Endodontic Practice US Summer 2021 Vol 14 No 2 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Summer 2021 – Vol 14 No 2 • endopracticeus.com

PROMOTING

EXCELLENCE

Evidence-based endodontic principles

ENDODONTICS Practice profile Stephen Thomas, DMD

Drs. Brett E. Gilbert and Richard Mounce

Corporate spotlight HighFive Endo

Endodontic irrigation: optimizing pulp dissolution from complex root canal systems Dr. L. Stephen Buchanan

Company profile U.S. Endo Partners

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

Summer 2021 - Volume 14 Number 2 EDITORIAL ADVISORS 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 Stephen Cohen, MS, DDS, FACD, FICD Samuel O. Dorn, DDS Josef Dovgan, DDS, MS Luiz R. Fava, DDS Robert Fleisher, DMD Marcela Fridland, DDS Gerald N. Glickman, DDS, MS Jeffrey W Hutter, DMD, MEd Syngcuk Kim, DDS, PhD Kenneth A. Koch, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI Joshua Moshonov, DMD Richard Mounce, DDS Yosef Nahmias, DDS, MS David L. Pitts, DDS, MDSD 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 West, DDS, MSD

CE QUALITY ASSURANCE ADVISORY BOARD Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher) Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

riting in Dentistry Today in 2008, L. Stephen Buchanan relates a conversation he had with renowned prosthodontist Carl Reider.1 Reider is quoted as saying that “he [Reider] would prefer it if the endodontist could just suck the dying pulp out of the tooth without removing any dentin.” Buchanan continues, “He [Reider] made that paradigm-shifting statement to me back in 1990.” We may look back at this as the earliest beginnings of a sea change in endodontics that started with Buchanan’s realization that “root canal shaping procedures were complex because we were using relatively nontapered instruments to create tapered root canal shapes. What would it be like … to use variably tapered files that possessed the final canal shape on a single instrument?”2 “The logical answer seemed to be that variably tapered shaping instruments would allow ideal predefined canal shapes …”2 with a predefined maximum flute diameter that limits coronal enlargement: engineered dentin preservation. These variably tapered instruments such as the GT NiTi File Series were not an outgrowth of the ISO standard steel root canal files with color-coded specified tip sizes, 0.02mm/mm of taper, 16mm of flute length. It was a complete departure from all previous file designs, concepts, and procedural steps of Endodontics 1.0: Conventional Instrumentation Endodontics (CIE). Up to that time, endodontists primarily operated out of this mindset: “‘The root is mine!’ meaning that the shapes we create in root canals when we treat patients are our business.”2 These operator needs trumped the tooth needs, much to the detriment and credibility of our specialty. Buchanan illuminated some questioning of endodontics being a credible treatment modality in dentistry, while others were calling for the end of endodontics as a specialty. Something had to give. Drs. David Clark, Eric Herbranson, and I extended these concepts of dentin preservation and introduced the Hierarchy of Tooth Needs.3 We also note that the restoratively aware “clinician needs to consider many factors that will affect the outcome. In simple terms, these factors can fall into three categories: the operator needs, the restoration needs, and the tooth needs. The operator needs being conditions the clinician needs to treat the tooth. The restoration needs being the prep dimensions and tooth conditions for optimal strength and longevity. The tooth needs being the biologic and structural limitations for a treated tooth to remain predictably functional.”4 So “what would it be like to use variably tapered files” ended up being the question that eventually led to the reversal of the Endodontic Triad’s myopic focus on debridement, disinfection, and destruction of the tooth in the process of fixing it. This reversal placed preservation of the pericervical dentin (PCD) as the primary objective and led to the second paradigm in endodontics: Endodontics 2.0, or minimally invasive, restoratively driven endodontics (MIE/RDE). Dr. Reider questions, “What would it be like not to use shaping files at all?” We believe the answer to his 30-year-old question leads to the next paradigm in endodontics: noninstrumentation endodontics (NIE). NIE or Endodontics 3.0 is perhaps first defined by what it is not. NIE does not mean “no files are ever used,” but instead, the purpose of files, if they are used, has changed. This leads to a central tenet of NIE: debridement and disinfection of the root canal system is no longer an instrumentation or file-based, chemomechanical procedure. Debridement and disinfection of the root-canal system is done by some other means. Files, if they are used, are not for “shaping,” but instead, for verification of existing anatomy, recovering original anatomy, establishing original anatomy and ensuring … for the time being … an obturatable space. REFERENCES 1. Buchanan LS. The new GT Series X rotary shaping system: objectives and technique principles. Dent Today. 2008;27(1):70,72,74. 2. Buchanan LS. The standardized-taper root canal preparation — Part 1. Concepts for variably tapered shaping instruments. Int Endod J. 2000;33(6):516-529. 3. Clark D, Khademi J. Modern endodontic access and dentin conservation, Part 1. Dent Today. 2009;28(10):86,88,90 4. Clark D, Khademi J. Modern endodontic access and dentin conservation, part 2. Dent. Today. 2009;28(11):86,88,90.

© 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.

John A. Khademi, DDS, MS, received his DDS from UCSF and his certificate in endodontics and his MS on digital imaging from the University of Iowa. He is in full-time private practice in Durango, Colorado, and was an Associate Clinical Professor in the Department of Maxillofacial Imaging at USC as well as an Adjunct Assistant Professor at SLU. In his “prior life,” he wrote software for laboratory automation, instrument control, and digital imaging. He lectures internationally about CBCT, clinical trial design, outcomes, and endodontic technique. As an RSNA member for over 25 years, his background in medical radiology allows him a perspective shared by very few dental professionals. He has contributed to many sections and chapters in textbooks and is the lead author for Quintessence’s Advanced CBCT for Endodontics.

ISSN number 2372-6245

Volume 14 Number 2

Endodontic practice 1

INTRODUCTION

Paradigms in endodontics: CIE, MIE/RDE, NIE

TABLE OF CONTENTS

Case study

Practice profile Stephen Thomas, DMD A HighFive to Endodontics

Lisa Moler, Founder/CEO, MedMark Media................................ 6

Dr. Rico D. Short discusses this promising option for endodontic treatment ........................................18

Clinical research Evaluation of the penetration time required by TruNatomy™ and ProTaper Next™ to reach the apical limit during guttapercha removal in simulated curved and narrow canals of Endo Training Blocks

Publisher’s perspective Clinical The Roaring 20s

Bioceramic sealer avoids shrinkage and excessive resorption

Management of a large, invasive, external, cervical root resorption of a maxillary canine Drs. Purvi D. Pandya, Dhaval P. Pandya, and Prashant D. Shirke illustrate a complicated restoration.....................12

Technology Using dental lasers to decrease pain and fear for patients Dr. Fernando J. Meza shares key differentiators in performing a root canal with traditional equipment versus dental lasers....................................22

Corporate spotlight HighFive Endo Entrepreneurial spirit and innovation supporting endodontic excellence ......................................................10 2 Endodontic practice

Company profile

ON THE COVER

U.S. Endo Partners

Inset image on cover courtesy of Dr. Paula Elmi. See article on page 29.

A strong partner for any practice.....16

Volume 14 Number 2

Endo Laser TECHNOLOGY & DESIGN TO ELEVATE YOUR PRACTICE

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TABLE OF CONTENTS Product profiles Brasseler USA®: your trusted leader in bioactives...................36 SkyPulse® Endo Laser by Fotona..........................................38

Small talk Continuing education Endodontic irrigation: optimizing pulp dissolution from complex root canal systems

Continuing education Evidence-based endodontic principles

Dr. L. Stephen Buchanan discusses a new concept in endodontic irrigation .......................................................24

Drs. Brett E. Gilbert and Richard Mounce discuss techniques and materials that lead to effective endodontic treatment...................... 29

Peak performance is a byproduct of our practice culture Drs. Joel C. Small and Edwin McDonald discuss how leaders need to create a compelling vision............. 39

Service profile Endo1 Partners The original and fastest-growing endodontic partnership organization, owned and led by endodontists .......................................................40

