BS, DDS, MS (Endodontics), has more than 40 years of experience in clinical endodontics, teaching, and image production since graduating with an MS from Loma Linda University. Dr. Herbranson has long been a thought leader in endodontics, on dentin preservation, and on maintaining the natural anatomy of the tooth, which closely aligns with Sonendo’s mission of saving teeth through Sound Science® Technology. He is actively involved in speaking and education at both universities and conferences and has authored and coauthored numerous national periodicals and contributed to dental textbooks. Disclosure: Dr. Herbranson is on Sonendo’s Scientific Advisory Board.

ISSN number 2372-6245

Volume 14 Number 1

Endodontic practice 1

INTRODUCTION

Spring 2021 - Volume 14 Number 1

TABLE OF CONTENTS Publisher’s perspective Renewed energy in 2021 Lisa Moler, Founder/CEO, MedMark Media................................ 6

Practice profile Ryan Duval, DMD, MSD

Educator profile Richard Simcock, DDS Coaching with Endo2Endo.............. 14

Attention to detail and compassion in practice

Company profile Who we are: 3DISC ......................................................15

Research Prevalence of extra canals and roots in mandibular molars of a Brazilian population

Innovations & insights Innovations during a crisis Dr. Brett Gilbert discusses how he thought clearly, was creative, and innovated, even during COVID-19

A study by Jessica Monteiro Mendes, Cristiane Melo Caram, Alexia da Mata Galvão, Nayara Rodrigues Nascimento Oliveira, Gisele Rodrigues da Silva, and Maria Antonieta Veloso Carvalho de Oliveira reaffirms the importance of techniques that improve the quality of endodontic diagnosis .....................16

ON THE COVER X-ray image on cover courtesy of Drs. Michael W. Ford and Gerald N. Glickman. See article on page 20.

2 Endodontic practice

Volume 14 Number 1

NEW Bioceramic Material from the expert in endodontics -

www.diadent.com 1-877-342-3368

NEW!

DIA-ROOT BIO SEALER ™

Bioceramic Root Canal Sealer

FEATURES & BENEFITS 22mm Flow

19µM Film Thickness

0.95% Solubility

8.1mm Radiopacity

SUPERIOR BONDING

Gutta Percha

Sealer

Dentin

Sealer

❶

Biocompatible: heals tissues & hydrophilic

❷

pH 12: highly antibacterial

❸

Superior bonding to dentin & GP

❹

Low solubility: zero shrinkage

❺

Washout resistant: prevent microleakage

❻

Optimal flowability to reach all canals

❼

Pre-mixed and pre-filled to save time

DIA-ROOT ™ BIO MTA

INDICATIONS

MTA Root Repair Material

FEATURES & BENEFITS ❶

Excellent biocompatibility

❷

Outstanding sealing capability

❸

White powder is ideal for anterior teeth

❹

Highly antibacterial w/ high pH 12

❺

Easy handling properties

❻

Washout resistant

❼

Setting time: approx. 45 minutes

OUTSTANDING SEALING ABILITY

BEFORE hydration

AFTER hydration

For more information or to purchase, contact our authorized dealers such as Henry Schein, Benco Dental, Darby Dental, Patterson Dental, Ultimate Dental, etc.

TABLE OF CONTENTS Technique GentleWave® facilitates disinfection and obturation of hidden middle mesial anatomy — a case series Drs. Michael W. Ford and Gerald N. Glickman discuss a promising technique to manage mandibular molar middle mesial anatomy and other complex anatomy....................20

Continuing education Accuracy of electronic apex locators in single-rooted teeth during endodontic retreatment with chloroform — an ex vivo study Drs. David Keinan, Aviv Shmuel, Shlomi Ritz, and Iris Slutzky-Goldberg study the effects of the presence of chloroform in the canal during retreatment......................................30

Continuing education Improving endodontic success through coronal leakage prevention: part 2

Dr. Gregori M. Kurtzman continues his discussion of coronal leakage prevention

Product profiles

Small talk

Boyd Industries’ featured endodontic products

After action reviews: a peak performance tool

Single-cone endodontic obturation with NeoSEALER™ Flo

Built to Last. Built for You. Built by Boyd .......................................................36

Dr. Karl Woodmansey discusses improved obturation with an emerging technique........................................35

EndoSequence® BC Temp

Drs. Joel C. Small and Edwin McDonald discuss a 5-minute way to maintain optimal functioning and flow ............................................................. 40

Product profile

....................................................... 38

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 14 Number 1

MEET THE ALL-NEW

A NEW GENERATION OF SPECIALIZED, INNOVATIVE, AND INTUITIVE ENDO LASERS

CALL 972-598-9000 OR EMAIL INFO@FOTONA.ORG TO SCHEDULE A VIRTUAL MEETING WITH A FOTONA SPECIALIST & LEARN ABOUT OUR ENTICING SPECIALS!

TECHNOLOGY & DESIGN TO ELEVATE YOUR PRACTICE • SWEEPS® PHOTOACOUSTIC ENDO SWEEPS®

TREATMENTS • HARD & SOFT TISSUE APPLICATIONS • PHOTOBIOMODULATION / PAIN RELIEF • FEATHER-LIGHT, FLEXIBLE UNIFLEX ARM • COMPACT & PORTABLE DESIGN • ADDITIONAL LASER WAVELENGTHS FOR EXPANDED APPLICATIONS • & MUCH MORE! @FotonaLasers_Official @FotonaLasersUS

FOTONA.COM/US

@FotonaLasersUSA

PUBLISHER’S PERSPECTIVE

Renewed energy in 2021

o here we are in 2021. While the challenges of 2020 have not completely disappeared, we can definitely see healing and hope on the horizon. Personally, I am energized — looking forward to seeing all of you at in-person conferences and meetings, setting new goals, and finishing some that were put on hold. What does this mean for MedMark and all of its publications? Since we thrive when you thrive, it means that we need you to share all of your thoughts with us. During the pandemic shutdowns, what ideas did you have for improving your office procedures and your clinical protocols when you returned? What are you doing to make those plans into actions? How are Lisa Moler Founder/Publisher, MedMark Media you focusing your renewed energy into more thriving practices? What were your challenges, and how are you going to make your practices more resistant to future forces that can get in the way of forward movement? We want to be the publication that brings you new techniques, cutting-edge technologies, innovative products, and articles that start conversations about how your dental talents can change lives for the better. Because of our readers, people overcome life-threatening sleep disorders, teenagers can smile without being self-conscious, and adults can obtain some orthodontic, implant, and endodontic treatments that weren’t even an option when they were teens. As we discover and spotlight new products and techniques, patients will not think of their dentist as just doing a root canal or implant but as being synonymous with healing and overall good health. In their CE, Dr. David Keinan and colleagues explore the accuracy of some electronic apex locators in the presence of chloroform. Our other CE by Dr. Gregori Kurtzman is part 2 of improving endodontic success through preventing coronal leakage, a frequent cause of endodontic failure. The technique column by Drs. Michael Ford and Gerald N. Glickman discusses disinfection and obturation in complex anatomy. The practice profile of Dr. Ryan Duval discusses the many philosophies, mentors, and experiences that were involved in realizing his vision of a compassionate and exceptional endodontic practice. We greet 2021 with so much hope, ideas, and energy. The MedMark team is ready to help you reach positive goals that exceed your expectations. With articles written by experienced and knowledgeable dental leaders and advertisements from technology and service leaders that involve all areas of dentistry, we aspire to be part of your healing, a source of your inspiration, and a vehicle for your success! 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 WEBMASTER Mike Campbell webmaster@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.endopracticeus.com SUBSCRIPTION RATES 1 year (4 issues) $149 3 years (12 issues) $399 Subscribe at www.medmarksubscriptions.com

6 Endodontic practice

Volume 14 Number 1

PRACTICE PROFILE

Ryan Duval, DMD, MSD Attention to detail and compassion in practice What can you tell us about your background? I was raised in a suburb of Seattle, Washington. I was greatly influenced by my mom and her career as a hygienist for 43 years. During that time, I was exposed to two dentists, Jeffrey Parrish, DDS, and Brian McKay, DDS, and their teams that showed me how to take great care of people and how dentistry can make a positive impact in people’s lives. I earned my dental degree at the University of Pittsburgh and practiced as a general dentist in central Washington with an amazing dentist and great friend. I earned my Endodontic Certificate and Master’s Degree at Case Western Reserve in Cleveland, Ohio, where I was Chief Resident and worked alongside some great residents and was mentored by dedicated faculty and an outstanding director.

When did you become a specialist, and why? I received my Endodontic Certificate and Master’s Degree in 2010 from Case Western Reserve School of Dental Medicine in Cleveland, Ohio. During dental school, I enjoyed treating the relatively straightforward cases that we were permitted to complete as an undergrad and was drawn to the challenge of the intricate cases that the Grad Endo residents were assigned. After dental school, I was fortunate to practice as a GP in Central Washington with a fantastic dentist and person, Michael Cole, DDS. During our time together, I learned what Ryan Duval, DMD, MSD, Diplomate, American Board of Endodontics great dentistry looked like and how to take amazing care of people. As a GP, I I have always been drawn to a challenge, always looked forward to every endodontic and I love the task of managing our patients treatment in my schedule and quickly realthrough all of aspects of endodontic therapy. ized that becoming an endodontist was my professional goal. I knew my private pracIs your practice limited solely to tice experience was important, and I wanted endodontics, or do you practice to become the most attractive Grad Endo other types of dentistry? candidate possible. I participated in research Our practice is limited to nonsurgical projects, and I purchased a dental operating endodontic therapy, retreatment, and microscope and used it for everything from surgical endodontic treatment. We have a root canal therapy to crown preps and restorfour-operatory practice in a medical/profesative procedures. Having the experience of sional building located in North Scottsdale. treating so many different types of cases We currently have three staff members and under the microscope made my transition are open 5 days a week. Our location is very to using the scope for all treatments in resi“freeway-friendly,” and we see patients from dency much easier and more successful. 8 Endodontic practice

Dr. Duval with a patient

all over Maricopa County. We designed and built our office from the ground up. Construction took longer than anticipated due to the pandemic, but we have been happily seeing patients since early October.

Why did you decide to focus on endodontics? While I enjoyed the variety of general dentistry, I learned that I was happiest and most engaged while performing endodontic procedures (both diagnostic and treatment). As my career progressed, I found that the diagnostic challenge, which many patients presented with, was a great puzzle that was worth solving.

Do your patients come through referrals? We are a referral-based practice. We rely on referrals from general dentists and past patients. This referral is something that we have to earn every day with each patient we treat. Scottsdale is a very competitive market, and we chose to establish our practice there. I understand the importance of building our reputation every single time someone walks in our door and believe that over time we will build a reputation of honesty and quality endodontic treatment. Volume 14 Number 1

I have been in private practice for 16 years and an endodontist for 11 years. I use a large array of rotary systems and ultrasonically activate all irrigants during the cleaning/ shaping process. I am evaluating all available options for additional irrigation delivery and irrigant activation devices.

What training have you undertaken? Before I became a dentist, I participated in a medical and dental mission trip to the Dominican Republic. It was an amazing experience to be a part of a humanitarian team that helped so many people and to have the memories of the lives that we touched. I earned my Diplomate status in 2017 when I became Board-certified.

of my own. I knew the kind of culture I wanted to create in the office, and how I wanted the patient experience to look and feel from start to finish. Being able to integrate these things from the ground up over the last year has been the realization of that vision.

Professionally, what are you most proud of? Becoming Board-certified was a source of great pride. Balancing private practice, quality family time, and commitment to the work/study required to feel prepared (nearly 8 years after residency) and confident was a great accomplishment.

What do you think is unique about your practice? Our practice is driven by the acronym ACE. ACE stands for Attention to detail, Compassionate care, and Exceptional endodontics. From the initial referral to following up with the patient a few weeks after treatment, there are so many details that need to be not only be investigated, but also must be a continual focus. Every case and patient are uniquely different in what the patient desires and how he/she navigates pain. Our role as providers is to make patients as comfortable as possible and allow each patient to feel heard and valued and address his/her concerns to the best of our ability.

Who has inspired you? I was inspired by some great general dentists and two endodontists. Drs. Willis Gabel and Dan Radatti were very instrumental in developing my clinical skills and diagnostic abilities. They both taught me a lot about how to successfully build and interact with a referral base and how to run a successful endodontic practice. I will always be grateful for the opportunity my program director, Dr. Andre Mickel, gave me at Case Western Reserve; I find myself using his teachings every day.

What is the most satisfying aspect of your practice? From the time I was accepted into endodontics, I envisioned having a practice

Loop 101 Endodontics operatory with A-dec dental chairs, Global Dental microscope, ASI cart, and Carestream intraoral imaging

Dr. Duval with Kari F. in the front office of Loop 101 Endodontics (left) and Ella L. with the Carestream CBCT (above) Volume 14 Number 1

Endodontic practice 9

PRACTICE PROFILE

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

PRACTICE PROFILE

Loop 101 Endodontics lobby (left) and sterilization room, including the Steri-Center from A-dec (right)

What has been your biggest challenge? Deciding to take the leap of faith and open my own practice has been my biggest challenge as an endodontist. As an associate, it’s not uncommon to become very comfortable and accept or overlook things that you wouldn’t necessarily want if you were the business owner. At the end of the day, I always struggled with this because even though it wasn’t my practice, it was my reputation and my name on the door also. Moving to a new state and opening a practice during the pandemic has definitely brought about its own set of challenges, but I know it was the right move for my professional development. Being able to execute my vision for how we treat people has been a welcome challenge, and I look forward to it each day.

Loop 101 Endodontics staff

What would you have been if you didn’t become a dentist?

What advice would you give to a budding endodontist?

Dermatology was interesting to me. Also, I always dreamed of being a naval aviator; carrier landings seem like an awesome challenge.

Just because your dream doesn’t happen in the timing you think it should, don’t abandon it altogether. Over a decade ago, I came to Scottsdale to look at starting my career here. It didn’t work out at that time for many reasons. I considered staying an associate in the Northwest and tried to convince myself that having my own practice wasn’t important anymore. Looking back, the past 11 years gave me the experience, the knowledge, and the courage to continue to chase my dream. I have had a few people tell me that I am little “late to the party” to start up my own practice, but I know the winding path I took to get here forged a large amount of our current success in Scottsdale.

What are your top tips for maintaining a successful specialty practice? From day one, we had a very clear vision for the practice. I had enough experience to understand what I wanted every facet to look like, and I had a few key role models that I could continually reach out to when I needed them. Having practiced in other offices for over 15 years, I also understood the importance of hiring people who could not only understand the vision, but also would buy into it and help bring it to life. I am a firm believer in finding the right people who already possess the values and mindset that fit our culture. 10 Endodontic practice

What are your hobbies, and what do you do in your spare time? My wife and I have two children, so much of my spare time is spent with my family. We

Dr. Duval with his family

all love to be outdoors and spend a lot of time playing in the pool and being together. I am an avid golfer and love to ability to play year-round here in Arizona. EP Volume 14 Number 1

Endodontic Practice US

Address the Endodontic Complexities You Face Everyday with... 3 EASY WAYS TO SUBSCRIBE VISIT www.endopracticeus.com EMAIL subscriptions@medmarkmedia.com

MO PRO

TIN

LL XCE

ENC

OD END

ONT

ICS

le profiers n pany Com.S. Endo Part U

s apon ar we gift to le c u er n gineer’s ntics Form en do endo , MS, PhD

CALL 1.866.579.9496

, BS

rimus

lyn P

Caro

149 $ 3 years 399 1 year

in to jo ices. unity do pract t r o p n p e o of your nity miss mmu Don’t wing co ro the g

les •

l artic

clinica

s review om ology ceus.c ti techn c ra • s dop • en profile e c 4 ti o c 13 N • pra – Vol vice 2020 nt ad inter geme a W n a m

ti odon g end coron in v o Impr through ventio pre ess succ leakage — par ri M.

rego

Dr. G

Kurtz

mand nt of ith a

atme

021

ntics dodo

1/25/2 df 1

tlines.p

r v5 Ou

Cove

les

l artic

clinica

rs w Tre views om mola : a case logy re eus.c first chno my . Yurii R ractic 1 PM o • te t p o a 4:47:1 s d n n le a Drs • e profi Svit ctice No 1 • pra l 14 o V e – ic 1 2 adv 0 t 2 n e g em Sprin anag • m

SUBSCRIBERS BENEFIT FROM: 16 continuing education credits per year linical articles enhanced by high quality C photography

PRO

itates tion ® facil ave nd obtura W le t Gen ection a le f d disin den mid y of hid l anatomrd and o mesiaichael W. F an

nalysis of the latest groundbreaking A developments in endodontics Real-life profiles of successful endo practices Technology reviews of the latest products

IN MOT

ND EARNE ERSI N TION CRCIBE EDUCA S N B E SUL UING EAR! EL ING Y TIN PAXYC E CON DITS PER CRE

ODO

NTI

le profi ator ock, DDS

Educ

imc

ard S

Rich

le profiISC pany D Comho we are: 3 W

M m Drs. Glick ld N. Gera

ractice management advice on how to make P endodontics more profitable

CMY

ic dont endo coronal 2 g in h v t g o Impr ss throu tion: par e n succ ge preve zman rt leaka ri M. Ku rego

Dr. G

Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

ro elect cy of gle-roo a r u c Ac s in sin o ndod or locat ring e ro apex teeth du with chloiv nt einan, Av atme retre Drs. David KIris Slutzky-G , and

i Ritz

Shlom

INNOVATION & INSIGHTS

Innovations during a crisis Dr. Brett Gilbert discusses how he thought clearly, was creative, and innovated, even during COVID-19 Background Innovation is the key to advancing a field or profession forward. Historically, endodontic innovations have largely been tied to technology. However, in the face of COVID-19, innovation was not a shiny new piece of technology, but a complete re-examination of how we practice and how we communicate with our referring practices. We were pioneers as we found ourselves as dental first responders, uncertain of how to protect ourselves, our team, our families, and our patients. I am passionate about endodontics and teaching. The pandemic presented an opportunity to tie these together to help others. I often search for “teachable moments” — unplanned opportunities to impart knowledge. In the opening days of the pandemic, I found many teachable moments.