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PUBLISHER’S PERSPECTIVE

The Roaring 20s

Published by

ere comes summer — we’re already halfway through the year, and many of us have hit the ground running into 2021 — a robust reboot of the “Roaring 20s!” During this past year, we have all had plenty of time to think about our personal and professional lives, what works and what needs to be changed. It’s definitely time to get back to business. Here are some interesting and positive facts from an ADA Health Policy Institute survey collected in January. • Patients are back! As of the week of January 18, patient volume was estimated at 80% of pre-COVID-19 levels, on average. Staffing in dental offices was at 99% of preCOVID-19 levels, and four out of five employee dentists Lisa Moler were being paid fully. Founder/Publisher, MedMark Media • Dentists are realizing their worth! At the beginning of the year, nearly a third of dentists had raised fees. Those who needed some extra help were proactive, taking out loans, reducing their dental team hours, and changing suppliers to those more appropriate to their goals. Retirement rates have not changed due to COVID-19. • Practices are ready to roar! The sector has recovered nearly fully in terms of hiring and employment. Based on vaccine rollout and perceptions, full recovery of dentistry is anticipated by the summer or fall. Research and development continue to bring new products and techniques to dental specialties, and now, it’s time to figure out how to stay ahead in this very competitive marketplace. One valuable way is letting MedMark publications educate you about products, services, and techniques that can add to your armamentarium and boost your patients’ options. The more choices that patients have for treatment, the more ways that you can expand your practice’s scope and profits. This issue of Endodontic Practice US features a CE by Dr. L. Stephen Buchanan on optimizing pulp dissolution from complex root canal systems. He discusses different forms of irrigation and then unveils details about a new technique. In another CE, “Evidence-based endodontic principles,” Drs. Brett E. Gilbert and Richard Mounce write about materials and techniques for effective endodontic treatment in key areas of diagnosis, shaping, irrigation, obturation, and restoration. Dr. Purvi Pandya and colleagues illustrate management of a complicated restoration and reports this successful outcome over a 2-year period. In our technology column, Dr. Fernando Meza discusses how to use dental lasers in RCT to decrease pain and fear. Many aspects of traditional dentistry have changed over the past year, and clinicians were pushed to find ways to serve patients better while maintaining safe protocols. Applications like teledentistry, patient texting, and online consultations showed that you can stay connected to your patients and serve their needs with secure options. Patients have embraced new technologies and still want these benefits even as offices return to full business as usual. Methods for scheduling fewer appointments and less chair time, while maintaining the personal connection with patients, have been created with more creativity and success that will continue into the future. While 2020 started out as one of the most unusual in our lives, 2021 promises continued healing and the potential for great success. Let us help you get ready to roar into the future with high expectations! To your best success, Lisa Moler Founder/Publisher MedMark Media

6 Endodontic practice

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

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PRACTICE PROFILE

Stephen Thomas, DMD A HighFive to Endodontics What can you tell us about your background? I grew up in a small town in Jackson, Tennessee. My father was a surgeon, which influenced my desire to want to be a part of the medical world. Because his long extended hours in the hospital and being on call did not allow for much family time, I desired a career in the medical arena that allowed me to care for patients and provide a greater balance in life between work and family. As a result, I chose to pursue dentistry.

When did you become a specialist, and why? Once I was in dentistry, and we began rotating through the different specialties, I recognized immediately endodontics was a good fit for me. It is very methodical, and the technique is consistent even though the teeth and patients vary. In addition, endodontics helps patients alleviate pain and save their teeth.

Is your practice limited solely to endodontics, or do you practice other types of dentistry? My practice is limited solely to endodontics. My focus every day is to help patients alleviate pain, save their teeth, and provide a personable and comfortable experience. When you focus on one aspect of dentistry solely, it allows you to excel in that area because it’s the one thing you do day in and day out every day. Many dentists would find this boring and prefer completing a variety of procedures; however, my personality is such that I like the predictability and consistency endodontics provides.

Do your patients come through referrals? The patients I see usually come to me through referrals from general dentists’ offices, other specialty offices, medical doctors, and/or patients’ word of mouth. I enjoy relationships. Endodontics has allowed me a multidimensional layering of building Volume 14 Number 2

Dr. Stephen Thomas

relationships from my team, our patients, and our referring offices. I thoroughly enjoy staying in touch with my colleagues and building strong relationships with my referring doctors in our profession and the medical community. It is definitely one of the highlights to my profession.

How long have you been practicing endodontics, and what systems do you use? I have been practicing endodontics for 20 years. As I mentioned earlier, my personality is such that I like consistency and a methodical way of accomplishing tasks. One could Endodontic practice 7

PRACTICE PROFILE imagine how much I thrive on systems. At Brookwood Endodontics (www.brookwood endo.com), we have amazing systems in place and an incredible team to help implement our systems. Technology, equipment, products, and a cohesive team have enabled us to become very efficient at providing root canals, increased our confidence in knowing we are providing them with the exact care needed and to do so in a timely manner, decreasing the anxiety of the patient.

What training have you undertaken? I attended the University of Alabama for my undergraduate degree. This was followed by 4 years of dental school at University of Alabama School of Dentistry (UABSOD) — a 1-year hospital dentistry residency and a 2-year endodontic residency. In addition, I complete a significant amount of continuing education annually to keep abreast of all the latest advancements in our field.

What is the most satisfying aspect of your practice? Most patients who come to see me are

in pain and are terrified of the dentist or of getting a root canal. The most satisfying aspect of my practice is to help patients overcome their fears by providing a personal experience in a compassionate and caring environment. I believe the efficiency of the root canal treatment also helps relieve the patients’ anxiety by decreasing the amount of time they actually spend in the dental chair. Our goal is to alleviate the patients’ pain, provide a caring and compassionate environment, while completing the root canal treatment needed as quickly and efficiently as possible. We strive to be the experts in our specialty utilizing the most up-to-date technology while providing the treatment our patients need.

Professionally, what are you most proud of? Professionally, I am most proud of the exceptional treatment we provide. We utilize 3D imaging on each tooth, which has elevated the accuracy of our treatment. Every root canal in our practice is completed with a microscope, and we utilize the most

up-to-date tools and techniques to accomplish the exceptional treatment we provide. In addition, having partners elevates the care provided as we hold one other accountable, consult with one another, and learn from one another.

What do you think is unique about your practice? The uniqueness of our practice is the excellent and efficient treatment provided in a caring and compassionate environment. In addition, practicing with partners also has a unique advantage as we can learn from one another, grow together, and encourage one another.

What has been your biggest challenge? My biggest challenge has been continuing to maintain the vision of our practice in the face of growth. As we grow to increased capacity and add more endodontists/partners, the responsibilities of the business aspect of the practice become increasingly challenging to maintain. This

Dr. Stephen Thomas treating patients at Brookwood Endodontics in Birmingham, Alabama 8 Endodontic practice

Volume 14 Number 2

1. HighFive Endo, Chad Trull, the H5 team, and their partnership (www.h5endo.com) 2. My endodontic practicing partners 3. The relationship established with referring doctors and offices 4. The excellent Brookwood Endo team members 5. The personalized patient experience — providing patients with personal calls and messaging 6. Same-day emergency care appointments 7. Dentsply Sirona and their team 8. EndoVision® office software (Specialtytl@HenrySchein.com) 9. Benco Dental and their team 10. Each and every patient and his/her word of mouth Josh Till is HighFive’s business development officer and works closely with the practice

has resulted in an extraordinary partnership with HighFive Endodontics. HighFive support has enabled me to focus on excellence in patient care, while their focus has been on operations. I was in private practice for 18 years prior to joining HighFive, and it has been encouraging to have a team come alongside me, enabling me to continue to pursue my passion for excellence in endodontics and patient care.

What would you have become if you didn’t become a dentist? If I had not become a dentist, I probably would have been a physician of some sort because my passion is caring for patients.

What are your thoughts about the future of endodontics? I believe endodontics and dentistry continue to have a bright future. The profession is excellent at providing a balance between work and family. In today’s environment, dentists have options. They can own their own practice, or if they prefer not to carry all the responsibilities of running the business aspect of dentistry, dentists and endodontists now have the option to practice in a group-type setting.

What advice would you give to a budding endodontist? I would share with a budding endodontist that their future is bright. Endodontics is a secret profession that is rewarding on Volume 14 Number 2

The team at Brookwood Endodontics follow the mission of providing the very best endodontic care in a compassionate and loving environment

multidimensional levels, challenging, and fun all at the same time. Becoming an endodontist is definitely one of the best decisions I have made in my lifetime.

What are your top tips for maintaining a successful specialty practice? My top tip as an endodontist is to never lose sight of our primary goal — caring for the patients and providing excellent treatment. It is also important to maintain outstanding relationships with our referring offices that trust us to help provide care to their patients.

I also enjoy having partners and practicing with other endodontists. When you are constantly helping patients in pain, the pressure can build, and it’s refreshing to have partners who understand and can relate to what you are experiencing. At the end of the day, it’s all about relationships, excellent care, and service.