Referral engagement Prior to the pandemic, connecting with referring dentists was often done face to face, physically visiting with them at dental meetings or other activities. However, in the blink of an eye, a thriving community of professionals was suddenly under stay-at-home orders. In-person meetings were not going to be possible for the foreseeable future. I instantly recognized that I had to innovate how I would connect with our referring dental practices. Primarily, I wanted to support my existing and new referrers who were seeking support to accommodate their emergency patients. I also realized that dentists needed other forms of support that required me to Brett E. Gilbert, DDS, graduated from the University of Maryland Dental School in 2001 and attained his Certificate in Endodontics in 2003. He is currently a clinical assistant professor in the Department of Endodontics at the University of Illinois-Chicago, College of Dentistry and on staff at Presence Resurrection Medical Center in Chicago. He has served as President of the Illinois Association of Endodontists and President of the Northwest Side Branch of the Chicago Dental Society. Dr. Gilbert was honored by the Seattle Study Club as a Top Ten Young Dental Educator in America in 2017. Dr. Gilbert is Board-certified and a Diplomate of the American Board of Endodontics. Dr. Gilbert owns and operates a thriving private practice limited to Endodontics in Niles, Illinois. Disclosure: Dr. Gilbert is a clinician-partner of U.S. Endo Partners.

12 Endodontic practice

My ability and clarity on how to innovate during a crisis were empowered by knowing that I was not alone or vulnerable. I knew I had an entire partnership and team behind me. be creative. As dentists sat at home, month after month, they wondered what they would need to do to reopen their practices in a new COVID-19 reality. There was fear surrounding practicing dentistry. The fear was powerful; I felt it too!

Unplanned opportunities to impart knowledge I decided that videos could tell a powerful and intimate story to support dentists. I created a live webinar presentation on managing stress and also shared all of the precautions and protocols we were using in the office. This gave my referrers a glimpse at what was needed to prepare for reopening their own offices. However, it was not just the logistics and techniques that I wanted to share. I expressed my own initial fear and how I personally pushed through it to stand in my own power as a leader of my team. The messages resonated with the doctors, and they reported how helpful it was for them leading up to their own reopening.

Communication The pandemic gave everyone a crash course in alternative communication. I wanted to keep the lines of communication open but wrestled with how to achieve it. Calling each dentist directly opened the door for long conversations, which were not sustainable. I decided to use existing technology and innovate my approach. I started to send out voice texts to my referrers. One nice feature with voice text messages is that they automatically erase, preventing the electronic dissemination of written protected health information (PHI). I saved time and was able to communicate intimately and personally with my referring partners by using my voice. When more in-depth communication was needed, I opted to connect by

Zoom. These communication strategies served my practice well in the midst of the shutdown and fostered closer relationships with my referrers.

Specialty services partnerships My ability to think clearly, be creative, and innovate was facilitated by a significant shift in my practice just days before the pandemic hit. I partnered my practice with U.S. Endo Partners, a specialty services partnership for endodontists, the week before the shutdown. One day I was a solo practitioner, feeling vulnerable and on my own island. The next day I was partnered with U.S. Endo Partners and had an entire team of partners who were there to support me. The partners all worked together in the face of tragedy and uncertainty. The support was tangible. Difficult-to-obtain PPE started showing up at my office even before I requested it. Written protocols and template letters to send to referring doctors and patients were sent to me before any other organization had created them. The support of being a partner in U.S. Endo Partners allowed me to focus on being a supportive leader to the dental community and a clear-headed clinician to my patients. Being free of many administrative responsibilities of running my practice, I was able to encourage and support others. As a solo practitioner, I had always felt vulnerable. When the crisis actually hit, U.S. Endo Partners alleviated the vulnerability and replaced it with strength and reassurance. My ability and clarity on how to innovate during a crisis were empowered by knowing that I was not alone or vulnerable. I knew I had an entire partnership and team behind me. Joining U.S. Endo has allowed me to pursue more teachable moments with a clear mind and unwavering passion. EP Volume 14 Number 1

‘‘

I’m reaping the rewards of retirement today while doing what I love.

– Dr. Olivia Cook, DMD, MS Highland Endodontics

Practice valuation

U.S. Endo Partners stock

Ongoing production

Equity events

The benefits of joining are just the beginning. With U.S. Endo Partners, you have an ongoing share in our joint success. www.USEndoPartners.com/Success

EDUCATOR PROFILE

Richard Simcock, DDS Coaching with Endo2Endo What can you tell us about your background? I currently own North Sound Root Canal Specialists, and I’ve been a practicing endodontist for 23 years. After graduating from Loma Linda University Dental School in 1997, I was accepted into the endodontic residency at Albert Einstein Medical Center and graduated in 1999. I opened my first practice in Skagit County, Washington. Eighteen years later, I opened a second location in Whatcom County, a 30-minute drive from our Skagit office. In 2020, I sold my original practice and set my sights on developing a coaching program called Endo2Endo.

on helping other endodontists utilize advanced technology to help their practices become more profitCredit: Demri Rayanne Photography able. There are a lot of wonderful business What originally attracted you coaches out there, but there are no programs to the specialty of endodontics? that are taught by a practicing endodonThe simplicity of having patients who tist who’s in the trenches with you. I focus want to keep their natural dentition and not on helping my colleagues adopt specific needing to “sell” dentistry. Also, it’s just me methods that help streamline their schedand the tooth. uling, improve clinical efficiency and workWhat aspect of your training flow to help them increase their net revenue. inspired you to add educator to From there, they can pay down their debt, hire a new associate, and take more time your list of accomplishments? away from the office, all while improving their Having some great mentors and coaches bottom line. early in my career who inspired me to grow. At this point in my career, I feel like there are As an educator, what have you a lot of new endodontists with open minds learned from your clinical students? who want to excel. Endodontics is a fun way to make a What are your proudest moments living. There has never been a better time to in the clinical and teaching aspects be an endodontist.

of your life?

In the office, I love it when patients ask, “Is that it?” They are so surprised by the concept of a pain-free root canal performed in one visit that is often less than 40 minutes. When I’m coaching on clinical efficiency, it’s rewarding to watch the light go on in a client’s eyes. It’s also great to hear that they’re integrating technology to help complete more cases per day, but in fewer hours without increasing their stress.

What do you think is unique about the topics you teach? After you graduate from school, you know how to practice endodontics, but running a business is whole other ball game. So, I put together a program that’s centered 14 Endodontic practice

What has been your biggest challenge in sharing information and educating endodontists? Endodontics is a field that’s been traditionally slow to adopt change, and therefore, it can become a bit stale and monotonous. Even for me, when I first purchased the GentleWave® for our office, the new technology wasn’t easy to integrate into my clinical protocol at first. It took longer to treat patients and threw us behind schedule, so it collected dust for a while until I was determined to implement new changes to my routine. Once I opened my mind to the new system, I quickly saw how this technology could help me become even more efficient. I think our field, like many others, is quick to

resist change. It’s been fun watching the light bulb go on when my colleagues learn how they can improve treatment times with this new technology and maintain a high level of patient care.

What advice would you give to budding endodontists? Open your mind! And find a mentor to lead and guide you. We simply don’t know what we don’t know, and having a coach can help those blind spots that we all have. When you can streamline your scheduling and clinical protocols, everything falls into place because now you have solid systems that can handle a productive workflow.

What is the future of endodontics? Minimally invasive endodontics. Our goal is to preserve as much of the natural tooth structure as possible while treating the infection, so our patient gets to keep his/her tooth, while maintaining quality of life for as long as possible. I always say endodontics is one of the most exciting fields to work in right now and that’s because we get to employ amazing technology that helps us save 99% of the teeth we treat.

What would you have become, had you not become a dentist? A rock star.

What are your hobbies, and what do you do in your spare time? My wife, Hannah, and I live on Bellingham Bay with our two dogs, Eloise and Darby, and we love getting out to play in the mountains and on the water. We also love traveling, reading, and music. I’m a bassist, and I was playing regionally with my band before the pandemic. EP Volume 14 Number 1

COMPANY PROFILE

Who we are: 3DISC

Company overview Founded in 2007, 3DISC started off as an R&D company but quickly matured into an agile American manufacturer and global provider of digital-imaging solutions for dental practices. Fourteen years later, 3DISC is a privately owned company with headquarters based in the United States and France with a diverse team of digital experts curated from a variety of high-tech backgrounds for one mission — to pioneer the digital dentistry landscape of tomorrow. Our goal is to deliver relevant clinical benefits to doctors through inclusively digital solutions, specifically intraoral scanners. When dental clinics choose 3DISC, they’re taking digital beyond; they can trust our commitment to the continuous innovation of our solutions that will help bring simplicity to their workday and empower doctors to provide the highest quality treatment to their patients. That’s why we created the Heron IOS.

Solution overview The Heron™ IOS is a digital 3D-imaging solution bringing simplicity to the beauty of

Volume 14 Number 1

“The Heron has arrived, and it has set a new bar for all other scanners. The choices among optical scanners have become vastly overwhelming. In its inception clinicians demanded quality scans and simplified workflow. The Heron from 3DISC not only has those qualities but is unsurpassed in ergonomics and accessibility. Finally, we have a comfortable lightweight scanner that feels like it belongs in the palm of your hand.” – Isaac Tawil, DDS, MS your work as a medical professional. One of the most ergonomic and easy-to-use scanners on the market, the Heron weighs in at 150 grams with a compact, streamlined design for more efficient scanning and increased patient comfort. For an allinclusive price, the Heron IOS is presented as a turnkey solution that takes less than 10 minutes to unbox and set up — including a pre-calibrated scanner, three autoclavable tips, and optimized acquisition PC equipped with HeronClinic Software. Using the HeronClinic Software, your team can easily navigate the intuitive, user-friendly interface to meet all your restorative, orthodontic, and implant needs. With clear workflows and a cloud platform, the Heron IOS makes it easier than ever to create or browse patient cases, scan, and share with your labs. Our team is committed to providing superior service and support, so you can trust that when you introduce a Heron IOS into your practice, we will be there providing thorough in-office training as well as a variety of online resources. Our optimized acquisition PC automatically deploys software

updates as they are released to ensure that you always have the latest as well as instant remote access capabilities when you have questions or need help.

Why go digital? Digital impressions have a number of advantages over traditional techniques. The increased accuracy of a digital impression results in fewer lab remakes and better-fitting crowns and appliances. Intraoral scanners (IOS) are also faster and more cost-efficient for users, while being less intrusive and uncomfortable for patients. Traditional impression taking methods may be triedand-true, but the reliability and performance intraoral scanning for digital impressions have increased dramatically in recent years. Switching to intraoral scanning has never been easier or more reliable than it is today. The Heron IOS is a fast and easy-to-use system that provides reliable and accurate results every day — take advantage of this technology in your own practice today. EP This information was provided by 3DISC.

Endodontic practice 15

RESEARCH

Prevalence of extra canals and roots in mandibular molars of a Brazilian population A study by Jessica Monteiro Mendes, Cristiane Melo Caram, Alexia da Mata Galvão, Nayara Rodrigues Nascimento Oliveira, Gisele Rodrigues da Silva, and Maria Antonieta Veloso Carvalho de Oliveira reaffirms the importance of techniques that improve the quality of endodontic diagnosis Abstract The aim of this study is to evaluate the prevalence of extra roots and canals in the first and second lower molars over a 10-year period and correlate their occurrence with the patient’s age and gender, treatment type, tooth type, and the use of operating microscope. For this study, 519 dental records and their digital radiographs (550 teeth) were analyzed and classified into four groups. The prevalence of an extra canal in the distal root, an extra canal in the mesial root, and an extra root were 39.65%, 2.90%, and 3.64%, respectively. Gender and treatment type were not statistically significant. The extra canals of the distal root are more common than the extra canals and extra roots of the distal root, and it was most frequent in younger (<40 years old) patients and in first molars. The operating microscope improved the identification of extra canals in the mesial root.

Introduction The success of endodontic treatment is directly related to the location, instrumentation, and cleaning of all root canals, which can reduce bacteria and optimize the conditions needed for an effective obturation technique.1 Knowledge of internal and external Jessica Monteiro Mendes, DDS, is from the College of Dentistry, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil. Cristiane Melo Caram, MSc, is a dentist in private practice at EndoMais, Uberlândia, Minas Gerais, Brazil. Alexia da Mata Galvão, MSc, is from the Department of Dentistry, College of Dentistry, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil. Nayara Rodrigues Nascimento Oliveira, MSc, is from the Department of Dentistry, College of Dentistry, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil. Gisele Rodrigues da Silva, PhD, is from the Department of Dentistry, College of Dentistry, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil. Maria Antonieta Veloso Carvalho de Oliveira, PhD, is from the Department of Endodontics, College of Dentistry, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil.

16 Endodontic practice

Figure 1: Number (n) and frequency (%) of anatomical variation in mandibular molars

root anatomy is fundamental for successful endodontic practices.2 Molars are anatomically complex and, therefore, have been the subject of numerous studies.3,4,5 Mandibular molars usually have two mesial root canals plus one distal root canal — called mesiobuccal, mesiolingual, and distal — but may also have fused roots or extra roots, isthmuses, and extra canals. The prevalence of the radix root is directly related to ethnicity, occurring in 3.4% to 6.8% of Caucasians6,7 and 21% to 24.5% in populations of Mongolian origin.8 The isthmus has a prevalence of 64.7% to 87%,9,10 while the middle mesial canal (MM) has a prevalence of 14.7%10 to 45.6%.11 The prevalence of anatomical variations in mandibular molars has been studied in relation to patient type (gender and age), tooth type (first or second mandibular molars),12 crown aspect and pulp chamber floor,10,13,14 root canal compliance/morphology,9,14,15 and the influence of complementary tests, technologies, and instrumentation techniques.9,10,11,12 Some studies have analyzed the prevalence and/or anatomy of these anomalies in a Brazilian population16,17,18,19 but have not correlated anatomical variations with patient and treatment factors. Therefore, the present

study evaluates the prevalence of extra roots and canals in the first and second mandibular molars over a 10-year period of endodontic treatment and correlated their occurrence with factors such as patient age and gender, treatment type, tooth type, and the use of operating microscope.

Material and methods Clinical and radiographic data from 519 dental records (550 teeth) were analyzed after receiving approval from the Research Ethics Committee of the Uberlândia Federal University (#1603416). The medical records belonged to patients attended from 2009 to 2019 at a private clinic (EndoMais, Uberlândia, Minas Gerais, Brazil) and by a single, experienced operator using standardized techniques. Only cases of endodontic treatment or retreatment on the first or second mandibular molars were included, while cases that were incomplete by December 2019 were excluded. The following data was collected from digital files (ProDent® Dental Software, HartSystem, Blumenau, Santa Catarina, Brazil): number of canals treated, patient age (less or more than 40 years old), patient gender (male and female), tooth type (first or second molar), treatment type (treatment Volume 14 Number 1

teeth that had an extra root were entomolaris, while four were paramolaris.

Discussion The inability to locate root canals may result in microbial material within the tooth,

which may lead to apical periodontitis and a greater risk of failure.1 The most prevalent anatomical variation found in the 550 teeth analyzed in the present study was the extra canal in the distal root, followed by extra root and extra canal in the mesial root. The extra

Table 1: Number (n) and frequency (%) of anatomical variations in mandibular molars regarding age and gender Age Category

CRM

Gender

≤40 years old n/(%)

>40 years old n/(%)

Female n/(%)

Present

Absent

Present Absent

7 (1.3%)

252 (47.9%)

126 (23.95%)

133 (25.3%)

7 (1.3%)

260 (49.5%)

11 (2%)

328 (59.65%)

189 (33.95%)

125 (22.75%)

214 (38.9%

p = 0.831

CDR

78 (14.8%)

Male n/(%) Present Absent 5 (0.9%)

206 (37.45%)

p = 0.739

p < 0.001

206 (37.45%)

p = 0.122 14 (2.55%)

CRR

93 (16.9%)

325 (59.1%)

6 (1.1%)

206 (37.45%)

p = 0.583

Results The results of the number and percentage of extra canals and roots in the mandibular molars are shown in Figure 1. Statistical differences regarding age (Table 1) were only found in the CDR group, which showed a higher frequency of extra canals in patients under 40 years old (p <0.001). Teeth with extra roots (CRR group) were not analyzed relative to age, as this variable does not vary over time. Statistically significant differences were not found regarding gender (Table 1) or treatment type (Table 2). However, the presence of an extra canal in the distal root of the first molar was statistically higher in the CDR group (Table 2). The operating microscope (Table 3) was a determining factor in increasing the ability to locate extra canals in the mesial root of the CRM group. Among the 16 teeth with an extra canal in the mesial root (CRM group), one was classified as “independent” (6.25%), one was “fin” (6.25%), and 14 were “confluent” (87.5%). Six of the cases with confluent anatomy had a mesiolingual canal, five had a mesiobuccal canal, and three had both. Sixteen of the Volume 14 Number 1

INCREASE YOUR REVENUE AND REDUCE YOUR STRESS By making simple changes to your scheduling & clinical protocols you’ll be able to spend more time with patients and less time doing administrative work. Sign up for my affordable, 2 1/2 hour coaching program by visiting www.Endo2Endo.com

“At the completion of this program, you’ll have the skills and tools to complete more cases effortlessly and efficiently.” Rick Simcock, DDS

Endodontic practice 17

RESEARCH

or retreatment), and the use of an operating microscope. The microscope used was a model MC12 DFV (D. F. Vasconcelos, Valença, RJ, Brazil). It was used in every case since 2015. The canal location (mesial, distal, buccal, and lingual) was determined by using clinical data and digital radiographs from all treatment stages (FONA Sensor and CDR DICOM Software, Schick, Dentsply Sirona, São Paulo, Brazil). After data collection, these teeth (n = 550) were classified into four groups according to canals and roots: 1. SNC group: teeth with a standard number of canals (one to three canals) 2. CDR group: teeth with an extra canal in the distal root 3. CRM group: teeth with an extra canal in the mesial root 4. CRR group: teeth with canal in the radix The chi-square test was used to determine the prevalence of anatomical abnormalities in the mandibular molars relative to patient age, gender, treatment type, tooth type, and the influence of operating microscopy. The analysis was based on presence of absence of the following: • an extra canal in the mesial root • an extra canal in the distal root • an extra root The data was analyzed using SigmaPlot 12.0 (Systat Software, Inc., Chicago, Illinois) at a significance level of 5%.