What are your hobbies, and what do you do in your spare time? My hobbies are spending time with my family, friends, and playing golf. EP Endodontic practice 9

PRACTICE PROFILE

Top 10 favorites

CORPORATE SPOTLIGHT

HighFive Endo Entrepreneurial spirit and innovation supporting endodontic excellence

ighFive Endo incubated with the belief that applying business proficiency and entrepreneurial savviness to already highperforming endodontists can unlock practice growth while ensuring best-in-class patient care. Launched by Chad Trull, who has been recognized by Ernst & Young as an Entrepreneur of the Year, HighFive Endo started with a simple goal: to help dedicated endodontists be the best they can possibly be. The proposition of HighFive is straightforward. HighFive focuses on the practice, while the endodontists focus on the patients. By applying technology and software advancements while leveraging a unique Center of Excellence, HighFive provides a compelling suite of services and resources to powerfully support practice partners. While embarking on the company launch, HighFive and Mr. Trull had the great fortune of partnering with two of the best endodontists in the business, Dr. Stephen Thomas and Dr. John Collier. The initial collaboration with Dr. Thomas and Dr. Collier helped lay the foundation for the HighFive culture, creating the mantra “Better, Stronger, Together.” Better, Stronger, Together is reflective of the emphasis HighFive places on nurturing a strong and supportive culture. The company believes there is no more important facet to a successful enterprise than a strong cultural foundation. As a result of prioritizing culture, HighFive applies a disciplined, strategic approach to expansion, avoiding a growth-for-growth’s sake mindset. HighFive thoroughly screens

“We operate with an obsession for finding and delivering value. And that drive is rooted in serving and helping people. People are the heart of innovation, the fuel behind transformative progress. This marriage of ambition with heart ensures we deliver value while staying true to our values.” — Chad Trull, CEO HighFive Endo

potential partners, ultimately pairing likeminded professionals with shared philosophies of attaining greater practice excellence through collaboration, diligently treating everyone as family, and viewing practice success with both a commercial and noncommercial lens. The benefits of becoming a HighFive Practice are numerous. Higher reimbursements, better equipment pricing, and access to some of the sharpest healthcare and business professionals that exist today are just a few of the advantages gained by becoming a partner with HighFive. While partners have consistently seen practice revenue and profits grow post-acquisition, value and

“Partnering with HighFive was a result of wanting the best for me and my practice. The ability to achieve continued growth and excellent patient care, while removing the burdens of the everincreasing administrative workload, has made my productivity soar. My clinical care is just that — mine. I’m proud to say HighFive is my family.” — Dr. Christopher Cook, Louisville Endodontics

HighFive Fast Facts: •

Over $70 million in annual revenue

•

Over 160 employees

•

Projected 2021 revenue growth of 107%

•

Average clinical revenue growth post acquisition is +41%

•

Average clinical EBITDA growth post acquisition is +96%

benefit extend beyond quantitative metrics. Doctors really do become part of a family — a family that shares best practices with regular roundtables and experiences personal and professional growth through a peer mentoring platform, coupled with values, integrity, and grit that is competitive and exclusive. Partners at HighFive are different and challenge the status quo each day. The impressive growth of HighFive illustrates the value and impact of an entrepreneurially driven endodontic partnership model. The HighFive formula of applying technology and best business practices facilitates operational success and cuttingedge endodontics leading to a whole new era of endodontic care. EP This information was provided by HighFive Endo.

10 Endodontic practice

Volume 14 Number 2

Making Endodontics Fun Again.

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Our partnership contract is simple: Take care of your patients and we’ll handle the rest.

Team Approach

We operate as a family! Our goal is for every patient to have the best experience in all of our practices. Our open, fun and collaborative culture creates an innovative approach to operations, quality and buying power.

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CLINICAL

Management of a large, invasive, external, cervical root resorption of a maxillary canine: a case report with a 2-year follow-up Drs. Purvi D. Pandya, Dhaval P. Pandya, and Prashant D. Shirke illustrate a complicated restoration Abstract Introduction Invasive cervical resorption of teeth is the loss of dental hard tissues. Proper management can be carried out if the etiology and the extent of the pathology are known. Objective The objective of this article is to describe the diagnosis and management of a large, invasive, external cervical root resorption associated with the maxillary right canine tooth in a patient in his 70s. Method A 73-year-old male patient requested an opinion for mild pain and swelling over his maxillary right canine region. A clinical and radiologic diagnosis of a large idiopathic invasive cervical resorption was established after which the patient was scheduled for surgical endodontic therapy. Subsequent recall visits showed complete repair of the pathology. Conclusion A 2-year clinical and radiologic follow-up showed complete absence of the signs and symptoms associated with the resorption pathology and repair of the lesion.

Introduction External root resorption is a progressive and destructive loss of hard dental tissue, initiated by a demineralized or denuded area of the root surface.1 Heithersey described

Purvi D. Pandya, MDS, is a consultant endodontist and conservative dentistry specialist in Mumbai, India. Dhaval P. Pandya, MDS, MFDS RCPS (Glasg), is a Fellow of the International College of Dentists (India, Sri Lanka and Nepal), a Diplomate of the International Congress of Oral Implantologists, and a consultant periodontist and implantologist in Mumbai, India. Prashant D. Shirke, MDS, is a consultant in oral medicine and dental radiologist in Mumbai, India.

12 Endodontic practice

one of the frequent types of external root resorption — namely, the invasive cervical resorption in detail. It is a clinical term used to describe a relatively uncommon, insidious, and aggressive form of external tooth resorption, which may occur in any tooth in the permanent dentition. Invasive cervical resorption is defined as a localized resorptive process that begins on the surface of root below the epithelial attachment and the coronal aspect of the supporting alveolar process — namely, the zone of the connective tissue attachment.”1 This pathology involving the tooth structure is characterized by its cervical location and its invasive nature. The resorbed tooth structure is replaced by a highly vascular tissue, which may become visible through the thin residual enamel as a pink discolored tooth.2 The etiologic factors follow: A. Physical history of orthodontic treatment, traumatic injuries involving the teeth, excessive pressure associated with impacted teeth or with an oral pathology like a large tumor. Some oral habits that may lead to excessive pressure on the teeth like playing a woodwind instrument3 or trauma related to the cementoenamel junction due to interdental wiring4 B. A chemical procedure performed like intracoronal bleaching C. Idiopathic Patients presenting with root resorptive pathology are usually asymptomatic, and in many situations, the diagnosis may present as an incidental finding on routine radiographic examinations.5 To further determine the extent of the pathology, especially in large invasive lesions and to treatment plan the case with an interdisciplinary approach, cone beam computed tomography imaging modality is an important adjuvant tool.

pain and gingival swelling over his maxillary right canine region. On clinical examination (Figure 1), mild gingival swelling over the labial aspect and slight tooth discoloration with the cervical third was observed with respect to the maxillary right canine tooth. The marginal gingiva associated with the cervical third of the tooth was inflamed and red in color. A periodontal probing examination at all aspects of the tooth detected the presence of a deep pocket with respect to the labial gingiva with presence of loss of attachment in the area. Probing under infiltration anesthesia also suggested a loss of the labial cortex of the bone plate with the canine. Endodontic examination that included a vitality test performed with the tooth showed it to be nonvital, and the tooth was not responding to percussion. After the clinical examination, an intraoral digital radiograph was obtained and processed using a phosphor plate system (Durr Dental, GmbH, Germany) (Figure 2). A large radiolucent lesion was detected in the middle third of the tooth extending from the mesial line angle to the distal line angle horizontally involving the pulp chamber of the tooth and from the cervical third up to the middle third of the tooth in the vertical plane of the canine. Minor horizontal bone loss was noted at the mesial and distal aspect of the canine with a periapical radiolucency seen at the apex of the canine. Periodontal ligament widening was also a finding in the periapical radiograph. Based on the preceding findings and the extent of the pathology, a cone beam computed tomography of the maxilla was advised with detailed reading and different

Case report A 73-year-old male with a noncontributory medical history presented to us with mild

Figures 1 and 2: 1. Pre-op photo. 2. Pre-op X-ray Volume 14 Number 2

CLINICAL

views of the maxillary right canine region to further evaluate the extent of the lesion on the canine. This would work as an adjuvant tool to establish the prognosis and treatment plan the case. A cone beam computed tomography (CBCT) evaluation confirmed the presence of a large cervical resorption pathology of the canine root in all the section views (Figure 3). A volume reconstruction tomography view of the tooth also revealed the absence of the buccal cortical plate with partial denudation of the tooth root structure (Figure 4). Surgical endodontic treatment was instituted under infiltration anesthesia. An envelope flap incision to open the area cervically from the maxillary right lateral incisor up to the maxillary right first premolar was undertaken with Bard-Parker® blade No. 15 (Aspen Surgical) (Figure 5). An endodontic access was performed with diamond drills from the lingual surface of the canine tooth. It was decided to perform a single visit endodontic procedure. The cervical onethird was curetted to remove the diseased granulation tissue and understand the extent of the resorption pathology on the root. Once the area was debrided, it was irrigated with normal saline to clear off any remnants of debris over the resorbed root surface. The root canal length was estimated by taking an initial radiograph (Figure 6). The canals were irrigated with 5.25 % of sodium hypochlorite,

Figures 3A and 3B: Pre-op CBCT. 3A. Sagittal view. 3B. Axial view

and final agitation of 17% EDTA was done. The resorbed area was filled internally with MTA repair HP (Angelus, Londrina, Brazil). Filling of the resorbed area was performed by spreading the MTA by way of condensation with radiologic examination to ensure complete sealing of the area and prevent the material leakage to the periodontium (Figure 7). Endodontic obturation followed the vertical condensation technique with gutta-percha points and AH Plus® cement (Dentsply Sirona). The restorative procedure was completed in the same visit at the end of the endodontic procedure. The inlet ducts were sealed with glass ionomer cement, and then 35% phosphoric acid gel (Ultradent) was applied for 20 seconds. The enamel and dentin surfaces were then washed and dried. The bonding agent (Tetric® N-Bond, Ivoclar Vivadent) was applied and polymerized

according to the manufacturer’s instructions. The pulp chamber was filled with a low viscosity single increment resin, SureFil® SDR® (Dentsply Sirona).The flap closure was accomplished by means of a simple interrupted sutures (Figure 8). Clinical and radiographic examination at recall visits showed decrease in the absence of symptoms (Figure 9), and the subsequent X-ray follow-ups (Figures 10-17) showed resolution of the resorption process with complete repair of the pathology at 2 years.

Discussion The exact etiology of invasive cervical resorption is still unknown. According to Gold and Hasselgren,6 three environmental factors may contribute to root resorption: 1. Absence of protection for the root surface

Figures 6 and 7: 6. Baseline intraoral X-ray with canal length determination. 7. Defect seen after degranulation Figures 4 and 5: 4. 3D volume reconstruction view. 5. Full thickness flap reflection and presence of inflammatory granuloma

Table 1: 3D classification for external cervical resorption of teeth8 Height (H)

Circumferential spread (Circ)

Proximity to canal (p)

1. Supracrestal /CEJ level

A. ≤ 90º

d: lesion in dentin

2. Subcrestal / Extends into coronal 1/3rd

B. > 90º but ≤ 180º

p: lesion in pulp

3. Extends into mid one-third

C. >180º to ≤ 270º

4. Extends into apical one-third

D. > 270º

Volume 14 Number 2

Figure 8: Flap closure accomplished by means of simple interrupted sutures Endodontic practice 13

CLINICAL 2. Presence of vascular connective tissue 3. An inflammatory stimulus The origin of stimulation factor is different for each type of root resorption, and when these factors are identified, it may be possible to reverse the process by removing the etiological factor.7 When the infection originates from the gingival sulcus and stimulates the resorption process, removal of the granulation tissue from the resorption lacuna and reliable sealing are necessary for repair since the elimination of microorganisms in the periodontal sulcus is unlikely.7 External cervical resorption is most commonly detected in maxillary central incisor teeth, followed by the maxillary canine, maxillary lateral incisor, mandibular first molar, and the maxillary first molar. This similar pattern of tooth distribution in these studies may be associated with the high prevalence of traumatic injuries (anterior teeth) (Bastone, et al., 2000) and parafunctional habits (molar tooth) in patients (Chatzopoulos, et al., 2017). Patients are generally asymptomatic, and therefore, the diagnosis of this pathology is usually as an incidental clinical or radiologic finding. In more advanced cases, when the pathology has affected the pulp such as in this case, there may be symptoms of irreversible pulpitis and or apical periodontitis. In our case, the patient complained of mild discomfort with the maxillary right canine, mild-to-moderate swelling over the buccal

soft tissue of the tooth, and slight discoloration of the tooth, observed over a period of time. There have been attempts to classify the resorption pathology defects of the tooth, but the most recent 3D classification is by Patel, et al.,8 which takes into account the exact 3D dimension of the pathology, the degree of circumferential spread, and the proximity of the root canal. The 3D classification for external cervical resorption of teeth According to this classification In Table 1, our case is classified as H3 Circ spread B and p with lesion in pulp. Invasive cervical resorption requires two stages9 — injury and stimulation. Injury can be caused by either mechanical or chemical, whereas the origin of stimulation is different for each type of root resorption. When these factors of stimulation are identified, it is possible to reverse the process by removing the etiological factors. Our case report demonstrates the outcome of sealing the resorptive defect with the restorative materials. Although the pathology defect revealed the presence of a granulation tissue inside the defect crater, subsequent recall visits showed the gingiva to be healing, indicating that no further presence of inflammatory stimulus. External cervical resorption (ECR) is a dynamic and evolving process with phases of destruction and repair (Luso and Luder 2012, Mavridou,

Figures 9A and 9B: 9A. Ten-day follow-up clinical. 9B. One-year recall clinical follow-up

Figure 11: One-year recall CBCT sagittal view 14 Endodontic practice

et al., 2016). The pathogenesis of ECR consists of: 1. Resorption initiation 2. Resorption progression 3. Reparative stage Mineral trioxide aggregate (MTA) has been considered a promising material in root canal treatment of root resorption. An important biological property is the stimulation of new bone formation, and due to its alkaline pH and biocompatibility, it does not trigger severe inflammation at the local regeneration. This material seems to be advantageous for the repair of perforations and resorption, since it allows the deposition of cement, providing a very effective biological seal, mainly due to its ability to set itself up in the presence of moisture. For these and other characteristics, MTA has several potential clinical applications to possess dimensional stability in the presence of blood and microbial byproducts besides being biocompatible and radiopaque.10

Conclusion Accurate diagnosis, case selection, material consideration, and an interdisciplinary planning for root resorption pathology can lead to successful outcomes and prediction of long-term prognosis of the pathologically involved tooth. This case showed the possibility of treating a large

Figures 10A and 10B: 10A. One-month follow-up X-ray. 10B. Four-month follow-up X-ray

Figures 12 and 13: 12. One-year recall CBCT view axial section. 13. One-year CBCT view 3D VRT section Volume 14 Number 2

REFERENCES

Figures 14 and 15: 14. Two-year recall intraoral X-ray. 15. Two-year recall clinical photo

Figures 16: Two-year recall panoromic X-ray

Figure 17: Two-year recall sagittal view CBCT

Tronstad L. Root resorption — etiology, terminology and clinical manifestations. Endod Dent Traumatol. 1988;4(6):241-252.

Heithersay G. Invasive cervical resorption. Endod Topics. 2004;7:73-92.

Brooke B, Rebekah Pryles RL. Inside Dentistry. 2017;13(7).

Heithersay GS. Invasive cervical resorption following trauma. Aust Endod J. 1999;25:79-85.

Darsey J, Qualtrough A. Resorption: part 2: Diagnosis and management. Brit Dent J. 2013;214(10):493-509.

Gold SI, Hasselgren G. Peripheral inflammatory root resorption: A review of the literature with case reports. J Clin Periodontol. 1992;19(8):523-534.

Fuss Z, Tsesis I, Lin S. Root resorption — diagnosis, classification and retreatment choices based on stimulation factors. Dental Traumatology. 2003;19(4):175-182.

Patel S, Mavridou AM, Lambrechts P, Saberi N. External cervical resorption — part 1: histopathology, distribution and presentation. Int Endod J. 2018;5(11):1205-1223.

Kqiku L, Ebeleseder KA, Glockner K. Treatment of external cervical resorption with sandwich technique using mineral trioxide aggregate : a case report. Oper Dent. 2012;37(1):98-106.

10. Dos Santos JB, Castillo JFM, Nishiyama CK, et al. External root resorption diagnosis and treatment: clinical case report. J Dent Health Oral Disord Ther. 2018;9(2):160-164.