RESEARCH canal in the distal root — the most prevalent anatomical variation (25.5%) found in the mandibular molars — had been higher in first molars (34.9%). Similarly, Estrela, et al.,20 found that 51% of the first molars analyzed by cone beam computed tomography had four canals but did not specify whether the extra canal was distal or mesial. However, the microscopy did not influence the ability to identify these extra canals in the distal root — perhaps extra canals on distal roots are easy to locate in the pulp chamber floor when the endodontic access is adequate. Usually, the entrance of the distal canal is centralized between buccal and lingual walls. However, if this entrance is located to lingual or buccal, the existence of another root canal is highly probable.2 Extra canals in the distal root are more prevalent in patients younger than 40 years old. This may be related to aging, which causes alterations in root canal conformation due to the deposition of tertiary dentin. This deposition is in turn due to small daily occlusal traumas and pathological stimuli such as caries or dental erosion, which obliterate root canals as a defense form.21 Our study shows that the occurrence of an extra root, called a radix, is not influenced by patient age, tooth type, or the use of an operating microscope. The radix can be found in both first and second mandibular molars but is more prevalent in first molars.8,22 This root is classified as entomolaris when located lingually23 and paramolaris when located buccally.24 Prevalence is highly related to ethnicity, which hinders analysis in an ethnically diverse Brazilian population.18 Studies using radiographic analysis7 have shown a 2.8% to 4.2% prevalence in a Brazilian population, while studies using cone beam computed tomography have shown a prevalence of 2.58%16 or a total absence.18 The extra canal in the mesial root, referred to as a middle-mesial canal9,10,11,12,15,17 or an accessory mesial canal,25,26 is located between the mesiobuccal (MB) and mesiolingual (ML) canals. The entrance of this canal may be located anywhere between the pulp chamber floor to 2.0 mm below this limit.11 Studies show a prevalence of 14.7%,10 18.6%,17 and even 46.2%,11 using tomography, microtomography and operating microscopy, respectively. The middle-mesial (MM) canals can be classified as “independent” when they are separate from the pulp chamber floor to the apical foramen; “fin” when the MM joins the MB and/or the ML at some point and has separate foramens; and “confluent” when the MM has a separate entrance (or not) from that of the canals and joins the MB and/or ML on its path to the apical foramen.15 Most of the MM canals 18 Endodontic practice

Table 2: Number (n) and frequency (%) of anatomical variations in mandibular molars regarding tooth and treatment type Age Category

CRM

Gender

Treatment n/(%) Present

Absent

9 (1.6%)

403 (73.3%)

Retreatment n/(%)

First molar n/(%)

Second molar n/(%)

Present Absent

7 (1.3%)

131 (23.8%)

11 (2%)

328 (59.65%)

p = 0.146

CDR

166 (30.2%)

246 (44.7%)

52 (9.5%)

CRR

396 (72%)

4 (0.7%)

206 (37.45%)

p = 0.164 86 (15.6%)

192 (34.9%)

146 (26.54%)

p = 0.658 16 (2.9%)

5 (0.9%)

26 (4.72%)

186 (33.83%)

p < 0.001 134 (24.4%)

16 (2.9%)

322 (58.55%)

p = 0.785

4 (0.75%)

208 (37.8%)

p = 0.133

Table 3: Number (n) and frequency (%) of anatomical variations in mandibular molars regarding the use of an operating microscope Use on an operating microscope Category

Yes n/(%) Present

No n/(%) Absent

Present

P Absent

CRM

15 (2.73%)

181 (32.9%)

1 (0.18%)

353 (64.19%)

< 0.001

CDR

72 (13.09%)

124 (22.55%)

146 (26.55%)

208 (37.81%)

0.345

CRR

10 (1.81%)

344 (62.55%)

10 (1.81%)

186 (33.83%)

0.259

in the current study are confluent (87.5%), similar to that found by Azim, et al.,11 with 78.57% of MM canals being confluent and Nosrat, et al.,12 with a percentage equal to 46.7%. Both studies used operating microscope in all procedures. Our study showed no difference in the MM canals considering the patient age; however, Nosrat, et al.,12 found a lower prevalence with increasing age, and Akbarzadeh, et al.,10 found a 4 times higher probability in patients under 42 years old. These studies used an operating microscope and a cone beam computed tomography, respectively. We attribute the difference in results due to the difficulty of locating of an MM canal without using an operating microscope, since in the present study this use occurred during the past 4 years only, probably reducing the number of MM canals analyzed. In addition to magnification, surgical microscopy provides better illumination, which allows better differentiation of pulp chamber details.25,26 The microscope can improve the identification of extra canals in the mesial root, and this ability to locate MM canals in mandibular molars by 27x corroborates previous studies that reported increases

of 16% to 20%.12,26 The prevalence of MM canals in the current study (2.9%) differs from other studies, probably because we used the operating microscope in only 35.63% of the cases, whereas the other studies used tomography,10 microtomography,17 and operating microscopy11 in all cases.

Conclusion Extra canals in mandibular molars are more common in distal roots, first molars, and younger patients (<40 years old). Furthermore, extra roots are uncommon in mandibular molars in a Brazilian population. The relationship between extra canals or extra roots and patient gender was not statistically significant — a finding corroborated by other studies.9,12 It was troubling that there was no difference between the two treatment types, suggesting that, in most cases, extra canals are not found in the first treatment and, therefore, may require another intervention. Finally, this study reaffirms the importance of techniques that improve the quality of endodontic diagnosis such as using an operating microscopy and improving operators training and experience. Volume 14 Number 1

The authors would like to acknowledge the valuable contribution of the EndoMais Clinic for allowing them to complete the research. EP

REFERENCES 1. Tabassum S, Khan FR. Failure of endodontic treatment: The usual suspects. Eur J Dent. 2016;10(1):144-147. 2. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg. 1984;58(5):589-599. 3. Wolf TG, Paqué F, Zeller M, Willershausen B, BriseñoMarroquín B. Root canal morphology and configuration of 118 mandibular first molars by means of micro-computed tomography: an ex vivo study. J Endod. 2016;42(4):610-614. 4. Tomaszewska IM, Skinningsrud B, Jarzebska A, et al. Internal and external morphology of mandibular molars: an original micro-CT study and meta-analysis with review of implications in endodontic therapy. Clin Anat. 2018;31(6):797-811. 5. Marceliano-Alves MF, Lima CO, Bastos, LGPMN, et al. Mandibular mesial root canal morphology using microcomputed tomography in a Brazilian population. Aust Endod J. 2019;45(1):51-56. 6. Martins JNR, Gu Y, Marques D, Francisco H, Caramês J. Differences on the Root and Root Canal Morphologies between Asian and White Ethnic Groups Analyzed by Cone-beam Computed Tomography. J Endod. 2018;44(7):1096-104. 7. Ferraz JA, Pécora JD. Three-rooted mandibular molars in patients of Mongolian, Caucasian, and Negro origin. Braz Dent J. 1993;3(2):113-117.

8. Song JS, Choi HJ, Jung IY, Jung HS, Kim SO. The prevalence and morphologic classification of distolingual roots in the mandibular molars in a Korean population. J Endod. 2010;36(4) 653-657. 9. Tahmasbi M, Jalali P, Nair MK, Barghan S, Nair UP. Prevalence of middle mesial canals and isthmi in the mesial root of mandibular molars: an in vivo cone-beam computed tomographic study. J Endod. 2017;43(7):1080-1083. 10. Akbarzadeh N, Aminoshariae A, Khalighinejad N, et al. The association between the anatomic landmarks of the pulp chamber floor and the prevalence of middle mesial canal in mandibular first molars: an in vivo analysis. J Endod. 2017;43(11):1797-1801. 11. Azim AA, Deutsch AS, Solomon CS. Prevalence of middle mesial canals in mandibular molars after guided troughing under high magnification: an in vivo investigation. J Endod. 2015;41(2):164-168. 12. Nosrat A, Deschenes RJ, Tordik PA, Hicks ML, Fouad AF. Middle mesial canals in mandibular molars: incidence and related factors. J Endod. 2015;41(1):28-32. 13. Kim KR, Song JS, Kim SO, et al. Morphological changes in the crown of mandibular molars with an additional distolingual root. Arch Oral Biol. 2013;58(3):248-253. 14. Gu Y, Lu Q, Wang H, et al. Root canal morphology of permanent three-rooted mandibular first molars - part I: pulp floor and root canal system. J Endod. 2010;36(6):990-994. 15. Pomeranz HH, Eidelman DL, Goldberg MG. Treatment considerations of the middle mesial canal of mandibular first and second molars. J Endod. 1981;7(12):565-568. 16. Rodrigues CT, Oliveira-Santos C, Bernardineli N, et al. Prevalence and morphometric analysis of three-rooted mandibular first molars in a Brazilian subpopulation. J Appl Oral Sci. 2016;24(5):535-542. 17. Versiani MA, Ordinola-Zapata R, Keles A, Alcin H, Bramante

CM, Pécora JD, et al. Middle mesial canals in mandibular first molars: a micro-CT study in different populations. Arch Oral Bio. 2016;61:130-137. 18. 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. 19. Caputo BV, Noro Filho GA, de Andrade Salgado DM, et al. Evaluation of the root canal morphology of molars by using cone-beam computed tomography in a Brazilian population: part I. J Endod. 2016;42(11):1604-1607. 20. Estrela C, Bueno MR, Couto GS, et al. Study of Root Canal Anatomy in human permanent teeth in a subpopulation of Brazil’s center region using cone-beam computed tomography — part I. Braz Den J. 2015;26(5):530-536. 21. Carvalho TS, Lussi A. Age-related morphological, histological and functional changes in teeth. J Oral Rehab. 2017;44(4):291-298. 22. De Moor RJG, Deroose CAJG, Calberson FLG, The radix entomolaris and paramolaris: clinical approach in endodontics. J Endod. 2007;33(1):58-63. 23. Carlsen O, Alexandersen V. Radix entomolaris: identification and morphology. Scand J Dent Res. 1990;98(5):363-373. 24. Carlsen O, Alexandersen V. Radix paramolaris in permanent mandibular molars: identification and morphology. Scand J Dent Res. 1991;99(3):189-195. 25. de Toubes KM, Côrtes MI, Valadares MA, et al. Comparative analysis of accessory mesial canal identification in mandibular first molars by using four different diagnostic methods. J Endod. 2012;38(4):436-441. 26. 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.

The Full Package

Strength. Durability. Performance. Price. We know most everyone has taken a hit during these challenging times, so we’re continuing our BUY 5 GET 1 FREE special on all our Ultrasonic Tips and Finishing Files throughout 2021. Thank you to our growing number of loyal customers!

Starting at

Buy Online:

Made In:

TunUltrasonics.com Volume 14 Number 1

Call to Order:

Ask Your Rep:

(262) 501-0075 Endodontic practice 19

RESEARCH

Acknowledgments

TECHNIQUE

GentleWave® facilitates disinfection and obturation of hidden middle mesial anatomy — a case series Drs. Michael W. Ford and Gerald N. Glickman discuss a promising technique to manage mandibular molar middle mesial anatomy and other complex anatomy Abstract Thorough cleaning and disinfection of the root canal system is the prerequisite for successful endodontic treatment. Hidden anatomy within the mesial roots of mandibular molars poses a special challenge to cleaning. This case series presents five treatments where the middle mesial anatomy of mandibular molars was accessed and identified only after multisonic irrigant cleaning and subsequent obturation. Follow-up radiographs demonstrated healing of the periapical lesions (where present). Multiple cases of uninstrumented, but obturated middle mesial anatomy have not been previously reported.

Introduction

Therefore, it is incumbent upon the clinician to apply an appropriate treatment strategy for maximum cleaning and disinfection efficacy. The following case series describes the use of a new multisonic approach that may help detect and clean middle mesial anatomy. This multisonic approach, known as the GentleWave® System (Sonendo, Inc.) consists of a console and a Procedure Instrument (PI). It has been developed as a neoteric approach for cleaning and disinfection of the root canal system in a way that appears to be superior to conventional methods.19-22

Case series Similarities in all cases For brevity, please note that all case treatments would demonstrate the following:

Treatment options were discussed with the patient, and informed consent was obtained. All patients received local anesthetic followed by the placement of a dental dam. A dental operating microscope (DOM) was used for the entirety of the procedures. Endodontic access, patency, and working lengths using an electronic apex locator (EAL) were established. The use of ultrasonics via ENAC OE-505™ (Osada Electric Company) was used in an attempt to locate any middle mesial anatomy but was unsuccessful. Debridement and disinfection of the root canal systems were completed using the GentleWave Procedure.10 An operator-formed platform opening into the endodontic access was created to form a fluid-tight seal on the tooth. The PI was then placed onto the platform, and the

Endodontic success depends on adequate cleaning and disinfection of the root canal system. In turn, a thorough understanding of canal morphology is fundamental to endodontic therapy.1 Otherwise, pulp tissue, debris, biofilm, and/or microorganisms may remain and contribute to a milieu favoring persistent inflammation.2 Mandibular first molars are among the most commonly treated teeth in endodontic therapy.3,4 Michael W. Ford, DDS, MS, is a private practice endodontist in Harker Heights, Texas. Dr. Ford completed his Bachelor of Science Degree from The Ohio State University and his Doctor of Dental Surgery Degree from The Ohio State University, College of Dentistry in Columbus, Ohio. Dr. Ford completed his postgraduate specialty training in endodontics with the U.S. Army, Fort Gordon, Georgia, and earned a Master’s degree in Oral Biology from the Medical College of Georgia at Augusta. Gerald N. Glickman, DDS, MS, MBA, JD, is a Professor in the Department of Endodontics at Texas A&M University College of Dentistry in Dallas, Texas. He is a Diplomate of the American Board of Endodontics (ABE) and is past President of the American Association of Endodontists, and from 2012-2013, he was President of the American Dental Education Association. Dr. Glickman is a Fellow of both the American College of Dentists and the International College of Dentists and is an associate editor for the Journal of Endodontics. Disclosure: The primary author speaks on behalf of Sonendo® and receives an honorarium.

20 Endodontic practice

Figure 1: Case 1 — 1A. Preoperative radiograph of tooth No. 30 with symptomatic irreversible pulpitis. 1B. Preoperative cross-sectional CBCT view of the mesial root. 1C. Immediate postoperative periapical radiograph. 1D. 1-week postoperative radiograph showing the filled middle mesial anatomy. 1E. 1-week postoperative cross-sectional view of the middle mesial anatomy. 1F. 4-month postoperative periapical radiograph shows the middle mesial anatomy as well as the final restoration Volume 14 Number 1

Case 1 A 27-year-old female with a history of hypertension and hypothyroidism presented to the clinic complaining of localized tooth pain. Upon presentation, the patient reported a pain level of 7 on the 11-point verbal numeric rating scale (VNRS).9 Based on the history of symptoms, clinical, and radiographic examination, tooth No. 30 was given a pulpal diagnosis of symptomatic

irreversible pulpitis and a periradicular diagnosis of symptomatic apical periodontitis, secondary to Cracked Tooth Syndrome (CTS) (Figures 1A and 1B). Three distinct canals were identified: mesiobuccal, mesiolingual, and distal canals. An EdgeFile® X7 (EdgeEndo™) size 20/.04 was used to shape all three canals and create a fluid and obturation path. Debridement and disinfection of the root canal system were completed using the GentleWave Procedure as previously described. Upon radiographic review, a distinct middle mesial anatomical configuration between the mesiobuccal and mesiolingual canals was visible. It spanned from the coronal third to the apical third and repeatedly connected and disconnected with the mesial canals (Figures 1C and 1D; CBCT Figure 1E). The patient was contacted 1 day postoperatively and reported a pain level of 0 on the VNRS and had taken only the first 800 mg Motrin (taken in our office). At the 4-month recall, it was noted that the final restoration had been placed, and the tooth was healing within normal limits (Figure 1F). The 18-month clinical and radiographic follow-up revealed the tooth was clinically asymptomatic, and the patient was pain-free.