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(262) 501-0075 Endodontic practice 15

CLINICAL

invasive cervical resorption defect of a tooth with satisfactory outcome over a 2-year recall period (Figures 14-17) based on clinical and radiologic findings. EP

COMPANY PROFILE

U.S. Endo Partners A strong partner for any practice

ince December 2018, U.S. Endo Partners has stood for endodontic excellence. We are a partnership founded by endodontists for the benefit of endodontists. In the constant effort to better ourselves and our clinical practices, U.S. Endo Partners’ unique business model partners endodontic specialists with business specialists to maximize both clinical and business results, giving focus to our patients and their care. Being endodontist-led and driven, we created the Clinical Advisory Board (CAB) to lead our business. Comprised of four exemplary clinical endodontists, the CAB has a cumulative knowledge base of over 115 years. The CAB acts as our “guiding star” for the relentless pursuit of excellence and ensures all decisions made for our group are founded first, in the patients’ best interest to provide the highest level of patient care and, second, in the best interests of the specialty followed by our partners and their families. The unique value our CAB brings to our partners and associates is immeasurable. The benefit of having mentors and collaborative endodontists on your side is an advantage to any endodontist. So too is the powerful sense of value contributed to your practice when difficult decisions are aided by those who have gone before you. Being challenged in new ways professionally is a necessary part of positive growth. It increases our professional worth to have access to peer mentorship. When COVID-19 first emerged as a threat to all medical providers, the CAB showed the safer path forward for our partner-clinicians who kept their doors open. They stayed glued to updates from the CDC and state guidelines, which helped inform best practices. They also used their personal contacts within the healthcare industry to acquire PPE for our endodontists and establish safe practice standards. Under CAB guidance, our partner-clinicians became the first responders of dentistry. The CAB contributes its expertise to the practice of our specialized field of dental treatments like root canal irrigation 16 Endodontic practice

U.S. Endo Partners’ clinician-partners are a special community of driven endodontists, led by a highly credentialed endodontists advisory board dedicated to patient-centered care

and obturation. Additionally, the CAB offers learned tips on the nuances of RCT retreatments. Even the latest in implant technology is up for discussion with our CAB. If it affects patient care, the CAB offers support for all U.S. Endo Partners. As much as the CAB increases our knowledge base, U.S. Endo Partners also understands the profession of endodontics beyond clinical expertise. As much as we excel in endodontics, most of us were never taught how to own and run an office. There were no endodontic classes offered in ordering PPE during a pandemic, legal requirements regarding HR issues, or navigating the complex taxation issues occurring within the myriad of business entities. These needs manifested into our proven business model that bifurcates the duties between the clinical guidance provided by the endodontists of U.S. Endo Partners and our organization’s business side. U.S. Endo Partners elevates endodontists to function at

the highest level by providing custom support in every business aspect. U.S. Endo Partners works with a team of professionals in business, finance, HR, compliance, and more to optimize the ROI of each practicing clinician and to support better patient care. This team of diverse and highly qualified professionals sets us apart and makes us a strong partner for any practice. Our guiding principle of allowing professionals to succeed in what they trained for creates an optimized organization where clinical excellence meets business expertise. U.S. Endo Partners understands that this mutually beneficial relationship, while novel for some, is a natural progression of the specialized realms of our expertise. We assembled endodontists and business leaders to deliver an optimized specialty services partnership for endodontists. We are the nation’s first and foremost: U.S. Endo Partners. EP This information was provided by U.S. Endo Partners.

Volume 14 Number 2

– Dr. Brett E. Gilbert, DDS King Endodontics, Course Karma’s Top Instructor of 2020 for Endodontics

Autonomy

Mentorship

Education & Development

Partner Connection

When you join U.S. Endo Partners, you keep your autonomy while gaining mentors, development opportunities and a supportive partner connection. What does success look like to you? www.USEndoPartners.com/Success

‘‘

I knew joining would really ensure, not only my practice, but the future of endodontics as a specialty.

CASE STUDY

Bioceramic sealer avoids shrinkage and excessive resorption Dr. Rico D. Short discusses this promising option for endodontic treatment Introduction Two commonly used sealers present two different challenges. Resin-based sealers will shrink upon setting, while calcium hydroxide and zinc-oxide eugenol-based sealers can resorb over time. In contrast, bioceramic sealers expand slightly during setting (typically less than 0.2% of total volume) and, once set, will not resorb as readily as calcium hydroxide and zinc-oxide eugenol-based sealers.

Case discussion A 41-year-old African American female referred to our office from her general dentist after having experienced pain on the lower right side of her mouth for several weeks. Clinical examination revealed a large carious lesion on tooth No. 30, and a periapical radiograph revealed a large periapical lesion on the mesial root (Figure 1). Because of the unusual anatomy of the mesial root, the patient was asked to approve a 3D CBCT to evaluate the root canal morphology and the periapical lesion in more detail. She declined the 3D CBCT scan. Pulp testing and periapical testing were then performed. A diagnosis of a necrotic pulp with acute apical periodontitis was confirmed. The patient agreed to have the treatment performed the same day. The patient was anesthetized with two carpules of 2% Xylocaine 1:100,000 epi via an inferior alveolar block. Buccal and

Rico D. Short, DMD, is a Board-certified endodontist, author, and speaker. In addition, he is an expert spokesperson on endodontics for the American Dental Association (ADA). Dr. Short attended the Medical College of Georgia School of Dentistry to attain a Doctor of Dental Medicine Degree in 1999. In 2002, he earned his postdoctorate degree in Endodontics from Nova Southeastern University. Dr. Short became a Diplomate of the American Board of Endodontics in 2009. His private practice, Apex Endodontics P.C, was opened in 2004 and is located in Smyrna, Georgia, just outside Atlanta. He is a Fellow in the International College of Dentists, an expert consultant in endodontics for the Georgia Board of Dentistry, and an assistant clinical professor at The Dental College of Georgia in Augusta.

18 Endodontic practice

Figures 1 and 2: 1. Pre-op radiograph of tooth No. 30 with large decay and periapical pathology. 2. Completion of the root canal using NeoSEALER Flo bioceramic sealer and gutta percha showing the three mesial canals; all have separate portals of exit

lingual infiltration was then performed with one carpule of Articaine 1:100,000 epinephrine. The tooth was isolated with a rubber dam, and the decay was removed in the clinical crown. Upon access and debridement, five canals (MB, MM, ML, DB, and DL) were located. Irrigation was performed using full-strength sodium hypochlorite with side-vented syringes while very carefully applying positive pressure. Working length was established with an apex locator. The five canals were cleaned and shaped using heat-treated nickel-titanium rotary files. A cone-fit radiograph was obtained to make sure proper length and fit were established after cleaning and shaping. A final rinse of 17% EDTA and 6% NaOCl was used in all five canals after which the canals were dried with paper points. Bioceramic sealer (NeoSEALER® Flo; Avalon Biomed™ — Houston, Texas) was placed in all the canals with flexible dispensing tips (Flex Flo Tip™; Avalon Biomed). Care was taken to ensure the stopper was approximately 5 mm to 7 mm from the working length to minimize extrusion of the sealer. Finally, gutta-percha cones were placed inside the canals and seared at the pulpal floor. The MB, MM, and ML canals had separate portals of exit (Figure 2), while the DB and DL canals joined at the apex. The presence of a third canal in the mesial root of mandibular first molars has been reported

to have an incidence rate of 1% to 15%.1 When confronted with this condition, it is very important to trough through the groove using a ball ultrasonic or high-speed bur to uncover this mid-mesial (MM) canal. The patient reported that she was largely asymptomatic the day following the procedure. Her slight discomfort was managed with a combination of acetaminophen and ibuprofen. The patient will be recalled in 6 months to ensure that satisfactory osseous healing is taking place. She was referred back to her general dentist for a final restoration within 30 days.

Summary The lack of shrinkage and the minimal resorption — as well as the non-resorbable hydrophilic nature, dimensional stability, biocompatibility, antibacterial property, bioactivity, and ease of delivery — make bioceramic sealers a promising option in endodontics. The gutta-percha cone used to drive the bioceramic sealer into cleaned isthmuses and irregular gaps serves as a soft core that allows for easier retreatment, as it is much less challenging to penetrate with hand or rotary files than is set cement. EP

REFERENCE 1. 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.

Volume 14 Number 2

Drs. Gonzalo García, Denise Alfie, Juan Antonio Araujo, Claudia Hernández Restrepo, and Fernando Goldberg discuss instruments that can be beneficial when faced with poorly instrumented and sealed curved and narrow canals Abstract Objective To evaluate the time recorded by TruNatomy™ (TN) (Dentspy Sirona) and ProTaper Next™ (PTN) (Dentsply Sirona) systems for gutta-percha penetration up to the working length in simulated, narrow and curved canals of Endo Training Blocks (ETBs). Materials and methods Twenty simulated canals were instrumented with PTN X1 and sealed with a single gutta-percha 20.04 cone and AH Plus® (Dentsply). The blocks were divided into two groups of 10 each. Group 1: Gutta percha was drilled to working length with TN small. Group 2: Gutta percha was drilled to the working length with PTN X1. Both instruments were used at 700 rpm and 4 Ncm torque. Penetration time was recorded in each group. The data obtained was statistically evaluated with the Student’s t-test. Results No statistically significant differences were observed between the groups (p > 0.05). Conclusion PTN X1 and TN small can be used for gutta-percha penetration in the retreatment of narrow and curved canals.

Figure 1: Endo Training Block with the canal instrumented and obturated with gutta percha and AH Plus

Figure 2: Instruments TruNatomy small (top) and ProTaper Next X1 (bottom)

Introduction Nonsurgical endodontic retreatment is now a routine procedure at the dental office. Success depends on the adequate removal of the obturation materials used in the initial treatment in order to allow for proper re-instrumentation, disinfection, and sealing.1,2 Removal of the obturation materials is one of the most difficult steps. Its correct performance depends on the anatomical difficulties, the modifications of the original path of the root canal, and the characteristics of the materials used and their compaction.3-5 On the other hand, the presence of

Gonzalo García, DDS, Denise Alfie, DDS, PhD, Juan Antonio Araujo, DDS, Claudia Hernández Restrepo, DDS, and Fernando Goldberg, DDS, PhD, are from the Department of Endodontics, School of Dentistry of the University of Buenos Aires, Argentina. Disclosure: The authors deny any conflicts of interest related to this study.

Volume 14 Number 2

intracanal posts can further complicate this procedure. For the removal of gutta percha, several instruments and procedures have been suggested: solvents, manual files, special design instruments, mechanized systems, ultrasound, and the combination of several of them.6 Numerous authors emphasize the difficulty of obtaining the total and complete removal of the obturation material that remains in the different thirds of the root canal system.4,5, 7-11 In curved and narrow canals that are poorly instrumented and sealed, the removal of the sealing material offers a unique challenge. In general, this intervention is performed with manual instruments and involves hard work and a long time. TruNatomy (TN) and ProTaper Next (PTN) are NiTi instruments Endodontic practice 19

CLINICAL RESEARCH

Evaluation of the penetration time required by TruNatomy™ and ProTaper Next™ to reach the apical limit during gutta-percha removal in simulated curved and narrow canals of Endo Training Blocks

CLINICAL RESEARCH Table 1: Descriptive summary Statistics

TruNatomy™ ProTaper Next™

Media

11.90

10.42

Standard deviation

1.74

2.56

Minimum

8.81

7.31

Media

11.64

9.79

Maximum

15.35

16.84

p > 0.05

Student's t-test

Significance

Removal of the obturation materials is one of the most difficult steps. Its correct performance depends on the anatomical difficulties, the modifications of the original path of the root canal, and the characteristics of the materials used and their compaction.

that work in continuous rotation. These instruments have a heat treatment that gives them greater flexibility, fracture resistance, and cyclic fatigue.12,13 TN is a new rotary system designed to achieve more conservative preparations of the root canal. It consists of three instruments: small 20/04, prime 26/04, and medium 36/03. The PTN is a rotary system composed of 5 instruments: X1, X2, X3, X4, and X5 that correspond to the gauges of 17/04, 25/06, 30 /07, 40/06, and 50/06, respectively. In the clinical cases of retreatment of curved and narrow canals, the use of mechanized instruments of low caliber and high flexibility would be appropriate. The objective of the present study is to evaluate the time required by TN and PTN to penetrate the gutta percha and reach the apical limit in retreatment procedures in simulated curved and narrow canals of Endo Training Blocks (ETBs).

Group 1: The gutta-percha was penetrated until reaching the WL, with a TruNatomy small instrument (Dentsply Sirona) in continuous clockwise rotation at 700 rpm and a torque of 4 Ncm. Group 2: The gutta-percha was penetrated until the WL with a ProTaper Next X1 instrument (Dentsply Sirona) in continuous clockwise rotation under the same conditions of group 1 (Figure 2). In both groups, the instruments penetrated the gutta percha with a constant crown-down motion until reaching the WL. The penetration maneuvers were performed by the same operator and the X-Smart Plus motor (Dentsply Sirona) was used. Each instrument was used in three ETBs. The time required to reach the WL was recorded with a Tressa digital timer (LatCrom, China), and an Excel table was used to collect the data. For statistical evaluation the Student’s t-test was used.

Materials and methods

Results

Twenty ETBs (Dentsply Sirona, Ballaigues, Switzerland) with simulated curved canals (SCC) of circular section, 16 mm of working length (WL), ISO 0.15 gauge at apical level, and 2% continuous taper with approximately 40 degrees of curvature14 were used. SCC permeability was verified with a K-File No. 10 (Dentsply Sirona), and the WL was set at 16 mm. The blocks were then prepared to WL with an X1 instrument from ProTaper Next system (Dentsply Sirona) used with an X-Smart motor (Dentsply Sirona) following the manufacturer’s instructions. Subsequently, they were sealed with a single guttapercha cone 20.04 caliber (Meta Biomed, Co. Ltd., Korea) and AH Plus (Dentsply Sirona) (Figure 1). Samples were stored in 100% humidity at 37ºC for 10 days to allow the sealer to set. Samples were divided into 2 groups of 10 units.

The summary of the results is described in Table 1. No statistically significant differences were observed between the groups (p > 0.05).

20 Endodontic practice

Discussion During endodontic retreatment, penetration into the gutta-percha mass and its subsequent removal generally requires different procedures, which vary according to the compaction of the filling material, the apical limit, and iatrogenic or anatomical difficulties within the root canal.3 In this study, only the time needed to penetrate the gutta percha and reach the WL was analyzed. In straight and properly prepared canals, any instrument in rotational dynamics of caliber compatible to the root canal can penetrate and remove gutta percha more easily and efficiently.

In general, canals that are referred for retreatment present a poor primary preparation, and the obturation is made up of a small caliber gutta-percha cone and some sealer. If the path of the root canal is also curved, it is dangerous to penetrate and remove the gutta percha with rotary instruments of a greater taper than the one of the root canals. Consequently, the objective of the present study was to evaluate the penetration ability of instruments with reduced caliber and taper in simulated curved and narrow canals sealed with gutta percha. In that sense, the TN system, manufactured with NiTi SuperFlex™ (Vista Apex Dental Products, Racine, Wisconsin), has a flexibility that allows it to easily adapt to the curvature of the root canal without losing penetration capacity in the gutta-percha mass. TN small and PTN X1 instruments were selected because of the SCC narrowness. The results obtained showed that the instruments used penetrated the gutta percha up to the WL in a similar time. Although the penetration time with PTN was shorter, the difference was not statistically significant. Similarly, comparing the penetration time with other studies, the results of this work showed greater speed to penetrate and reach the WL.15,16 This could be related to the lack of compaction that would facilitate the faster advance of the instrument. Since penetration into the gutta-percha mass requires a greater pressure on the instrument, this difficulty was compensated by increasing its rotation speed to 700 rpm with a torque of 4 Ncm.16-18 TN and PTN have a similar cross-sectional design that promotes less contact with the dentinal walls. This would facilitate the gutta-percha removal to the coronal access. In this study, rotary instruments were used, considering that according to Azim, et al.,19 it is the most appropriate motion to penetrate gutta percha. Although some authors suggest the use of Volume 14 Number 2

Conclusion The ProTaper Next X1 and TruNatomy small could be used for gutta-percha penetration in the retreatment of curved and narrow canals.

Acknowledgments The authors express their sincere appreciation to Professor Ricardo L. Macchi for his help with the statistical analysis. EP

REFERENCES 1. Siqueira JF Jr, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod. 2008:34(11):1291-1301. 2. Schirrmeister JF, Wrbas KT, Schneider FH, Altenburger MJ, Hellwig E. Effectiveness of a hand file and three nickeltitanium rotary instruments for removing gutta percha in curved root canals during retreatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(4):542-547. 3. Gorni FGM, Gagliani MM. The outcomeof endodontic retreatment: A 2-yr follow-up. J Endod. 2004;30(1):1-4. 4. Somma F, Cammarota G, Plotino G, Grande NM, Pameijer CH. The effectiveness of manual and mechanical instrumentation for the retreatment of three different root canal filling materials. J Endod. 2008;34(4):466-469. 5. Giuliani V, Cocchetti R, Pagavino G. Efficacy of ProTaper Universal retreatment files in removing filling materials during root canal retreatment. J Endod. 2008;34(11):1381-1384. 6. Duncan HF, Chong BS. Removal of root filling materials. Endod Topics. 2011;19(1):33-57. 7. Files and rotary Ni-Ti instruments to remove gutta-percha and four types of sealer. Int Endod J. 2006;39(1):48-54. 8. Saad AY, Al-Hadlaq SM, Al-Katheeri NS. Efficacy of two rotary niti instruments in the removal of gutta-percha during root canal retreatment. J Endod. 2007;33(1):38-41. 9. Tasdemir T, Er K, Yildirim T, Celik D. Efficacy of three rotary NiTi instruments in removing gutta-percha from root canals. Int Endod J. 2008;41(3):191-196. 10. Gu LS, Ling JQ, Weix X, Huang XY. Efficacy of ProTaper Universal rotary retreatment system for gutta-percha removal from root canals. Int Endod J. 2008;41(4):288-295. 11. Hammad M, Qualtrough A, Silikas N. Three-dimensional evaluattion of effectiveness of hand and rotary instrumentation for retreatment of Canals filled with different materials. J Endod. 2008;34(11):1370-1373. 12. Scianamblo MJ, Flatland M. The advantages of instrument