Figure 2: Case 2 — 2A. Preoperative periapical radiograph of tooth No. 19 with apical periodontitis. 2B. Preoperative intraoral photograph of the closed sinus tract located along the buccal of tooth No. 19. 2C. 3-week postoperative radiograph showing the filled middle mesial anatomy with its own apical exit. 2D. 3-week postoperative intraoral photograph shows the final restoration as well as the buccal lesion no longer present. 2E. 2-year postoperative cross-sectional CBCT view showing the filled middle mesial anatomy. 2F. 2-year postoperative radiograph shows the bone healed as well as the middle mesial anatomy. Volume 14 Number 1

Case 2 A 51-year-old male with a history of hypertension presented to the clinic complaining of swelling at the gingival margin and tooth pain with a pain rating of 10 on the VNRS. Based on the history of symptoms, clinical, and radiographic examination, a pulpal diagnosis of pulpal necrosis and a periradicular diagnosis of chronic apical abscess were made for tooth No. 19 (Figure 2A). After receiving local anesthesia, periodontal probing confirmed there were no additional periodontal concerns (Figure 2B). Four distinct canals were identified: mesiobuccal, mesiolingual, distobuccal, and distolingual. Shaping up to size EdgeFile X7 20/.04 was used in all four canals to create a fluid and obturation path. Debridement and disinfection of the root canal system were completed using the GentleWave Procedure as previously described. Posttreatment radiographs revealed a distinct and separate uninstrumented middle mesial canal commencing in the coronal third with a distinct and separate exit within the apical third. In addition, an isthmus connecting the middle mesial and mesiolingual canals was visible (Figure 2C). The patient was contacted 4 days postoperatively and reported a pain level of 0 on the VNRS. At the 3-week recall, clinical examination revealed complete healing of the sinus tract (Figure 2D). The 2-year recall indicated that the patient remained infection- and pain-free. Clinical and radiographic examination revealed furcal and periapical osseous healing, and the tooth was asymptomatic. (Figures 2E and 2F). Case 3 A 58-year-old female presented to the clinic with a localized tooth pain level of 6 on the VNRS. From the history of symptoms, clinical, and radiographic examination, a pulpal diagnosis of previously treated and a periradicular diagnosis of symptomatic apical periodontitis were made for tooth No. 30 (Figures 3A and 3B). After endodontic access, the gutta percha placed during the previous root canal therapy was removed with 0.36 ml of chloroform. Debridement and disinfection of the root canal system were completed using the GentleWave Procedure as previously described. A radiograph was taken following the GentleWave Procedure to verify the removal of the previous fill. It was noted that some obturation material remained in the distal canal; however, the mesial canal appeared mostly clear (Figure 3C). Postoperative radiographs revealed a middle mesial anatomical variation visible from the coronal third of the mesiolingual and mesiobuccal canals to the apical third Endodontic practice 21

TECHNIQUE

seal was confirmed during the GentleWave System’s leakage test with a multisonic activation of distilled water for 30 seconds. The teeth were treated using the extended GentleWave Procedure setting with 3% sodium hypochlorite for 5 minutes, distilled water for 30 seconds, 8% ethylenediaminetetraacetic acid for 2 minutes, and finally rinsed by the GentleWave System with distilled water for 15 seconds. The canals were dried with absorbent paper points and obturated using a warm vertical compaction technique with gutta percha and AH Plus® sealer (Dentsply Sirona) for a final seal. Unless contraindicated, three ibuprofen (800mg; QID PRN) were given to each patient posttreatment with a postoperative instruction sheet and after-hours emergency contact information.

TECHNIQUE where it made a separate exit near the mesiolingual canal (Figure 3D). The patient was contacted 1 day postoperatively and reported a pain level of 0 on the VNRS and had discontinued use of all NSAIDs. The 7 month and one year recalls demonstrated apparent osseous healing. The tooth was clinically asymptomatic and fully functional per the patient (Figures 3E and 3F). Case 4 An 81-year-old male with a history of hypertension presented to the clinic with localized tooth pain stating a pain level of 4 on the VNRS. From the history of symptoms, clinical, and radiographic examination, a pulpal diagnosis of symptomatic irreversible pulpitis and a periradicular diagnosis of asymptomatic apical periodontitis were made for tooth No. 19 (Figure 4A). Four distinct canals were identified: mesiobuccal, mesiolingual, distobuccal, and distolingual. An EdgeFile X7 size 25/.04, with intermittent water irrigation was used to shape all four canals and create a fluid and obturation path. Debridement and disinfection of the root canal system were completed using the GentleWave Procedure as previously described. Upon radiographic review, separate and distinct uninstrumented middle mesial anatomy was visible between the mesiobuccal and mesiolingual canals. It commenced within the coronal third before joining all three canals at an isthmus within the apical third and converging to one distinct apical exit (Figure 4B). The patient was contacted 1 day postoperatively and reported a pain level of 0 on the VNRS and had discontinued all NSAIDs. The 4-month recall indicated that the patient remained pain-free. The 14-month clinical and radiographic exam revealed that the tooth was asymptomatic and appeared radiographically normal (Figure 4C). Case 5 A 54-year-old male with a history of angioplasty presented to the clinic with a chief complaint of pain when biting that rated an 8 on the VNRS. From the history of symptoms, clinical, and radiographic examination, a pulpal diagnosis of pulpal necrosis and a periradicular diagnosis of symptomatic apical periodontitis were made for tooth No. 30 (Figure 4D). An EdgeFile X7 size 25/.04 was used to shape all three canals — mesiobuccal, mesiolingual, and distal — to create a fluid and obturation path. The GentleWave Procedure, as previously described, was used to complete debridement and disinfection of the root canal system. The patient was contacted 22 Endodontic practice

Figure 3: Case 3 — 3A. Preoperative periapical radiograph of tooth No. 30. 3B. Preoperative cross-sectional CBCT view of the mesial canals showing no filled middle mesial anatomy. 3C. Mid-treatment radiograph shows the removal of the filling material from the mesial canals. 3D. Immediate postoperative radiograph shows the filled middle mesial anatomy. 3E. 1-year 7-month postoperative cross-sectional CBCTs view shows the filled middle mesial anatomy as well as healing. 3F. 1-year 7-month postoperative periapical radiography shows the filled middle mesial anatomy and apical healing

1 day postoperatively and reported a pain level of 0 on the VNRS as well as having discontinued use of all NSAIDs. Upon radiographic examination, a middle mesial anatomical variation was visible from the coronal third to the apical third of the mesiolingual and mesiobuccal canals (Figure 4E). It joined with the mesiobuccal canal in the middle third before exiting in the apical third. At the 16-month recall, the patient remained asymptomatic; cone beam computed tomography (CBCT) appeared to reveal significant osseous healing, and the tooth remained clinically asymptomatic (Figure 4F).

Discussion The presented case studies illustrate the difference between current endodontic terminology of “middle mesial canals (MMC)” as opposed to the potential, otherwise undetected, uncleaned, and unobturated presence of complex anatomy and tissue remnants between the mesiobuccal and mesiolingual canals of mandibular molars.6,8 This complex anatomy may be better termed middle mesial anatomy (MMA). As these cases demonstrate, the area apparently debrided, cleaned, and obturated was not mechanically opened with any endodontic file or by conventional ultrasonics.

Middle mesial canals in mandibular molars are currently reported as an uncommon but well-recognized anatomical phenomena.5,7,12 However, MMA can be difficult to detect, which may lead to a greater underestimation of its incidence. Cone beam computed tomography is a powerful tool to examine root canal morphology; however, the CBCT’s ability to detect MMA, in most cases, has been shown to be low.13,14 MicroCT scans appear promising due to higher resolution but at present are not clinically feasible.13 Middle mesial canal detection requires clear visibility, specialized instruments, and extra clinician attention to avoid iatrogenic events.7 Even so, locating smaller variances of MMA would still prove difficult as it may not be confluent with the pulp chamber and thus not visibly detectable. Furthermore, morphological complexities associated with the MMC such as isthmuses, can jeopardize debridement and disinfection efficacy. In the present case series, the multisonic cleaning and debridement applied by the GentleWave Procedure, without instrumentation, allowed for obturation of the space with likely sealer only. This case series demonstrates the ability of the GentleWave Procedure to clean complex molar anatomies. No mechanical Volume 14 Number 1

Special thanks to Jami Lynn Trobaugh for her thorough and comprehensive insights and administrative support. EP

REFERENCES 1. Tabassum S, Khan FR. Failure of endodontic treatment: The usual suspects. Eur J Dent. 2016;10(1):144-147. 2. Nair PNR. Pathogenesis of apical periodontitis and the causes of endodontic failures. Crit Rev Oral Biol Med. 2004;15(6):348-381.

3. Ahmed H, Sadaf De, Rahman M. Frequency and distribution of endodontically treated teeth. J Coll Physicians Surg Pak. 2009;19(10):605-608. 4. Poorni S, Kumar R, Indira R. Canal complexity of a mandibular first molar. J Conserv Dent. 2009;12:37-40. 5. Baugh D, Wallace J. Middle mesial canal of the mandibular first molar: a case report and literature review. J Endod. 2004;30(3):185-186. 6. Vertucci FJ, Williams RG. Root canal anatomy of the mandibular first molar. J N J Dent Assoc. 1974;45(3):27-28. 7. Azim AA, Deutsch AS, Solomon CS. Prevalence of middle mesial canals in mandibular molars after guided troughing under high magnification: An in vivo investigation. J Endod. 2015;41(2):164-168. 8. Ricucci D, Siqueira JF Jr. Biofilms and apical periodontitis: Study of prevalence and association with clinical and histopathologic findings. J Endod. 2010;36(6):1277-1288.

9. Mccarthy PJ, Mcclanahan S, Hodges J, Bowles WR. Frequency of localization of the painful tooth by patients presenting for an endodontic emergency. J Endod. 2010;36(5):801-805.

Figure 4: Case 4 — 4A. Preoperative periapical radiograph of tooth No. 19 with asymptomatic irreversible pulpitis. 4B. 4-month postoperative cross-sectional CBCT view shows the middle mesial anatomy. 4C. 1-year 2-month postoperative periapical radiograph showing the final restoration as well as the middle mesial anatomy. Case 5: 4D. The preoperative radiograph of tooth No. 30 with a diagnosis of chronic apical 4E. 3-month postoperative radiograph showing the filled middle mesial anatomy. 4F. 1-year 4-month cross-sectional CBCT view showing bone healing as well as the middle mesial anatomy

10. Sigurdsson A, Garland RW, Le KT, Woo SM. 12-month healing rates after endodontic therapy using the novel Gentlewave System: a prospective multicenter clinical study. J Endod. 2016;42(7):1040-1048.

cleaning the natural MMA even when not visible on pretreatment radiographs. This may reduce the need to trough the mesial pulpal groove 1 mm-2 mm, as recommended by Azim7; unfortunately, troughing is associated with significant dentin removal and procedural complications (e.g., perforations).7,16,23 The cases presented here cannot support a claim that the GentleWave Procedure can detect the MMA in all cases. Prospective studies are required to test this hypothesis. Nevertheless, this case series suggests that the GentleWave Procedure may be a promising technique to manage mandibular molar middle mesial anatomy and other complex anatomy when present. Since not all MMA is accessible, even with troughing preparations,16 incorporating new techniques such as the GentleWave Procedure into a clinician’s armamentarium to manage various and/or unique clinical scenarios may be useful in our goal of cleansing the canal system. The present findings are the first to demonstrate in vivo evidence of canal debridement in MMA using this novel procedure. With further research and clinical findings, establishing technique(s) to clean MMA and associated anastomoses, as well as other complex anatomy, may demonstrate improved patient outcomes.

12. 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.

instrumentation or further opening of the mid-mesial areas previously described was performed. It is proposed that this case series has clinically demonstrated the “hidden” existence of the MMA complexities in contrast to the somewhat risky procedure of artificially creating a mid-mesial canal through conventional endodontic therapy practices.15-18 This new approach uses multisonic technology whereby degassed fluids are delivered into the pulp chamber to clean the root canal system through negative apical pressure and the generation of a broad spectrum of acoustic waves.19-22 Prior to utilizing the GentleWave procedure, there was no radiographic or clinical evidence of MMA in these cases. Posttreatment radiographs revealed the presence of the uninstrumented MMA with various configurations (Figures 1C, 2C, 3D, 4C, and 4E) indicating that this technique and the use of the GentleWave Procedure were able to: 1. Remove possible dentinal projections and pulp tissue, and provide a fluid path to the MMA present 2. Sufficiently debride the natural MMA without instrumentation with subsequent obturation While these findings cannot yet be said to be clinically significant, they do indicate that this technique may aid in debriding and Volume 14 Number 1

11. D’Souza AL, Rajkumar C, Cooke J, Bulpitt CJ. Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis. BMJ. 2002;324(7350):1361.

13. Ordinola-Zapata R, Bramante CM, Versiani MA, et al. Comparative accuracy of the clearing technique, CBCT, and micro-CT methods in studying the mesial root canal configuration of mandibular first molars. Int Endod J. 2017;50(1):90-96. 14. Pawar AM, Pawar M, Kfir A, et al. Root canal morphology and variations in mandibular second molar teeth of an Indian population: an in vivo cone-beam computed tomography analysis. Clin Oral Investig. 2017;21(9):2801-2809. 15. 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. 16. Kele 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. 17. Bond J, Hartwell G, Donnelly J, Portell F. Clinical management of middle mesial root canals in mandibular molars. J Endod. 1988;14(6):312-314. 18. Holtzmann L. Root canal treatment of a mandibular first molar with three mesial root canals. Int Endod J. 1997;30(6):422-423. 19. Haapasalo M, Shen Y, Wang Z, et al. Apical pressure created during irrigation with the GentleWaveTM system compared to conventional syringe irrigation. Clin Oral Investig. 2016;20(7):1525-1534. 20. Ma J, Shen Y, Yang Y, et al. In vitro study of calcium hydroxide removal from mandibular molar root canals. J Endod. 2015;41(4):553-558. 21. Mohammadi Z, Jafarzadeh H, Shalavi S, Palazzi F. Recent advances in root canal disinfection: a review. Iran Endod J. 2017;12(4):402-406. 22. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement of human molars using the GentleWave System. J Endod. 2015;41(10):1701-1705. 23. Schäfer E, Dammaschke T. Development and sequelae of canal transportation. Endod Topics. 2006;15(1):75-90.

Endodontic practice 23

TECHNIQUE

Acknowledgments

CONTINUING EDUCATION

Improving endodontic success through coronal leakage prevention: part 2 Dr. Gregori M. Kurtzman continues his discussion of coronal leakage prevention Introduction As discussed in part 1, coronal leakage is a frequent cause of endodontic failure related to salivary bacteria percolating between the coronal aspect of the tooth, down the obturated canals to lead to apical reinfection. This can be prevented by how the tooth is treated immediately before initiation of endodontic treatment through that care, and how the tooth is managed before the definitive restorative phase can be initiated.

Coronal restoration (access sealing) As microorganisms have been shown to be able to penetrate through different temporary restorative materials and a supposedly well-obturated root canal system, the use of adhesive sealers may play an important role by minimizing coronal leakage. In addition, the importance of an immediate definitive coronal seal should be emphasized after obturation of the canal system.1-3 One study reported that 70 extracted single-rooted mandibular premolars were studied to determine the length of time

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 750 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 with the companies mentioned in this article.

24 Endodontic practice

Educational aims and objectives

Part 2 of this article aims to show the reader how to improve the prognosis of root-canaltreated teeth by sealing the canal and minimizing the leakage of oral fluids and bacteria into the periradicular areas.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 29 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: •

Realize the important role that sealers may play by minimizing coronal leakage.

•

Recognize some considerations regarding the temporary restoration’s ability to prevent coronal leakage and how the material behaves under functional loading and thermocycling.

•

Recognize the role the smear layer can play to prevent sealer penetration into the dentinal tubules.

•

Recognize that irrigation is key to removal of the smear layer lining the canal walls.

•

Realize that the sealer used is as important as the core material that is placed within the canal.

needed for bacteria present in saliva to penetrate through three commonly used temporary restorative materials and through the entire root canal system obturated with the lateral condensation technique. The average time observed for contamination of access cavities sealed with gutta percha (7.85 days), IRM (12.95 days), and Cavit-G (9.80 days). Thus, indicating that even during short periods of time normally permitted between visits, complete leakage may result. IRM, a common temporary material, was shown to leak to a significantly higher degree then glass ionomers.4,5 Glass-ionomer cement due to its adhesive nature has demonstrated an ability to prevent bacterial penetration to the periapex of obturated teeth for over a 1-month period as compared to IRM or Cavit™ (3M ESPE) temporary restorations.6 Another important consideration, regarding the temporary restoration’s ability to prevent coronal leakage, is how the material behaves under functional loading and thermocycling.7 Nonadhesive temporaries present with a greater degree of marginal breakdown and increased microleakage after thermocycling and loading. There was no significant improvement with increased thickness of the temporary material.8-10 When teeth were sealed with IRM, recontamination was detected within 13.5 days in the canals

Figure 1: Temporary restoration using the glass ionomer Fugi Triage® Pink (GC America, Alsip, Illinois) to seal endodontic access

medicated with chlorhexidine, after 17.2 days in the group medicated with Ca(OH)2 and after 11.9 days in the group medicated with both chlorhexidine and Ca(OH)2. The group that had no medication but was sealed with IRM demonstrated recontamination after 8.7 days. Statistically significant differences between the teeth with or without coronal seal were observed. A coronal seal delayed but did not prevent leakage of microorganisms.11 This has been confirmed in other studies that IRM started to leak after 10 days, whereas Cavit and Dyract® (Dentsply) leaked after 2 weeks.12,13 Utilization of a resin-based temporary restorative material or glass ionomer over partially removed resin composite restorations could be beneficial in achieving better Volume 14 Number 1

Results indicate that the sealing ability of adhesive and flowable materials can decrease coronal leakage potential.21 Because of the risk of coronal microleakage, endodontically treated teeth should be restored as quickly as possible.22 It is more prudent to use a permanent restorative material for provisional restorations to prevent potential for coronal leakage and the resulting risk of bacterial penetration through the canal system between endodontic treatment appoointments.23 To minimize the potential of perforation when re-entering the tooth to place either a post at a subsequent appointment or for endodontic retreatment should that be necessary at a later date, placement of a contrasting colored resin over each orifice may be beneficial. This is followed by

covering the entire pulpal floor with a toothcolored flowable resin (Figures 4-6). These are available in a multitude of easily identifiable colored flowable composites available in pink (PermaFlo® Pink) or purple (PermaFlo® Purple) from Ultradent (South Jordan, UT) or dark blue from DenMat (Santa Maria, CA). Coronal microleakage has received considerable attention as a factor related to failure of endodontic treatment, and much emphasis is placed on the quality of the final restoration. Intracanal posts are frequently used for the retention of coronal restorations. Many authors have examined coronal microleakage with respect to gutta-percha root fillings and coronal restorations, but few have investigated the coronal seal afforded by various post systems. The seal provided

Figure 4: The pulp chamber has been etched and an adhesive applied to all surfaces

Figure 5: To assist in locating the orifices later, a contrasting color light-cure resin is applied over each orifice and cured

Figure 6: The entire pulpal floor is covered by a flowable composite and cured

Volume 14 Number 1

Figures 2 and 3: 2. Placement of an immediate coronal restoration with Fugi IX™ (GC America, Alsip, Illinois) glass ionomer following endodontic therapy with evident periapical lesion. (Courtesy of Dr. Martin Trope). 3. Coronal seal has been maintained allowing apical healing of periapical lesion 1 year following treatment. (Courtesy of Dr. Martin Trope)

Endodontic practice 25

CONTINUING EDUCATION

resistance to marginal leakage (Figure 1). Maintaining partially removed permanent restorations does not seem to cause a problem with achieving marginal seal.14 Glass ionomers demonstrated a statistically better coronal seal then bonded composite or even a bonded amalgam preventing bacterial apical migration.15 This appears to be related to the glass ionomer’s ability to adhere to sclerotic dentin found on the pulpal floor better then adhesive resins.16 Key to healing of periapical lesions following completion of endodontic treatment seems to be locking out coronal bacteria, and the apical area will heal (Figures 2 and 3). Mineral trioxide aggregate (MTA) has since its introduction been advocated as a sealing material especially when perforation has occurred. But an investigation found mild inflammation was observed in 17% and 39% of the roots with and without an orifice plug, respectively; without development of severe inflammation, the sealing efficacy of MTA orifice plugs could not be determined.17,18 Should amalgam be the material of choice for the dentist, a bonded amalgam produced significantly less leakage than did the non-bonded amalgams. To prevent the reinfection of the endodontically treated molar, it may be preferable to restore the tooth immediately after obturation by employing a bonded amalgam coronalradicular technique.19 Whereas, good longterm leakage resistance with a core buildup or access closure, with adhesive materials has been shown. A GI base with overlaying composite (referred to as the “sandwich” technique) or a composite resin restoration allowed significantly less coronal leakage than glass ionomer cement restorations. This may be because the composite resin prevents salivary dissolution of the glass ionomer long term.20

CONTINUING EDUCATION

Figures 7 and 8: 7. Periapical lesions present associated with lower premolar and molar obturated with a resin obturation at completion of endodontic treatment. (Courtesy of Dr. Joseph Maggio). 8. Seven months post completion of endodontic treatment, showing lose of coronal restorations, yet apical lesions seen previously have resolved significantly due to the coronal leakage prevention afforded by the resin obturation. (Courtesy of Dr. Joseph Maggio)

by a cemented post depends on the seal of the cement used. It appears that the dentinbonding cements (adhesive resins and glass ionomers) have less microleakage than the traditional, non-dentin-bonding cements (i.e., zinc phosphates and polycarboxolates).24 Resin fiber and glass fiber posts showed lower coronal leakage when compared with metal (stainless steel or titanium) and zirconia posts. This may be related to superior adhesion of the luting agent to these resin impregnated posts than to metal or ceramic posts, which do not allow adhesive penetration to the surface of the post. There were no significant differences between resin fiber and glass fiber posts at any time period. The initial leakage measurement in zirconia and metal posts were similar but became significantly different at 3 and 6 months. Those resin fiber and glass fiber posts tested exhibited less microleakage compared to zirconia post systems.25

Cleansing the canal (smear layers) Coronal sealing ability is not the only factor that influences the seal of the canal and prevents apical leakage. How well the sealer adheres to the canal walls is also important. Smear layer can play a factor, which may prevent sealer penetration into the dentinal tubules. The frequency of bacterial penetration through teeth obturated with intact smear layer (70%) was significantly greater than that of teeth from which the smear layer had been removed (30%). Smear layer removal enhanced sealability as evidenced by increased resistance to bacterial penetration.26 Apical leakage incidence was reduced in the absence of the smear, 26 Endodontic practice

Figure 9: SEM demonstrating microgap formation with AH-26 epoxy sealer due to polymerization shrinkage. (ES – epoxy sealer, D – dentin)

Figure 10: SEM demonstrating intimate contact with methacrylic sealer and dentinal tubule penetration of the sealer. (RS – methacrylic sealer, D – dentin)

and the adaptation of gutta percha was improved no matter what obturation method was used later.27-29 However, regardless of the obturation technique (single cone, lateral, vertical condensation, or thermoplastized), when a nonadhesive sealer was utilized, leakage increased after 30 days.30 What material used for obturation of the canals is important; however, the manner in which the canal was prepared prior to obturation also determines how well the canal is sealed when treatment is completed. Rotary instrumentation with NiTi files has demonstrated less microleakage than hand instrument prepared canals irrespective of what was used to obturate the canal.31 The better the canal walls are prepared, the more smear layer and organic debris is removed, which is beneficial to root canal sealing. NiTi rotary instrument machining of the canal walls provides a smoother canal wall and shapes that are easier to obturate than can be achievable with hand files. The resulting

better adaptation of obturation material to the instrumented dentinal walls, the less leakage is to be expected along the entire root length. Smear layer removal is best achieved by irrigating the canals with sodium hypochlorite (NaOCL) followed by 17% EDTA solution,32,33 whereas the NaOCL dissolves the organic component of the smear layer exposing the dentinal tubules lining the canal walls. EDTA, a chelating agent, dissolves the inorganic portion of the dentin opening the dentinal tubules. Alternating between the two irrigants as the instrumentation is being performed will permit removal of more organic debris further into the tubules, increasing resistance to bacterial penetration once the canal is obturated.34-36

Obturation The purpose of the obturation phase of endodontic treatment is twofold: to prevent microorganisms from re-entering the root Volume 14 Number 1

Volume 14 Number 1

Endodontic success is multifactorial. The full picture, like a jigsaw puzzle, can only be seen when all the pieces are fit together. How the canals are instrumented is as important as what is used to obturate the canal system.

the second day. Results indicated that none of the ZOE formulations tested could predictably produce a fluid-tight seal even up to the 4th day.41 AH-26® (Dentsply), an epoxy sealer originally introduced over 40 years ago, was also unable to bond to gutta percha, leading to coronal leakage issues. Leakage with AH-26 was not dependent on obturation technique showing gross leakage increasing within the first 4 months following obturation when coronally challenged. Coronal leakage was significantly greater during the first 4 months.42 Complete bacterial leakage with AH-26 may be seen in as few as 8.5 weeks should the coronal restoration permit leakage.43 Additionally, in vitro studies found gutta percha and AH-26 or AH-26 Plus permitted leakage of both bacteria and fungi. Leakage in experimental teeth occurred between 14 and 87 days with 47% of the samples showing leakage. AH-26 sealer permitted bacterial leakage in 45% and fungi leakage in 60% samples. Whereas the samples with AH Plus demonstrated bacterial leakage in 50% and fungi 55% of the samples. There was no statistically significant difference in penetration of bacteria and fungi between the two versions of the sealer.44 As AH-26 is unable to bond to gutta percha, polymerization shrinkage of the epoxy resin can result in a microgap leading to the leakage reported in the literature. (Figure 9) The goal is creation of a monoblock with no interspersed gaps between the canal wall, gutta percha (or alternative cone material), and sealer (Figure 10). Should the practitioner wish to continue using these materials, a permanent restoration needs to be placed at the appointment when endodontic therapy is completed. Traditional sealers that have been in use in endodontics for many decades exhibit some cytotoxicity, especially if any extrudes apically during the obturation phase of treatment.45

These include calcium hydroxide Ca(OH)2 and zinc oxide eugenol (ZOE)-based sealers. An additional problem with these type sealers is when coronal leakage occurs, the sealer is prone to dissolution increasing leakage and the potential for endodontic failure. This has led to research to find alternative sealers with better properties that can resist coronal leakage and are more biocompatible. Bioceramic sealers have been used increasingly in endodontics over the past 10 years. These materials are calcium silicate in chemistry. Studies have evaluated their physical properties, biocompatibility, sealing ability, adhesion, solubility, and antibacterial efficacy.46 These materials have been used in orthopedics for several decades, and biocompatibility has been verified with the material being non-host reactive following placement.47 The use as a replacement sealer in endodontic treatment was an extension of the success observed in orthopedics and its biocompatibility and ability to resist dissolution when challenged with fluids.48,49 Additionally, antimicrobial effects have been reported for various bioceramic sealers currently available for clinical use.50, 51 When compared to epoxy resin sealers (AH-26), calcium silicate sealers exerted higher antimicrobial effects against E faecalis biofilms for longer periods of time.52 These bioceramic sealers are provided as either ready-to-use sealers consisting of only one component (does not require mixing) with a need for external water supply from fluid in the canal system when obturation occurs and two component sealers with internal water supply that is mixed prior to use. Both of these material types have the similar setting reactions, whereby a hydration reaction of the calcium silicate is followed by a precipitation reaction of calcium phosphate.53 The result upon setting is a relatively insoluble sealer that can resist coronal leakage, thereby Endodontic practice 27

CONTINUING EDUCATION

canal system and to isolate any microorganisms that may remain within the canal system from nutrients in oral or tissue fluids. No matter how well we seal the canal, if the coronal portion of the tooth is not thoroughly sealed, then bacterial leakage may just be a matter of time. Accessory canals maybe present in the pulp chamber leading to the furcation area, which may be an additional source of leakage that often goes unaddressed either following obturation of the canal system or during the restorative phase. Placement of a layer of resin-modified glass ionomer cement or an adhesive resin to seal this area immediately following obturation can prevent leakage prior to final restoration of the tooth.37 But success can only be achieved if the root canal system has been as thoroughly debrided as possible of pulpal tissue and the bacteria associated with it lining the canal system walls (smear layer). To this goal, irrigation is key to removal of this smear layer lining the canal walls. The obturation material is a doubleedged sword. Which sealer is used is as important as which core material is placed within the canal. Gutta percha has limitations in resistance to coronal leakage which have been overcome with the newer resin alternatives. Although sealers can form close adhesion to the root canal wall, none is able to bond to the gutta-percha core material. Upon setting, shrinkage of the sealer allows the sealer to pull away from the gutta-percha core, leaving a microgap gap through which bacteria may pass.38 Several alternatives are available for core material selection. Gutta percha demonstrates leakage in 80% of specimens related to coronal leakage when inadequate coronal sealing is not achieved, which is not dependent on obturation technique nor which sealer was used.39 Because of these limitations seen with gutta percha, the seal of a coronal restoration may be as important as the gutta-percha fill-in preventing reinfection of the root canal.40 The significance of this is, should the coronal break down, the adhesive obturation material may slow down or prevent apical migration of bacteria allowing healing to occur (Figures 7 and 8). Sealer selection is very important in prevention of microleakage and permits a bond to the core material. Zinc oxide and eugenol (ZOE) sealers have been a mainstay in endodontic therapy for over 100 years. When exposed to coronal leakage, ZOE sealers demonstrated complete leakage by

CONTINUING EDUCATION preventing reinfection of the canal system from salivary bacteria.

Conclusion Of 41 articles published between 1969 and 1999 (the majority from the 1990s), the literature suggests that the prognosis of root-canal-treated teeth can be improved by sealing the canal and minimizing the leakage of oral fluids and bacteria into the periradicular areas as soon as possible after the completion of root canal therapy.54 Endodontic success is multifactorial. The full picture, like a jigsaw puzzle, can only be seen when all the pieces are fit together. How the canals are instrumented is as important as what is used to obturate the canal system. This is also influenced by what is placed coronally and when the coronal aspect is sealed. NiTi rotary instruments and an irrigation protocol that includes NaOCL and EDTA will maximize the sealing ability of glass ionomer or the newer methacrylic resin sealers. The last piece of the puzzle — sealing coronally — should be performed with adhesive permanent restorative materials immediately at the conclusion of the first endodontic appointment to prevent apical migration of bacteria and assure sealability of the canals. EP

REFERENCES 1. Imura N, Otani SM, Campos MJA, Jardim EG, Zuolo ML. Bacterial penetration through temporary restorative materials in root-canal-treated teeth in vitro. Inter Endod J. 1997;30:381-385 2. Uranga A, Blum JY, Esber S, Parahy E, Prado C.: A comparative study of four coronal obturation materials in endodontic treatment. J Endod. 1999;25(3):178-180. 3. Fox K, Gutteridge DL.: An in vitro study of coronal microleakage in root-canaltreated teeth restored by the post and core technique. Int Endod J. 1997;30(6):361-368 4. Barthel CR, Zimmer S, Wussogk R, Roulet JF.: LongTerm bacterial leakage along obturated roots restored with temporary and adhesive fillings. J Endod. 2001;27(9):559-562 5. Babu NSV, Bhanushali PV, Bhanushali NV, Patel P. Comparative analysis of microleakage of temporary filling materials used for multivisit endodontic treatment sessions in primary teeth: an in vitro study. Eur Arch Paediatr Dent. 2019;20(6):565-570. 6. Barthel CR, Strobach A, Briedigkeit H, Gobel UB, Roulet JF. Leakage in roots coronally sealed with different temporary fillings. J Endod. 1999;25(11):731-734 7. Balkaya H, Topçuoğlu HS, Demirbuga S. The Effect of Different Cavity Designs and Temporary Filling Materials on the Fracture Resistance of Upper Premolars. J Endod. 2019;45(5):628-633. 8. Mayer T, Eickholz P. Microleakage of temporary restorations after thermocycling and mechanical loading. J Endod. 1997;23(5):320-322 9. Deveaux E, Hildelbert P, Neut C, Boniface B, Romond C. Bacterial microleakage of Cavit, IRM, and TERM. Oral Surg Oral Med Oral Pathol. 1992;74(5):634-643 10. Deveaux E, Hildelbert P, Neut C, Romond C. Bacterial

28 Endodontic practice

microleakage of Cavit, IRM, TERM, and Fermit: a 21-day in vitro study. J Endod. 1999;25(10):653-659 11. Gomes BP, Sato E, Ferraz CC, Teixeira FB, Zaia AA, SouzaFilho FJ. Evaluation of time required for recontamination of coronally sealed canals medicated with calcium hydroxide and chlorhexidine. Int Endod J. 2003 Sep;36(9):604-609. 12. Balto H.: An assessment of microbial coronal leakage of temporary filling materials in endodontically treated teeth. J Endod. 2002;28(11):762-764. 13. Balto H, Al-Nazhan S, Al-Mansour K, Al-Otaibi M, Siddiqu Y. Microbial leakage of Cavit, IRM, and Temp Bond in post-prepared root canals using two methods of guttapercha removal: an in vitro study. J Contemp Dent Pract. 2005;6(3):53-61. 14. Tulunoglu O, Uctasli MB, Ozdemir S.: Coronal microleakage of temporary restorations in previously restored teeth with amalgam and composite. Oper Dent. 2005;30(3):331-7. 15. Nup C, Boylan R, Bhagat R, Ippolito G, Ahn SH, Erakin C, Rosenberg PA. An evaluation of resin-ionomers to prevent coronal microleakage in endodontically treated teeth. J Clin Dent. 2000;11(1):16-19. 16. Karakaya S, Unlu N, Say EC, Ozer F, Soyman M, Tagami J. Bond strengths of three different dentin adhesive systems to sclerotic dentin. Dent Mater J. 2008;27(3):471-479. 17. Mah T, Basrani B, Santos JM, Pascon EA, Tjaderhane L, Yared G, Lawrence HP, Friedman S.: Periapical inflammation affecting coronally-inoculated dog teeth with root fillings augmented by white MTA orifice plugs. J Endod. 2003;29(7):442-446. 18. Alves AMH, Pozzobon MH, Bortoluzzi EA, et al. Bacterial penetration into filled root canals exposed to different pressures and to the oral environment-in vivo analysis. Clin Oral Investig. 2018;22(3):1157-1165. 19. Howdle MD, Fox K, Youngson CC.: An in vitro study of coronal microleakage around bonded amalgam coronalradicular cores in endodontically treated molar teeth. Quintessence Int. 2002;33(1):22-29. 20. Kleitches AJ, Lemon RR, Jeansonne BG. Coronal microleakage in conservatively restored endodontic access preparations. J Tenn Dent Assoc. 1995;75(1):31-34. 21. Shindo K, Kakuma Y, Ishikawa H, Kobayashi C, Suda H. The influence of orifice sealing with various filling materials on coronal leakage. Dent Mater J. 2004;23(3):419-423. 22. de Souza FD, Pecora JD, Silva RG. The effect on coronal leakage of liquid adhesive application over root fillings after smear layer removal with EDTA or Er:YAG laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(1):125-128.