compressibility and ProTaper Next™. Endodontic Practice US. 2017;10(1):15-19. 13. van der Vyver PJ, Vorster M, Peters OA. Minimally invasive endodontics using a new single-file rotary system. Int Dent African Edition. 2019;9(4):6-20. 14. Berutti E, Alosivi M, Pastorelli MA, et al. Energy consumption of ProTaper Next X1 after glide path with PathFiles and ProGlider. J Endod. 2014;40(12):2015-2018. 15. Ma J, Al-Ashaw AJ, Shen Y, et al. Efficacy of ProTaper Universal Rotary Retreatment system for gutta-percha removal from oval root canals: a micro-computed tomography study. J Endod. 2012;38(11):1516-1520. 16. Garcia G, Alfie D, Rodriguez PA, Goldberg F. A comparative study of the penetration time of different instruments and kinematics for reaching the apical limit during gutta-percha removal in endodontic retreatment. Endodontic Practice US. 2019;12(3):14-19. 17. Nevares G, de Albunquerque DS, Freire LG, et al. Efficacy of ProTaper Next compared with Reciproc in removing obturation material from severely curved canals: a micro-computed tomography study. J Endod. 2016;42(5):803-808. 18. Martins MP, Duarte MA, Cavenago BC, Kato AS, da Silveira Bueno CE. Effectiveness of ProTaper Next and Reciproc Systems in removing root canal filling material with sonic or ultrasonic irrigation: a micro-computed tomographic study. J Endod. 2017;43(3):467-471. 19. Azim AA, Wang HH, Tarrosh M, Azim KA, Piasecki L. Comparison between single-file rotary systems: Part 1— Efficiency, effectiveness, and adverse effects in endodontic retreatment. J Endod. 2018;44(11):1720-1724. 20. Betti LV, Bramante CM. Quantec SC rotary instruments versus hand files for gutta-percha removal in root canal retreatment. Int Endod J. 2001;34(70:514-519. 21. Unal GC, Kaya BU, Taç AG, Keçeci AD. A comparison of the efficacy of conventional and new retreatment instruments to remove gutta-percha in curved root canals: an ex vivo study. Int Endod J. 2009;42(4):344-350.

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CLINICAL RESEARCH

gutta-percha solvents to facilitate penetration in retreatments, others consider its use inappropriate to the extent that it softens the gutta percha, making it difficult to remove it later.10,15,20 In the present study, no solvents were used to avoid these inconveniences. Different publications indicate the fracture of the instruments used during the removal procedure of the sealing material.2,19,21 It is important to note that in the TN group, one instrument presented an inelastic deformation during the first use without fracturing. There was no deformation or fracture of instruments in the PTN group.

TECHNOLOGY

Using dental lasers to decrease pain and fear for patients Dr. Fernando J. Meza shares key differentiators in performing a root canal with traditional equipment versus dental lasers

he “dreaded root canal” is known among patients as one of the most painful dental procedures. However, endodontists can help change this narrative, starting at the root of patients’ concerns — pain. While time is required for education and understanding around devices like dental lasers, the return on the time investment is invaluable for both the provider and patient alike. Many endodontists may be surprised to learn the stark differences between leveraging traditional dental equipment and new technologies for a procedure like a root canal, and the change in patient perception and experience both during and post-procedure. Patients who need a root canal may be already experiencing significant pain due to inflammation or infection of the pulp. This inflammation or infection of the pulp can have a variety of causes, including deep decay, repeated dental procedures on the tooth, or a crack or chip in the tooth. In addition to the pain that comes from one or more of these issues, the equipment used during a root canal can further irritate the inflamed or infected area by insufficient cleaning and shaping. This idea alone is enough to deter some patients from seeking treatment sooner, which flows into another concern; if pulp inflammation or infection is left untreated, it can lead to more serious health issues, like an abscess.

Traditional dental devices for a root canal procedure There are more than 25 million root canals that are performed each year,1 with the most common equipment used during root canals listed as being nickel-titanium hand and rotary files, stainless-steel hand files, endodontic burs, files and reamers, and

ultrasonic units. When patients undergo a root canal and experience pain or significant discomfort stemming from some of the equipment, it can lead to negative feedback around the procedure — ultimately inciting fear among family and friends. As a result, the root canal has received a bad reputation over the years. While we cannot eliminate all of the traditional equipment used in root canal treatments, adding a dental laser to your endodontic armamentarium can greatly decrease the amount of the equipment that needs to be utilized during this procedure. It can also improve the overall efficiency of a root canal because patients typically spend less time in the chair when a dental laser is the primary device that is being used. This benefits endodontists as well, as they can treat more patients throughout each day. The dental laser offers a greater level of precision than traditional equipment because it has the ability to clean and disinfect anatomy of teeth, which some endodontists previously thought was impossible.

Dental lasers for a root canal procedure Most endodontists are actively seeking out the latest technologies to implement in order to improve their patients’ experience, as well as their own when performing a procedure. The American Association of Endodontists shares that there have been significant advances in technology and endodontic treatment procedures,2 including dental lasers, microscopy, enhanced irrigation technologies, digital radiography, cone beam computed tomography (CBCT), ultrasonic tips and files, and bioceramic sealers. The reason lasers can be so effective in dental procedures is because these lasers

Fernando J. Meza, DMD, is a graduate of Vanderbilt University where he received his BA in Psychology in 1997. In 2002, he received his DMD from the University of Connecticut School of Dental Medicine. After graduating from dental school, Dr. Meza went on to receive his specialty training from Temple University School of Dentistry where he obtained his Certificate in Endodontics. Disclosure: During his residency, Dr. Fernando J. Meza and colleagues conducted research using the BIOLASE Er,Cr,YSGG laser to investigate its effectiveness in disinfecting root canals. The results of his research led to a publication in the Journal of the American Dental Association.9

22 Endodontic practice

Figures 1A and 1B: Preoperative images

emit light energy that has the ability to interact with biologic tissues, such as tooth enamel, dentin, gingiva or dental pulp.3 As a result of this interaction, these lasers can improve disinfection during a root canal, particularly when compared to traditional equipment. When a patient undergoes a root canal procedure with a dental laser, tissue also has the ability to heal more quickly than it would if a traditional device is used because of more effective regeneration and the enhanced ability of the laser to disinfect the canal system, thereby cleaning more deeply and allowing the body to heal faster. Highintensity visible light has been found to kill bacteria regularly found in infected wounds.4 Root canal treatment with dental lasers also becomes more efficient than that of traditional treatments because patients spend less time in the chair, which on its own is less traumatic to the patient and biologic tissues. The idea of enhanced cleaning and disinfection with less treatment time is a primary reason that the laser can lead to less postoperative pain. When compared to traditional devices, laser light can penetrate deeper into the dentin,5 creating the potential for high levels of canal disinfection. For example, BIOLASE’s dental lasers (the ones I use in my practice) are indicated for cleaning and Volume 14 Number 2

Which laser is right for my endodontic practice?

power increased, and ultimately, we found that the Er,Cr:YSGG laser with a radial emitting tip has a significant antimicrobial effect leading to 99.7% bacterial reduction. During a root canal, when an inflamed or infected pulp needs to be removed and the inside of the tooth is carefully cleaned and disinfected, dental lasers provide the necessary precision required to conduct these treatments without causing further inflammation for the patients.