32. Morago A, Ruiz-Linares M, Ferrer-Luque CM, Baca P, Rodríguez Archilla A, Arias-Moliz MT. Dentine tubule disinfection by different irrigation protocols. Microsc Res Tech. 2019;82(5):558-563. 33. Nogo-Živanović D, Kanjevac T, Bjelović L, Ristić V, Tanasković I. The effect of final irrigation with MTAD, QMix, and EDTA on smear layer removal and mineral content of root canal dentin. Microsc Res Tech. 2019;82(6):923-930. 34. Clark-Holke D, Drake D, Walton R, Rivera E, Guthmiller JM. Bacterial penetration through canals of endodontically treated teeth in the presence or absence of the smear layer. J Dent. 2003;31(4):275-81. 35. Vivacqua-Gomes N, Ferraz CC, Gomes BP, Zaia AA, Teixeira FB, Souza-Filho FJ. Influence of irrigants on the coronal microleakage of laterally condensed gutta-percha root fillings. Int Endod J. 2002;35(9):791-5. 36. Zaparolli D, Saquy PC, Cruz-Filho AM. Effect of sodium hypochlorite and EDTA irrigation, individually and in alternation, on dentin microhardness at the furcation area of mandibular molars. Braz Dent J. 2012;23(6):654-658. 37. Carrotte P.: Endodontics: Part 8. Filling the root canal system. Br Dent J. 2004;197(11):667-672. 38. Teixeira FB, Teixeira EC, Thompson J, Leinfelder KF, Trope M.:Dentinal bonding reaches the root canal system. J Esthet Restor Dent. 2004;16(6):348-54. 39. Maggio JD.: RealSeal--the real deal. Compend Contin Educ Dent. 2004;25(10A):834, 836. 40. Shipper G, Trope M.: In vitro microbial leakage of endodontically treated teeth using new and standard obturation techniques. J Endod. 2004;30(3):154-158. 41. Tewari S, Tewari S.: Assessment of coronal microleakage in intermediately restored endodontic access cavities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(6):716-9. 42. De Moor RJ, Hommez GM.: The long-term sealing ability of an epoxy resin root canal sealer used with five gutta percha obturation techniques. Int Endod J. 2002;35(3):275-282. 43. Chailertvanitkul P, Saunders WP, MacKenzie D, Weetman DA. An in vitro study of the coronal leakage of two root canal sealers using an obligate anaerobe microbial marker. Int Endod J. 1996;29(4):249-255. 44. Miletic I, Prpic-Mehicic G, Marsan T, Tambic-Andrasevic A, Plesko S, Karlovic Z, Anic I. Bacterial and fungal microleakage of AH26 and AH Plus root canal sealers. Int Endod J. 2002;35(5):428-32. 45. Fonseca DA, Paula AB, Marto CM, et al. Biocompatibility of Root Canal Sealers: A Systematic Review of In Vitro and In Vivo Studies. Materials (Basel). 2019;12(24):4113.

23. Uranga A, Blum JY, Esber S, Parahy E, Prado C. A comparative study of four coronal obturation materials in endodontic treatment. J Endod. 1999;25(3):178-180.

46. Al-Haddad A, Che Ab Aziz ZA. Bioceramic-Based Root Canal Sealers: A Review. Int J Biomater. 2016;2016: 9753210.

24. Ravanshad S, Ghoreeshi N. An in vitro study of coronal microleakage in endodontically-treated teeth restored with posts. Aust Endod J. 2003;29(3):128-133.

47. Oonishi H, Hench LL, Wilson J, et al. Comparative bone growth behavior in granules of bioceramic materials of various sizes. J Biomed Mater Res. 1999;44(1):31-43.

25. Usumez A, Cobankara FK, Ozturk N, Eskitascioglu G, Belli S. Microleakage of endodontically treated teeth with different dowel systems. J Prosthet Dent. 2004;92(2):163-169.

48. Al-Haddad A, Che Ab Aziz ZA. Bioceramic-Based Root Canal Sealers: A Review. Int J Biomater. 2016;2016: 9753210.

26. Behrend GD, Cutler CW, Gutmann JL. An in-vitro study of smear layer removal and microbial leakage along root-canal fillings. Int Endod J. 1996;29(2):99-107 27. Karagoz-Kucukay I, Bayirli G. An apical leakage study in the presence and absence of the smear layer. Int Endod J. 1994;27(2):87-93 28. Saunders WP, Saunders EM.: Influence of smear layer on the coronal leakage of Thermafil and laterally condensed gutta-percha root fillings with a glass ionomer sealer. J Endod. 1994;20(4):155-158.

49. Jitaru S, Hodisan I, Timis L, Lucian A, Bud M. The use of bioceramics in endodontics - literature review. Clujul Med. 2016;89(4):470-473. 50. Bukhari S, Karabucak B. The Antimicrobial Effect of Bioceramic Sealer on an 8-week Matured Enterococcus faecalis Biofilm Attached to Root Canal Dentinal Surface. J Endod. 2019;45(8):1047-1052. 51. Du TF, Wu LD, Tang XZ, et al. Zhonghua Kou Qiang Yi Xue Za Zhi. 2019;54(10):656-661.

29. Gencoglu N, Samani S, Gunday M. Dentinal wall adaptation of thermoplasticized gutta-percha in the absence or presence of smear layer: a scanning electron microscopic study. J Endod. 1993;19(11):558-562.

52. Alsubait S, Albader S, Alajlan N, Alkhunaini N, Niazy A, Almahdy A. Comparison of the antibacterial activity of calcium silicate- and epoxy resin-based endodontic sealers against Enterococcus faecalis biofilms: a confocal laser-scanning microscopy analysis. Odontology. 2019;107(4):513-520.

30. Pommel L, Camps J. In vitro apical leakage of system B compared with other filling techniques. J Endod. 2001;27(7):449-451.

53. Donnermeyer D, Bürklein S, Dammaschke T, Schäfer E. Endodontic sealers based on calcium silicates: a systematic review. Odontology. 2019;107(4):421-436.

31. von Fraunhofer JA, Fagundes DK, McDonald NJ, Dumsha TC. The effect of root canal preparation on microleakage within endodontically treated teeth: an in vitro study. Int Endod J. 2000;33(4):355-360.

54. Heling I, Gorfil C, Slutzky H, Kopolovic K, Zalkind M, Slutzky-Goldberg I. Endodontic failure caused by inadequate restorative procedures: review and treatment recommendations. J Prosthet Dent. 2002;87(6):674-678.

Volume 14 Number 1

REF: EP V14.1 KURTZMAN

FULL NAME

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

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise, and judgment of a trained healthcare professional.

TELEPHONE/FAX

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

Your CE certificate(s) will be emailed to the address you provided above. Please add medmarkmedia.com to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

Improving endodontic success through coronal leakage prevention: part 2 KURTZMAN

Glass-ionomer cement due to its adhesive nature has demonstrated an ability to prevent bacterial penetration to the periapex of obturated teeth for over a _______ period as compared to IRM or Cavit™ (3M ESPE) temporary restorations. a. 2-week b. 1-month c. 6-week d. 2-month

2. Nonadhesive temporaries present with _______. a. a greater degree of marginal breakdown b. increased microleakage after thermocycling and loading c. decreased microleakage after thermocycling and loading d. both a and b 3. Utilization of a resin-based temporary restorative material or glass ionomer over partially removed resin composite restorations ________ achieving better resistance to marginal leakage. a. could be beneficial in b. has no positive aspects on c. can interfere with d. is the only choice for 4. Should amalgam be the material of choice for the dentist, a bonded amalgam ________ leakage than

Volume 14 Number 1

did the non-bonded amalgams. a. had an equal amount of b. produced significantly more c. produced significantly less d. none of the above 5. Results indicate that the sealing ability of adhesive and flowable materials can _____ coronal leakage potential. a. decrease b. increase c. totally eliminate d. multiply 6. It appears that the dentin-bonding cements (adhesive resins and glass ionomers) have _______ the traditional, non-dentin bonding cements (i.e., zinc phosphates and polycarboxolates). a. an equal amount of microleakage as b. more microleakage than c. less microleakage than d. a worse track record than 7.

The frequency of bacterial penetration through teeth obturated with intact smear layer ( ____ ) was significantly greater than that of teeth from which the smear layer had been removed (30%). a. 50% b. 60%

c. 70% d. 80% 8.

Regardless of the obturation technique (single cone, lateral, vertical condensation, or thermoplastized), when a nonadhesive sealer was utilized, leakage __________. a. decreased after 14 days b. increased after 30 days c. decreased after 30 days d. stayed the same after 30 days

9. Gutta percha demonstrates leakage in _____ of specimens related to coronal leakage when inadequate coronal sealing is not achieved, which is not dependent on obturation technique nor which sealer was used. a. 30% b. 50% c. 60% d. 80% 10. Bioceramic sealers have been used increasingly in endodontics over the past _____ years. a. 10 b. 20 c. 30 d. 40

Endodontic practice 29

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Accuracy of electronic apex locators in singlerooted teeth during endodontic retreatment with chloroform — an ex vivo study Drs. David Keinan, Aviv Shmuel, Shlomi Ritz, and Iris Slutzky-Goldberg study the effects of the presence of chloroform in the canal during retreatment Abstract Objectives The aim of the study was to evaluate the accuracy of the Apex NRGXFR and Apit11 electronic apex locators (EALs) in the presence of chloroform during endodontic retreatment ex vivo. Methods and materials Thirty-five extracted single-rooted teeth were used in this study. Following access cavity preparation, the actual (AL) and electronic (EL-1) canal lengths were measured. The teeth were divided into four groups. Group O (5 teeth) was the negative control. Electronic measurements were performed in empty canals (EL-2). In group A (10 teeth), canals were filled with chloroform, and electronic measurements were performed (EL-2). The remaining teeth were obturated. After 7 days, the root fillings were removed using chloroform and stainless-steel files; these teeth were divided into groups B and C (10 teeth each). In group B, the electronic length during retreatment (EL-2) was measured when patency was achieved. In group C, the EL-2 was measured after chloroform had been allowed to evaporate for 10 minutes. The EL-1 and EL-2 were compared to the AL. Results The average EL-1-AL distances using the Apex NRGXFR and Apit11 were 0.6157 mm ± 0.1179 mm and 0.5297 mm ± 0.8993 mm, respectively; the EL-1 was significantly shorter than the AL (p < 0.01). The average AL-EL-2 distances using the Apex NRGXFR and Apit11 were 1.0 ± 0.6152 mm and 0.5667 ± 0.5381 mm, respectively; the Drs. David Keinan, Aviv Shmuel, Shlomi Ritz, and Iris SlutzkyGoldberg are affiliated with the Department of Endodontics, faculty of dental medicine, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel 91120.

30 Endodontic practice

Educational aims and objectives

This article aims to evaluate the accuracy of two electronic apex locators (EALs) in the presence of chloroform during endodontic retreatment ex vivo.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 34 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: •

Realize some history of electronic apex locators (EALs) and the limitations of earlier models.

•

Realize some positive aspects of the newer generation of EALs.

•

Recognize the effect of chloroform alone or in combination with gutta percha on the accuracy of electronic apex locators.

•

Realize other factors that may influence measurement accuracy.

•

Recognize why the use of an EAL is important for accurate determination of WL.

EL-2 was significantly shorter than the AL (p < 0.05). In group A, the readings (EL-2) were longer for both EALs than for the EL-1 (p < 0.01). In group B, the EL-2 reading was not significantly longer than the AL using both EALs. In group C, the AL-EL-2 distance was shorter than the AL-EL-1 distance using both EALs (p < 0.05). Conclusion The presence of chloroform in the canal during retreatment is associated with inaccurate prolonged EAL measurements.

Introduction Determining the apical terminus of a root canal during preparation is an important step in root canal treatment. Thus, electronic apex locators (EALs) are currently used in root canal treatment. The use of EALs is based on the findings of Custer in 1918 and Suzuki in 1942; they reported a constant difference in electrical resistance between the oral mucosa and the root canal.1 The first EALs had several limitations, particularly regarding the presence of fluids inside the root canal.2 These limitations restricted their use, and the necessary working length (WL) was determined based on radiographic

estimation of the canal length, combined with obtaining a tactile sensation in the apical constriction using an endodontic file.3 The distance between the radiographic apex and the location of the apical foramen can be diverse,4 and the apical constriction can assume a wide range of locations and histological shapes within the canal;5 thus, prudent clinicians used EALs to determine the WL.6,7 New generations of EALs that are more user-friendly and precise have become available. These devices are not affected by the presence of solutions in the root canal.8,9 EALs are highly accurate, as evidenced by a clinically accepted tolerance of 0.5 mm –1 mm.10 Various factors may influence measurement accuracy, including the pulp status11,12 and type of EAL used.13,14 Notably, the presence of solutions in the canal during root canal retreatment affects the accuracy of measurements using EALs.15-18 The apical extent of canal filling is an important prognostic factor for root canal treatment, including retreatment.19-21 The use of apex locators during endodontic retreatment has been evaluated.22-24 However, controversy exists regarding their accuracy for WL determination after removal of the root canal filling material.24 Volume 14 Number 1

CONTINUING EDUCATION

In a study regarding the effects of organic solvents on the accuracy of EAL, electronic measurements were conducted after the canal had been filled with chloroform, orange solvent, or eucalyptol. There were no differences among the solvents or devices used.15 In contrast, after the removal of gutta percha, the Root ZX Mini (J. Morita) yielded a reading shorter than the actual WL in the presence of Guttasolv (Septodont), Endosolv R (Septodont), and Resosolv (Acteon).24 The aim of this study was to evaluate the effect of chloroform alone or in combination with gutta percha on the accuracy of two electronic apex locators during endodontic retreatment.

Methods and materials The protocol was adapted from the method used by Alves, et al.23 Thirty-five extracted intact, straight, single-rooted human teeth with completely formed roots were used. The extracted teeth were obtained from a pool of teeth that had been extracted for reasons irrelevant to the study (generally during periodontal treatment); written informed consent had been provided by all patients prior to extraction. The teeth were stored in 0.9% sterile saline until use. The teeth were serially marked to enable comparison of the results of the two apex locators. The crowns were ground to establish a flat surface, which was used as a reproducible reference point for all measurements. The access cavity was created using A3 diamond burs (Strauss Co., Israel); GatesGlidden burs Nos. 1–3 (Dentsply Maillefer, Ballaigues, Switzerland) were used to prepare the coronal third of each canal. During access cavity preparation, the canals were irrigated with saline; the patency of the apical foramen was verified using a No.10 K-File (Dentsply Maillefer). Canal length was established by passive introduction of a 15K-File (Dentsply Maillefer) into the canal until its tip was visible at the apical foramen. This procedure was conducted under 2.6 x magnification using surgical loupes (Orascoptic™). After adjustment of a silicone stop at the incisal surface, the file was removed from the canal, and the distance between the file tip and the rubber stop was measured using an endodontic ruler (Dentsply Maillefer). This measurement was repeated 3 times, and the mean value for each tooth was calculated and recorded as the actual length (AL). Next, the roots were mounted in alginate (Plastalgin, Septodont) in a plastic container. Volume 14 Number 1

Figure 1: Study design

The presence of chloroform in the canal during retreatment is associated with inaccurate prolonged EAL measurements.

Each root was passed through a central hole in the top of the container and fixed with acrylic resin to prevent movement during instrumentation. A second, smaller hole was made in the top of the container to stabilize the electrode (lip-clip) and allow it to contact the alginate; this simulated the conductivity of the periodontium. The ex vivo model was adapted and modified from the method of Kaufman, et al.25

Apex locator accuracy For each tooth, an electronic length measurement was carried out using a No. 15K-file (Dentsply Maillefer) attached to the EAL until the 0.5 marking on the Apex NRGXFR (Medic NRG Ltd., Tel Aviv, Israel) or the middle of the yellow zone for the Apit11 (Osada, Tokyo, Japan) was reached. This measurement was repeated 3 times for each apex locater; the mean value for each EAL was calculated and recorded as electronic length-1 (EL-1).

Experimental phase The 35 root canals were serially enlarged up to the apical size of a No. 45K-file (Dentsply Maillefer). The root canals were irrigated with 2.5% sodium hypochlorite for each instrument change; at the end of preparation, the canals were dried using paper points. • Group O: 5 teeth (control). These teeth did not receive root filling. The canals were irrigated with sodium hypochlorite (0.9%) prior to electronic length measurement. • Group A: 10 teeth (positive control). The root canals were filled with chloroform after preparation. • The remaining teeth were filled using lateral compaction of gutta-percha cones and AH Plus Sealer (Dentsply De Trey, Konstanz, Germany). The access cavities were sealed with Coltosol® (Coltene/Whaledent AG, Switzerland); the roots were stored at 37°C and 100% humidity for 7 days. Endodontic practice 31

CONTINUING EDUCATION The temporary fillings were removed using an A3 round diamond bur (Strauss Co., Israel), and the teeth were randomly divided into the following two groups: º Group B: 10 teeth. Following removal of the filling material from the cervical and middle thirds of the canal using Gates-Glidden drills (No. 1 and No. 2), the access cavities were filled with 0.1 mL of chloroform to soften the gutta percha. º Group C: 10 teeth. Following removal of the filling material from the cervical and middle thirds of the canal using Gates-Glidden drills (No.1 and No. 2), the access cavities were filled with 0.1 mL of chloroform to soften the gutta percha. The chloroform was allowed to evaporate for 10 minutes. The working area was kept ventilated. A No. 15K-file was inserted through the residual root canal filling. When the file reached the “APEX” signal of the EAL Apex NRGXFR (Medic NRG Ltd.) or Apit11 (Osada), a second electronic length measurement was carried out for each tooth. These measurements were repeated 3 times for each apex locater; the mean value for each EAL was calculated and recorded as electronic length-2 (EL-2) (Figure 1). All measurements were performed by the same operator (A.S.), who was blinded with respect to the true length measurements.

Table 1: AL-EL-2 readings in the presence of media in the root canal

Apit11

apexNRG

Medium in the canal

Group

Number of teeth

Mean difference Std. AL-EL-2 deviation

Significance

Saline

0.5667

0.53813

p < 0.05

Chloroform

0.1852

0.37680

p < 0.05

Gutta percha and chloroform

0.375-

0.53178

p > 0.05

Gutta percha after chloroform evaporation

0.4083

0.50986

p < 0.05

Saline

1.0000

0.61520

p < 0.05

Chloroform

0.2778

0.41248

p < 0.05

Gutta percha and chloroform

0.150-

0.4108

p > 0.05

Gutta percha after chloroform evaporation

0.4188

0.37966

p < 0.05

Differences among AL, EL-1, and EL-2 were analyzed by Student’s t-test and two-way analysis of variance. Statistical significance was set at p < 0.05.

it contained an obstruction in the root canal that prevented electronic measurement (EL-2). The results are listed in Table 1. In group O, the average AL-EL-2 distances for Apex NRGXFR and Apit11 were 1 ± 0.6152 and 0.5667 ± 0.5381 mm, respectively (p < 0.05). In group A (chloroform only), the mean readings were similar to the AL (0.1852 and 0.2778 mm for Apit11 and Apex NRGXFR, respectively); the difference in AL-EL-2 was smaller but remained significant (p < 0.01). In group B (chloroform and gutta percha), the mean differences between AL and EL-2 were −0.15 and −0.375 for the Apex NRGXFR and Apit11, respectively (p > 0.05). In group C (gutta percha, after evaporation of chloroform), the EL-2 was shorter than the AL using both EALs (p < 0.05); average differences of 0.4188 and 0.4083 mm were found for the Apex NRGXFR and Apit11, respectively.

Results

Discussion

Differences between AL and EL‑1: After gaining access to the root canal and before preparation, the mean differences between the AL and EL-1 were 0.6157 ± 0.69752 mm (p = 0.00001) and 0.5297 ± 0.89939 mm (p = 0.002) with the Apex NRGXFR and Apit11, respectively. The EL-1 reading was shorter than the AL reading for both EALs (p > 0.05).

Chloroform is still widely used as an organic solvent for GP removal during retreatment, despite concerns regarding risk of cell cytotoxicity and carcinogenicity.26 The aim of the study was to examine the possible effect of solvents on EAL’s accuracy. Accurate determination of WL is a significant prognostic factor for the outcome of root canal retreatment.19-21 Therefore, the use of EAL during endodontic retreatment is compulsory.22-24 Epidemiological studies have shown that length determination impacts the outcome of endodontic treatment.19-21 The

Statistical analysis

Experimental phase One of the teeth in group B (chloroform only) was excluded from the study because 32 Endodontic practice

apical extent of canal filling was also a significant prognostic factor for root canal retreatment,19-21 although it was recently reported that overfilling does not influence treatment outcome.27 Furthermore, apical extrusion of debris may increase the risk of flare-ups28 and persistent periapical radiolucency.28-30 Hence, locating the apical constriction is an important step during retreatment.19 The use of apex locators during endodontic retreatment has been suggested.22-24 However, their accuracy in determining the WL after removal of root canal obturation materials is controversial.23,24 Evaluation of the difference between AL and EL-1 enabled assessment of the accuracies of both apex locators. The differences in their readings were not statistically significant. Using both devices, the minor foramen was 0.5 mm–1 mm from the major foramen. These results are consistent with reports of a 0.5 mm–0.8-mm distance between the foramen and the apical constriction, depending on patient age.4,5 It should be emphasized that AL represents the major foramen and differs from the desired WL; thus, the AL was considered to be reached when the tip of the file was visible through the major foramen, which is beyond the apical terminus of the canal. Accordingly, readings shorter than the AL represent measurement locations closer to the apical constriction. Notably, a study of the efficacies of two types of EALs integrated into rotary motors to accurately determine canal length while removing the gutta percha found that the Volume 14 Number 1

Table 2: Electric conductivity (µS/cm) Chloroform36

2.67´10-4

Saline37

~45´103

NaOCl 1%37

17´104

Rc-Prep

27±0.11

Eucalyptol38

98.2-105

A comparison of electric conductivity of different materials used during root canal treatment. Volume 14 Number 1

of the other solutions used in endodontic treatment (Table 2). This effect was reversed after chloroform was allowed to evaporate in group C. In comparison, eucalyptol, which is used for dissolution of the root-filling material, has a higher electric conductivity, and the risk of disrupting the EAL reading can be reduced. Further research is needed to compare the effect of solution conductivity on EAL readings.

Conclusion Longer measurements in the presence of chloroform were observed for both apex locators. Prudent clinicians should acknowledge the potential influence of chloroform on electrical readings during endodontic retreatment. To prevent overinstrumentation and extrusion of debris to the periapical tissue because of incorrect readings, remnants of chloroform should be allowed to evaporate from the canal space prior to the use of EALs. EP

D. An in vitro evaluation of performance of two electronic root canal length measurement devices during retreatment of different obturating materials. J Endod. 2010;36(9):1526-1530. 17. Mancini M, Palopoli P, Iorio L, Conte G, Cianconi L. Accuracy of an electronic apex locator in the retreatment of teeth obturated with plastic or cross-linked gutta-percha carrier-based materials: an ex vivo study. J Endod. 2014;40(12):2061-2065. 18. Cimilli H, Aydemir S, Arican B, Mumcu G, Chandler N, Kartal N. Accuracy of the Dentaport ZX apex locator for working length determination when retreating molar root canals. Aust Endod J. 2014;40(2):2-5. 19. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498-504. 20. Ng L-Y, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of nonsurgical root canal treatment: part 1: periapical health. Int Endod J. 2011;44(7):583-609 21. Bergenholtz G, Lekholm U, Milthon R, Engstrom B. Influence of apical overinstrumentation and overfilling on re-treated root canals. J Endod. 1979;5(10):310-314. 22. Goldberg F, Marroquín BB, Frajlich S, Dreyer C. In vitro evaluation of the ability of three apex locators to determine the working length during retreatment. J Endod. 2005;31(9):676-678. 23. Alves AM, Felippe MC, Felippe WT, Rocha MJC. Ex vivo evaluation of the capacity of the Tri Auto ZX to locate the apical foramen during root canal retreatment. Int Endod J. 2005;38(10):718-724. 24. Er O, Uzun O, Ustun Y, Canakcı BC, Yalpı F. Effect of solvents on the accuracy of the Mini Root ZX apex locator. Int Endod J. 2013;46(11):1088-1095.

REFERENCES

25. Kaufman AY, Keila S, Yoshpe M. Accuracy of a new apex locator: an in vitro study. Int Endod J. 2002;35:186-192.

1. Khattak O, Raidullah E, Francis ML. A comparative assessment of the accuracy of electronic apex locator (Root ZX) in the presence of commonly used irrigating solutions. J Clin Exp Dent. 2014;6(1):41-46.

26. Ribeiro DA, Matsumoto MA, Marques ME, Salvadori DM. Biocompatibility of gutta-percha solvents using in vitro mammalian test-system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(5):e106-e109.

2. Moshonov J, Slutzky-Goldberg I. Apex locators: update and prospects for the future. Int J Comput Dent. 2004;7(4): 359-370.

27. Goldberg F, Cantarini C, Alfie D, Macchi RL, Arias A. Relationship between unintentional canal overfilling and the long-term outcome of primary root canal treatments and nonsurgical retreatments: a retrospective radiographic assessment. Int Endod J. 2020;53(1):19-26.

3. Stabholz A, Rotstein I, Torabinejad M. Effect of preflaring on tactile detection of the apical constriction. J Endod. 1995;21(2):92-94. 4. Kuttler Y. Microscopic investigation of root apexes. J Am Dent Assoc. 1955;50(5):544-552. 5. Dummer PM, McGinn JH, Rees DG. The position and topography of the apical canal constriction and apical foramen. Int Endod J. 1984;17(4):192-198. 6. Gutmann JL. Origins of the Electronic Apex Locator Achieving Success with Strict Adherence to Business. J Hist Dent. 2017;65(1):2-6. 7. Fouad AF. The use of electronic apex locators in endodontic therapy. Int Endod J. 1993;26(1):13-14. 8. Jenkins JA, Walker WA 3rd, Schindler WG, Flores CM. An in vitro evaluation of the accuracy of the root ZX in the presence of various irrigants. J Endod. 2001;27(3):209-211. 9. Fouad AF, Rivera EM, Krell KV. Accuracy of the Endex with variations in canal irrigants and foramen size. J Endod. 1993;19(2):63-67. 10. Pagavino G, Pace R, Baccetti T. A SEM study of in vivo accuracy of the Root ZX electronic apex locator. J Endod. 1998;24(6):438-441. 11. Akisue E , Gavini G , De Fiqueiredo JA. Influence of pulp vitality on length determination by using the elements diagnostic unit and apex locator. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104(4):129-32.

28. Siqueira JF Jr. Microbial causes of endodontic flare-ups. Review. Int Endod J. 2003;36(7):453-463. 29. Nair PN, Sjögren U, Krey G, Sundqvist G. Therapy-resistant foreign body giant cell granuloma at the periapex of a rootfilled human tooth. J Endod. 1990;16(12):589-595. 30. Yusuf H. The significance of the presence of foreign material periapically as a cause of failure of root treatment. Oral Surg Oral Med Oral Pathol. 1982;54(5):566-574. 31. Uzun O, Topuz O, Tinaz C, Nekoofar MH, Dummer PM. Accuracy of two root canal length measurement devices integrated into rotary endodontic motors when removing gutta-percha from root-filled teeth. Int Endod J. 2008;41(9):725-732. 32. Al-bulushi A, Levinkind M, Flanagan M, Ng YL, Gulabivala K. Effect of canal preparation and residual root filling material on root impedance. Int Endod J. 2008;41(10):892-904. 33. Herrera M, Ábalos C, Lucena C, Jiménez-Planas A, Llamas R. Critical diameter of apical foramen and of file size using the Root ZX apex locator: an in vitro study. J Endod. 2011;37(9):1306-1309. 34. American Dental Association, Council On Dental Therapeutics. Accepted Dental Therapeutics. Chicago: Council on Dental Therapeutics of the American Dental Association; 1973-1974:35.

12. Dunlap CA. Remeikis NA , BeGole EA. Rauschenberger CR. An in vivo evaluation of an electronic apex locator that uses the ratio method in vital and necrotic canals. J Endod. 1998;24(1):48-50.

35. Takahashi CM, Cunha RS, de Martin AS, Fontana CE, Silveira CF, da Silveira Bueno CE. In vitro evaluation of the effectiveness of ProTaper universal rotary retreatment system for gutta-percha removal with or without a solvent. J Endod. 2009;35(11):1580-1583.

13. Keller ME, Browen CE, Newton CW. A clinical evaluation of the Endocater — an apex locator. J Endod. 1991;17(6): 271-274.

36. Fang F, Zhang YF. DC electrical conductivity of Au nanoparticle/chloroform and toluene suspensions. J Mater Sci. 2005;40:2979-2980.

14. Arora RK, Gulabivala K. An in vivo evaluation of the ENDEX and RCM Mark II electronic apex locators in root canals with different contents. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(4):497-503.

37. Shin HS, Yang WK, Kim MR, et al. Accuracy of Root ZX in teeth with simulated root perforation in the presence of gel or liquid type endodontic irrigant. Restor Dent Endod. 2012;37(3):149-154.

15. Al-Hadlaq SM. Effect of chloroform, orange solvent and eucalyptol on the accuracy of four electronic apex locators. Aust Endod J. 2013;39(3):112-115.

38. Nikolic I, Mitsou E, Pantelic I, et al. Microstructure and biopharmaceutical performances of curcumin-loaded lowenergy nanoemulsions containing eucalyptol and pinene: Terpenes’ role overcome penetration enhancement effect? Eur J Pharm Sci. 2020;142:105135.

16. Aggarwal V, Singla M, Kabi D, Aggarwal V, Singla M, Kabi

Endodontic practice 33

CONTINUING EDUCATION

passive insertion of files was more accurate than rotating insertion; however, it led to readings beyond the foramen in both types of EALs.31 The readings in empty canals (group O) demonstrated the position of the apical constriction. The EAL readings in the presence of chloroform alone (group B) or in combination with gutta percha (group C) were longer than the apical constriction and closer to the AL. Therefore, it can be assumed that chloroform disturbs the EAL readings, leading to overinstrumentation and overfilling. This may increase postoperative pain after retreatment.28 These findings are in contrast to a report that the readings of apex locators were not affected by solutions in the root canal, including chloroform, orange solvent, and eucalyptol.15 This issue has been addressed in several studies, although the accepted tolerance was ± 0.5-1 mm,16,22 allowing overestimation of the WL. Concerns have been raised regarding inaccurate measurement of the WL during root canal retreatment.17,18,24 However, some of the reported measurements were performed without dissolving solution.17 Remnant root-filling material reportedly influences the impedance of extracted human roots,32 which may explain the longer EAL readings in group C after evaporation of chloroform. The longer readings in group B are likely attributable to coating of the file with gutta percha, which prevented contact with the canal walls, thereby disrupting EAL readings similar to the inaccurate readings obtained in very wide canals.33 Furthermore, the ADA recommends the use of other solvents during retreatment.34 In view of the results, it may be advisable to use rotary retreatment files without a solvent, as previously suggested,35 which may be safer to the patient and prevent inaccurate readings. Moreover, the presence of chloroform in the root canal prolonged readings in groups A and B. The electrical conductivity of chloroform is lower than that of most

REF: EP V14.1 KEINAN, ET AL

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

Accuracy of electronic apex locators in single-rooted teeth during endodontic retreatment with chloroform — an ex vivo study KEINAN, ET AL

The use of EALs is based on the findings of Custer in 1918 and Suzuki in 1942; they reported a constant difference in ______ between the oral mucosa and the root canal. a. electrical resistance b. pulp status c. prognostic factorization d. organic resistance

a. 0.5291 ± 0.88848 mm (p = 0.0002) and 0.6277 ± 0.68852 mm (p = 0.00001) b. 0.6007 ± 0.68652 mm (p = 0.00001) and 0.50977 ± 0.877739 mm (p = 0.002) c. 0.6157 ± 0.69752 mm (p = 0.00001) and 0.5297 ± 0.89939 mm (p = 0.002) d. 0.7157 ± 0.68852 mm (p = 0.00001) and 0.5277 ± 0.88839 mm (p = 0.002)

2. The first EALs had several limitations, particularly regarding the presence of ______ inside the root canal. a. decay b. fluids c. bacteria d. chloroform

5. (In the results) The EL-1 reading was ______ the AL reading for both EALs (p > 0.05). a. shorter than b. longer than c. equal to d. not significant to

EALs are highly accurate, as evidenced by a clinically accepted tolerance of _______. a. 0.5 mm – 1 mm b. 2 mm – 2.9 mm c. 3 mm – 3.9 mm d. none of the above

6. Chloroform is still widely used as an organic solvent for GP removal during retreatment, despite concerns regarding risk of _______. a. cell cytotoxicity b. carcinogenicity c. cognitive interactions d. both a and b 7.

4. (In the results) After gaining access to the root canal and before preparation, the mean differences between the AL and EL-1 were _______ with the Apex NRGXFR and Apit 11, respectively.

34 Endodontic practice

The EAL readings in the presence of chloroform alone (group B) or in combination with gutta percha (group C) were ______ the apical constriction and closer to the AL. a. shorter than

b. longer than c. equal to d. none of the above 8. These findings (of the reading in the canals) are in contrast to a report that the readings of apex locators were not affected by solutions in the root canal, including _______. a. chloroform b. orange solvent c. eucalyptol d. all of the above 9. In view of the results, it may be advisable to use _______, as previously suggested, which may be safer to the patient and prevent inaccurate readings. a. hand retreatment files with a solvent b. hand retreatment files without a solvent c. rotary retreatment files without a solvent d. rotary retreatment files with a solvent 10. To prevent ______ because of incorrect readings, remnants of chloroform should be allowed to evaporate from the canal space prior to the use of EALs. a. overinstrumentation b. extrusion of debris to the periapical tissue c. underfilling d. both a and b

Volume 14 Number 1

CE CREDITS

ENDODONTIC PRACTICE CE

PRODUCT PROFILE

Single-cone endodontic obturation with NeoSEALER™ Flo Dr. Karl Woodmansey discusses improved obturation with an emerging technique

valon Biomed’s™ new NeoSEALER™ Flo is simplifying endodontic obturation. The goals of endodontic obturation have remained unchanged for decades; however, recent advances in bioceramic sealers now enable improved obturation with the simplicity and speed of inserting a single gutta-percha cone. This technique is generally termed, “the single-cone technique.” As specialists, endodontists are masters of all obturation techniques, including lateral compaction and warm vertical compaction, among others. These multistep procedures are proven to be successful, but the emergence of single-cone obturation using a bioceramic sealer is rapidly gaining acceptance. Simplicity, speed, and success are the reasons for this trend. Unlike the other techniques, single- cone obturation is sealer-centric — relying on the hydraulics imparted by the gutta-percha cone and the sealer’s flowability to three-dimensionally fill the canal space. NeoSEALER Flo is an affordable newly marketed sealer that has already proven itself. Based on the success of Avalon Biomed’s NeoMTA® Plus and NeoPUTTY™, this single-syringe bioceramic sealer is ideal for the single-cone technique. NeoSEALER Flo is a non-staining, resin-free, dimensionally stable endodontic sealer with biocompatibility and bioactivity imparted by its bioceramic formulation. Single-cone obturation requires only a few simple steps that can be accomplished in moments. My preferred technique follows. After preparing with instruments and irrigants, excess moisture is removed from the canal, and a gutta-percha cone is selected and fit to length. Most typically, the selected cone is one size smaller than the master apical file, but still binds at the determined working length. The slightly undersized cone permits adequate space for the NeoSEALER Flo. Karl Woodmansey, DDS, MA, is an endodontist in Dallas, Texas, and he also serves as the Chief of Dental Services for the 136th Medical Group of the Texas Air National Guard. He is a Diplomate of the American Board of Endodontists and has held notable academic appointments over the past 10 years. He has more than 50 publications with research interests that include bioceramic materials and endodontic applications of technology. He can be contacted at KFW@prodigy.net.

Volume 14 Number 1

Figure 1: Illustrating clinical application of NeoSEALER Flo (Photo courtesy of Dr. Jenny He)

Next, the NeoSEALER Flo is applied directly into the canal space using the Flex Flo Tip™, which is included in the kit. This unique application tip flexes and minimizes binding while the rubber stopper helps to gauge the appropriate canal depth. The barrel of the tip is designed with a small orifice that seats directly into the syringe tip, so waste is minimal. (The manufacturer claims an 81% reduction in waste compared to conventional tips based on its in-house testing.) The Flex Flo tip is inserted to one-half of the canal length, and then while slowly expressing sealer from the syringe, the tip is withdrawn from the canal. The goal is to fill the coronal one-half of the canal space. The pre-fitted gutta-percha cone is then slowly inserted through the NeoSEALER Flo to the desired length. This insertion motion hydraulically distributes the NeoSEALER Flo throughout the entire canal. After insertion of the gutta-percha cone, the canal’s obturation is complete. The top of the gutta-percha cone can be removed with a heated instrument, and any excess NeoSEALER Flo can be cleaned up with a damp cotton pellet. A radiograph can then assess the adequacy of the obturation. One common error is inadequate NeoSEALER Flo application. An insufficient volume of NeoSEALER Flo will not provide optimal hydraulics and will result in voids within the obturation. Some operators apply only a minimal amount of sealer, desiring to save a few pennies worth of material or fearing apical extrusion. With the minimum waste Flex Flo tip, this is not an issue with NeoSEALER Flo. When set, NeoSEALER Flo is highly biocompatible such that apical extrusion is

Figure 2: Posttreatment radiograph of two teeth obturated using NeoSEALER Flo and the single-cone technique. This demonstrates the radiopacity of NeoSEALER Flo. Note the sealer within an accessory canal in the apical one-third of tooth No. 9. This showcases the hydraulics of this technique and the flowability of NeoSEALER Flo

rarely consequential. Even so, caution should be exercised to prevent apical extrusion into the mandibular canal or maxillary sinuses. Although there are multiple ways to modify or hybridize this technique, I have found this simple single-cone obturation protocol to work well in a wide variety of canal anatomies. Showcasing its versatility, some of my colleagues prefer to use NeoSEALER Flo with modified techniques. For oval-shaped canals, some practitioners advocate adding gutta-percha points laterally (with or without a spreader) in a modified lateral compaction technique. Other endodontists feel more comfortable performing warm vertical compaction with this sealer. To date, no research has demonstrated any technique’s superiority. As long as basic endodontic principles are followed, all techniques with NeoSEALER Flo should be highly successful. Even the fast and easy singlecone obturation technique with NeoSEALER Flo should ensure a successful and enduring endodontic obturation. EP This information was provided by Avalon Biomed™.

Endodontic practice 35

PRODUCT PROFILE

Boyd Industries’ featured endodontic products Built to Last. Built for You. Built by Boyd

est known for the durability and reliability of our award-winning products — including exam and treatment chairs, surgery tables, mobile storage, and clinical cabinetry — we combine 60-plus years of design and manufacturing expertise to perfectly fit your unique space and esthetic preferences. The Boyd team takes great pride in the craftsmanship and longevity of all products built at our U.S.-based facility, so that you can take pride in your office for years to come. As an industry expert in the design of specialty equipment, Boyd has developed a line of products specifically for the endodontic market.

Featured product: S3100LC Endodontic Chair Boyd Industries is proud to promote our new dental treatment chair designed for endodontic procedures. This chair combines reliable functionality with elegant design, and includes ergonomic features to accommodate doctor, assistant, and patient needs. What makes the S3100LC design unique? • Lockable swivel base capable of 90 degrees of rotation from center (180 degree total rotation) to ensure greatest ease of patient positioning and entry/egress • Lift column base allows chair to be raised or lowered with precision • Tapered back design facilitates closer assistant positioning while maintaining patient comfort. Lowprofile, double-articulating headrest for proper positioning of patient head • Easy-to-access membrane switches on left and right side of chair back control both base and back adjustments. Three programmable settings for one-touch control to articulate chair to frequently used positions with a “Home” button to return chair to lowered and upright position for patient egress. • Upholstered with Ultraleather Pro™ fabric and memory foam come standard to support maximum patient comfort. Ultraleather Pro™ is ink and stain resistant with antimicrobial disinfecting ingredients. 36 Endodontic practice

Standard Features: • Integrated smooth swivel with easyaccess release lever • Programmable hand controls integrated on both sides of the chair back • Detachable and programmable foot control • Low-voltage DC actuator vertical lift column base (rated for patients up to 500 lbs.) • Tapered back with sculpted headrest location to allow proper positioning • Lever-release drop down arms • Fixed-toe section with clear plastic foot protector cover • Pinch-lock, double-articulating headrest

Featured product: Sterilization Center Boyd Sterilization Centers are offered in standard options as well as custom builds. They’re not prebuilt or limited in size or design, and are designed and built to suit your space. Sterilization center units are serialized to assist in qualifying for enhanced tax advantages. Standard Features: • Durable 3/4" plywood construction • High-pressure laminate with 2 mm edge banding • Undermount full extension soft-close drawers • Bow-style drawer pulls • Adjustable laminate shelving in storage area • Concealed-style hinges with selfclose feature on doors • Two (2) Corian sterilizer pull-outs • Task exam lights • Ventilation fan in clean storage • Faucet and sink (Corian or stainless) • Trash chute • Sharps chute and disposal container • Paper towel dispenser • Two (2) glove dispensers over sink module • Glass shelves for clean and dirty modules with blue and red exam lights • Built-in toe kick steps Options: • Countertop: Corian solid surface or laminate countertop

S3100LC Endodontic Chair

Featured product: Prestige Endodontic Cart The Prestige Endodontic Cart has been fitted with a lightweight aluminum body and all the features you need: aseptic surfaces for easy cleaning, sectioned drawers for intuitive organization, and a sleek, contemporary esthetic. Standard Features: • A removable plastic top designed for easy cleaning, in addition to dual slide-out surfaces for added work space. • 5-inch easy-rolling wheels for smooth transit from patient to patient. Wheels lock for stability. • Durable, scratch-resistant, nylonreinforced polycarbonate bumper protects the cart’s wheels and exterior from wear and tear over time. • Auto-closing, ball-bearing drawers. Features four 3-inch drawers, one 6-inch drawer, and one 9-inch drawer. Dimensions: 29" x 18.5" x 42" The Boyd team has made every effort to create specialized products that are truly Built for You. These featured products can be combined with Boyd’s custom clinical and office cabinetry to create a cohesive office space. Personalize your practice with limitless combinations of color and print laminates and the widest range of upholstery choices on the market. Reach out to your regional sales representative today to get started! To learn more, visit us at www.boyd industries.com. You can follow us on Instagram and Twitter @BoydIndustries. Boyd Industries is an ISO 13485:2016 certified company. EP This information was provided by Boyd Industries.

Volume 14 Number 1

PRODUCT PROFILE

EndoSequence® BC Temp

Temp is a premixed, non-setting bioceramic paste used for intracanal dressing. Unlike traditional calcium hydroxide pastes, the primary components of BC Temp are calcium silicates and calcium oxide, which allow BC Temp to exhibit a gradual and slow release of calcium and hydroxyl ions. This extends its effective antimicrobial activity and eliminates the need for frequent applications. BC Temp is highly radiopaque and non-staining, exhibits optimal flow characteristics, and does not set hard — thus it is easily removed, which reduces chair time. Furthermore, BC Temp is compatible with BC Sealer due to its bioceramic composition.

EndoSequence® BC Temp syringe

formation and faster healing of periapical lesions.* • Stronger antimicrobial activity: BC Temp has been shown to be effective against resistant bacteria such as E faecalis and S aureus at minimal inhibiting concentrations. Under the conditions of the study, a leading competitor did not show antimicrobial activity at the concentration tested.* While more studies are underway to compare BC Temp versus other Ca(OH)2 materials, the manufacturer believes that BC Temp is more effective due to its unique calcium silicate, calcium oxide, and glycol salicylate formulation and the small particle size, which allows for more effective penetration versus conventional Ca(OH)2. • Less cytotoxic with potential for better healing: BC Temp has

Why upgrade to BC Temp? • Gradual and sustained release of both hydroxyl and calcium ions: BC Temp is composed of calcium silicates and calcium oxide, which create Ca(OH)2 when exposed to moisture in the root canal. BC Temp has three different crystalline structures, each with a distinct rate of hydration: This gradual/staged release eliminates the need for frequent applications. Traditional intracanal dressings start as Ca(OH)2 and have a larger particle size, which leads to faster disassociation of calcium and hydroxyl ions. Furthermore, BC Temp’s unique formulation releases more calcium ions than traditional Ca(OH)2, which makes it more effective at hard tissue

Table 1: Mean ± standard deviation for calcium ions (mg/dL) released according to the experimental groups at different times Groups

7 days

14 days

21 days

BC Temp

7.32 (0.13)Aa

12.32 (0.15)Ab

15.88 (0.11)Ac

Leading Competitor

8.54 (0.21)Aa

7.54 (0.95)Ba

7.85 (0.77)Ba

Capital letters mean statistical difference between lines. Lowercase letters mean statistical differences between columns.

Table 2: Microcomputed tomography analysis of percentage (%) of the volume of material removed (mm3) after the use of different intracanal medication removal techniques of BC Temp and a leading competitor BC Temp % of material removal (mm3)

Leading Competitor

Con

86.90 ± 1.11

98.60 ± 1.39

94.70 ± 0.36

82.65 ± 2.43

94.54 ± 1.23

90.32 ± 1.34

Conv: conventional syringe and needle technique; XP: conventional technique associated with XP Endo Finisher Instrument; US: conventional technique associated with ultrasonic inserts. 38 Endodontic practice

been shown to be less cytotoxic compared to Ca(OH)2, A recent study concluded that the tissue damage, initially caused by BC Temp (due to the high pH, which is normal and required for a intracanal dressings) is suppressed more quickly compared to those caused by the leading competitor, favoring the repair of connective tissue.* • Better compatibility between BC Temp and bioceramic sealers: Push-out tests showed that BC Temp did not influence the reduction of bond strength in teeth filled with bioceramic sealers. Multiple other studies have shown that Ca(OH)2 reduces the bond strength of sealers when there are trace amounts left in the canal.* • Improved handling: BC Temp features a small particle size, so it exhibits optimal flow characteristics. Traditional Ca(OH)2 can be gritty and may be difficult to deliver into the canal. According to our clinical evaluators, BC Temp flows smoothly from the 29-gauge precision tips provided and is easy to apply deep into the canal. • Easier to remove: According to a recent study, BC Temp was easier to remove compared to a leading competitor under the conditions of all three of the removal methods. Three different removal methods utilized were a conventional syringe and needle, XP-3D irrigation, and ultrasonic irrigation.* For more information or to order, call 800-841-4522, or visit www.shop.brasseler usa.com. EP *

Studies referenced are available upon request and were not shown here due to space limitations.

This information was provided by Brasseler USA®.

Volume 14 Number 1

BY YOUR SIDE

NEW!

ENDOSEQUENCE® CM TAPER Uncompromised Quality. Now in a Progressive Taper.

The EndoSequence® CM Taper file provides clinicians with a progressive tapered instrument that delivers the cutting efficiency and flexibility of EndoSequence® CM with the familiar shape of the popular ProTaper Gold® files.

SX 16mm

S1 25mm

File/ Tip ID

16 mm

21 mm

25 mm

SX/16

5027891U0

—

Purple S1/18

—

5027892U0

5027899U0

White

S2/20

—

5027893U0

5027900U0

Yellow

F1/20

—

5027894U0

5027901U0

Red

F2/25

—

5027895U0

5027902U0

Blue

F3/30

—

5027896U0

5027903U0

Black

F4/40

—

5027897U0

5027904U0

N/A

STERILE

Variable Taper

Tip Size

ProTaper Gold® is a registered trademark of Dentsply Sirona.

Visit our website at BrasselerUSA.com To order call 800.841.4522 or fax 888.610.1937. In Canada call 800.363.3838

B-5471-EP-03.21

SMALL TALK

After action reviews: a peak performance tool Drs. Joel C. Small and Edwin McDonald discuss a 5-minute way to maintain optimal functioning and flow

n a previous article in Endodontic Practice US, we addressed the topic of peak performance. We defined peak performance as “a state of optimal functioning and flow.” Like a finely tuned Swiss watch, when we operate at our peak, all parts of a clinical practice function flawlessly and in perfect harmony. Those aspiring to reach peak performance must have a vision of what peak performance looks like. This is a responsibility of the owners/doctors who must collaborate with their staff to create a vision of this desired result. Another effective tool for achieving peak performance is one that has been utilized by the U.S. Armed Forces and is called an “After Action Review,” or AAR. The Navy’s Sea, Air, and Land Forces (commonly known as the Navy SEALs) use the AAR as a means of fine-tuning future operations. By conducting an in-depth post-mission review, the SEALs capitalize on the positive aspects of a mission or correct the underlying causes that led to less than desirable results. Marcus Luttrell is a highly decorated Navy SEAL and American patriot, and is the author of the book Lone Survivor: The Eyewitness Account of Operation Redwing and the Lost Heroes of SEAL Team 10. Lutttrel reportedly noted that the AAR is as important as the action itself. The coaches at Line of Sight Coaching have worked with clients to implement a shorter, yet equally as effective form of the AAR for clinical dental practices. Unlike the AAR utilized by the U.S. military, which entails extensive reporting and paperwork, the review that we have designed for dental practices should take no more than 5 minutes either at the end of the day or Drs. Joel Small and Edwin (Mac) McDonald have a total of over 75 years of dental practice experience. Both doctors are trained and certified Executive Leadership Coaches. They have joined forces to create Line of Sight Coaching, a business dedicated to helping their fellow dentists discover a better and more enjoyable way to create and lead a highly productive clinical dental practice. Through their work, clients experience a better work/ life balance, find more joy in their work, and develop a strong practice culture and brand that positively impact their bottom line. To receive their free ebook, 7 Surprising Steps to Grow Your Practice Through Leadership, go to www.lineofsightcoaching.com.

40 Endodontic practice

Those aspiring to reach peak performance must have a vision of what peak performance looks like. at the beginning of the following workday. We have found the AAR to be invaluable in moving an entire team toward peak performance. The AAR not only serves to create individual accountability for a team’s performance, but also, more importantly, shines a light on practice systems and protocols that often are hindering our ability to reach peak performance. Clients that have implemented AARs in their clinical practices are finding that their overall team performance is optimizing at a much faster pace than they thought possible. They are also finding that the AAR has allowed them to take a holistic view of their practice by seeing more clearly the interaction of the clinical and administrative practice functions and appreciating the necessity for creating more efficient and seamless systems that improve patient flow, increase productivity, and move the entire toward peak performance. The purpose of the AAR is to answer three questions; • Did our day go as we had planned? • If so, why? • If not, why not? The AAR starts with the team’s overall impression of the preceding workday. Did the preceding day go as planned, and what role did each individual team member play in achieving the end result? Hopefully, the day went as planned, or even better than planned, and the team can share a moment reflecting on what went right and how to duplicate this team effort to create more of these optimal days going forward. This is a moment of celebration and should not be overlooked. If the day did not go as planned, and the overall result was less than desirable, team members must self-critique (with no fear of reprisal) and explain what they could have done differently to create the desired result. Having a psychologically safe environment is critical for this process to be effective. The doctor, as a member of the team, must set the example by willingly participating and

offering his/her own self-critique. What could the doctor have done differently to make the preceding day better? The timing and duration of the AAR is important. We have found that the AAR should take no more than 5 minutes and should occur either at the end of the workday or the beginning of the following workday. Allowing too much time to elapse before conducting an AAR has proven to be ineffective. Furthermore, anything that would require more than 5 minutes’ discussion should be tabled, placed on the agenda for the next full staff meeting, and discussed at that time. Keeping the staff longer than 5 minutes at the end of a long workday can result in the staff losing interest in the process. It is a good idea to have a copy of the day’s schedule, so the group can reference certain patients and events that may have occurred throughout the day. The doctor should be listening to the day’s assessment while simultaneously questioning whether lack of training or resources have contributed to a less than desirable result. Often it becomes obvious that outdated systems or protocols have unknowingly hampered the team’s ability to reach peak performance. These topics are ones that need further and more in-depth discussion and should be tabled for the next full staff meeting. There can be numerous reasons why a doctor may not see the value in an AAR. Some doctors have questioned whether they can spare 5 minutes at the end of a workday. Others feel that the staff may not willingly participate, and some may even find the vulnerability of self-critiquing to be intimidating. These thoughts are unfortunate and will only serve to promote mediocrity. The AAR has been proven to be a vital and very successful tool for teams to move rapidly toward peak performance. If you have questions or need help implementing an AAR in your practice, we are available to help. You can contact us at info@lineofsightcoaching.com. EP Volume 14 Number 1

YOU’LL BE SMILING...

KNOWING WE ARE THE ONLY Endodontic Partnership led by Endodontists. You deserve to have control of your business, and the peace of mind that comes from a support system. Now you can have both. Endo1 Partners is the fastest growing Endodontic Partnership Organization with a fundamental understanding of patient care at the practice level. IT’S TIME TO THRIVE. TOGETHER!

305 - 206 -7388

Endo1partners.com

NeoSEALER

™

WITH

Every kit is packaged with 20 Flex Flo Tips at no additional cost. Plus, NeoSEALERTM Flo is optimized for both warm vertical and single cone obturation techniques for maximum efficiency and savings.

Integrated stopper for accuracy of placement. Designed for 81% less waste than conventional tips.

25.5 gauge flexible tip to reach deep into curved and small canals.

Purchase one 2.2gm NeoSEALER Flo Starter Kit and get the second one FREE!

USE CODE: BOGOENDO21

™

Offer expires 4/30/2021. Limit one BOGO offer per customer. Made in the U.S.A.

avalonbiomed.com | info@avalonbiomed.com | 941-896-9948