Traditional devices versus modern devices Overall, if we are keeping score, the benefits for both patients and providers that dental lasers provide significantly outnumber traditional devices by a landslide. As an endodontist, it is truly incredible to see the advances in devices over the years, and the sooner we begin to educate, train, and adopt these into our practices, the more patients we can help. It is no secret that root canals have a notorious reputation among patients, but I believe eventually, with the right equipment, we can change this story. EP

REFERENCES 1. Johnson M. Root Canal Safety. The Truth About Endodontic Treatment and Your Health. Dear Doctor. Dentistry & Oral Health. https://www.deardoctor.com/inside-the-magazine/ issue-37/root-canal-safety/. Accessed April 20, 2021. 2. American Association of Endodontists. Treatment Standards. AAE website © 2020. https://www.aae.org/specialty/ wp-content/uploads/sites/2/2018/04/TreatmentStandards_ Whitepaper.pdf. Accessed April 20, 2021. 3. American Association of Endodontists. Use of Lasers in Dentistry. AAE website © 2019. https://www.aae.org/ wp-content/uploads/2019/10/2019_LasersinDentistry.pdf. Accessed April 20, 2021. 4. Lipovsky A, Nirzan Y, Gedanken A, Lubart R. Visible light-induced killing of bacteria as a function of wavelength: Implication for wound healing. Laser Surg Med. 2010;42(6):467-472. 5. Simon MCJ, Pradeep S, Duraisamy R, Kumar MPS. Role of lasers in endodontics—A review. Drug Invention Today. 2018;10(10):1881-1886. 6. Dentists Deploy Lasers for Root Canal Treatment (blog). BIOLASE® website. https://www.biolase.com/blog/dentistsdeploy-lasers-treat-root-canals/#:~:text=A%20Waterlase%20is%20used%20for,with%20the%20chances%20 for%20success! Accessed April 20, 2021. 7. Why Waterlase? BIOLASE® website. https://www.biolase. com/patients/why-laser-dentistry/. Accessed April 20, 2021. 8. American Association of Endodontists. Use of Lasers in Dentistry. AAE website © 2019. https://www.aae.org/ wp-content/uploads/2019/10/2019_LasersinDentistry.pdf. Accessed April 20, 2021. 9. Gordon W, Atabakhsh VA, Meza F, et al. The antimicrobial efficacy of the erbium, chromium:yttrium-scandium-galliumgarnet laser with radial emitting tips on root canal dentin walls infected with Enterococcus faecalis. J Am Dent Assoc. 2007;138(7):992-1002.

Before adopting dental lasers, endodontists should research the benefits that they can provide to patients to ensure that they are implementing the right equipment to improve their practice and the patient experience. In 2007, a group of researchers, including myself, published findings on the Er,Cr:YSGG lasers’ involvement and effectiveness in bacterial recovery from dentin walls. The data9 displayed that bacterial recovery decreased when laser irradiation duration or

Figures 2A and 2B: Postoperative images exactly 2 months later show healing of the PA lesion Volume 14 Number 2

Endodontic practice 23

TECHNOLOGY

shaping of root canals and for laser root canal disinfection after endodontic treatment.6 The Waterlase® laser7 can be used to open the surface of the tooth to access the root canal, and using a combination of air/water spray and laser energy, endodontists can remove diseased tissue as well as clean and shape the canal. There is also additional data8 on dental lasers’ use during root canals, which suggests that the propagation of acoustic waves emanating from a pulsed low-energy laser can help distribute disinfecting solutions more effectively across the root canal system. There is also a photomechanical effect that occurs when light energy from the lasers is absorbed by water or diluted sodium hypochlorite solution causing cavitation of bubbles, resulting in shear forces generated that are able to remove the smear layer and disrupt the biofilms that shelter the bacteria within the walls of the canals, which also aids in disinfection.

CONTINUING EDUCATION

Endodontic irrigation: optimizing pulp dissolution from complex root canal systems Dr. L. Stephen Buchanan discusses a new concept in endodontic irrigation

ndodontic irrigation is the most important part of root canal therapy (RCT), but I confess it has never been the most interesting part of the process for me because there is so little to see going on during irrigation. All the other aspects of RCT have an easily visualized representation of procedural events — whether that is by direct magnified sight or indirectly, by mental visualization. When I am cutting tooth structure with a diamond bur spun at 200,000 RPM, I see most everything happening at the bur/tooth interface. When I’m directing a rotary file to cut through a canal, even when the file is mostly buried in the root, mentally visualizing the hidden part of the file is very straightforward as I know the file’s geometry, and I know the depth in the canal to which that file’s geometry has progressed. Having cut a 30/.06 rotary file within a millimeter of the canal terminus, I only need to view the instrument’s flute spaces to see where the file cut dentin in the canal, and I can clearly see the hidden surfaces of the just-shaped canal in my mind. Irrigation not so much. Endodontic irrigation is now the most interesting procedural topic in the field, primarily because of two of the most recent entries into the market — GentleWave® (Sonendo) and BioLase irrigation activation procedures. GentleWave’s irrigation system forged new ground in endodontics, and both of these systems are able to work in radically smaller instrumentation procedures. We are now seeing a remarkable number of lateral canal irregularities in vital cases

Educational aims and objectives

This self-instructional course for dentists aims to show information regarding endodontic irrigation as well as details regarding a new technique.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions by taking 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 factors that can cause irrigation failures during RCT.

•

Recognize some of the more recent systems in the marketplace for endodontic irrigation.

•

Realize some ramifications of inflamed pulp remnants.

•

Observe a novel in vitro irrigation model.

•

Realize the effect of different variables like concentration, temperature, and aeration on the dissolution efficacy of sodium hypochlorite.

Figure 1: Lower molar case with 15-.03* canal preparations, GentleWave cleaning, and Continuous Wave Obturation with bioceramic sealer. Note the uninstrumented but cleaned and filled cervical and apical bifurcations in the distal root (*Shapes by MiniKUT Files by PlanB Dental)

— cleaned and filled through preparations as small as 13-.03. More often than not these treatment results look more like one of Walter Hess’ anatomic castings1 than the overcut RCT results we used to associate with excellence in endodontics (Figure 1).

L. Stephen Buchanan, DDS, FICD, FACD, Dipl. ABE, was valedictorian of his class at the University of the Pacific School of Dentistry and completed the Endodontic Graduate program at Temple University in Philadelphia, Pennsylvania, in 1980. Dr. Buchanan began pursuing 3D-anatomy research early in his career, and in 1986, he became the first person in dentistry to use micro CT technology to show the intricacies of root structure. In 1989, he established Dental Education Laboratories and subsequently built a state-of-the-art teaching laboratory devoted to hands-on endodontic instruction, where he continues to teach today. Through Dental Education Laboratories, he has lectured and conducted participation courses around the world, published numerous articles, and produced an award-winning video series, “The Art of Endodontics.” In addition to his activities as an educator and practicing clinician, Dr. Buchanan holds a number of patents for dental instruments and techniques. Disclosure: Dr. Buchanan is a stockholder of Sonendo; he is the inventor and owner of the IP associated with the closed-system, negative pressure, positive outflow irrigation (PulpSucker) device described in this article, and he is PlanB Dental’s Clinical Director.

24 Endodontic practice

Fear inflamed pulp remnants Irrigating canals aside, diagnosing irrigation failures can be very mysterious, and patients unlucky enough to have an incompletely treated tooth containing inflamed pulp remnants are also at great risk of receiving unnecessary RCT and extractions if a diagnostic failure follows. A well-done study2 showed 11% of patients in pain who saw an endodontist were not relieved of their pain within 6 months. Half of these didn’t need an RCT — they had myofascial pain; the other half needed a root canal (better); but half of these had RCT done on the wrong tooth, leaving the last quarter of these pain management failures to irrigation failures such as the cases in Figure 2. Volume 14 Number 2

Figures 2A-2D: 2A. This maxillary premolar was treated twice in 9 months without relief of the severe and persistent pain referred to the “endodontic zone” of her face (images shown left to right). 2B. By simply extending treatment to the terminus of the primary canal, all of her symptoms were resolved. 2C. This lower molar was treated short in the ML canal and overfilled beyond the MB and D canal termini. The patient had persistent pain referred to his left side endodontic zone for 18 months after RCT. 2D. The ML canal was retreated, completely resolving the patient’s pain and revealing the etiology — an untreated mid-mesial canal harboring a pulp remnant with its own periradicular blood supply. The overfilled roots were never revised

Deliquesce the pulp How long does it take to deliquesce (dissolve) an inflamed pulp out of a complex root canal system? Researchers have done many in vitro and ex vivo studies of canalar biofilms3, and while some understand the mission better than others, they have a pretty good idea of what it takes and how long it takes to kill most or all the bugs in a root canal. Regarding pulp tissue in lateral recesses, however, it is generally agreed that it is more difficult and takes longer to digest pulp in lateral recesses than it does to kill biofilm in a pool of slime. The best pulpal irrigation studies have been done in teeth slated for extraction, splitting their roots open after delivery and using a SEM to view the exposed surfaces (Figure 3) or embedding, slicing, and viewing sections through a light microscope to view the canalar contents. I was inspired to design a novel in vitro irrigation model (Figure 4) by a surprising failure I had using multisonic ultracleaning technology5 in a lower C-shaped molar. The most likely etiology I could figure for the tooth to remain sensitive after completion was inflamed pulp fragments remaining in the broad buccal isthmus between the MB and D canals. The first time an isthmus dissolution study was done in this new model that, theory was confirmed (Figure 5); at the end Volume 14 Number 2

Figure 3: SEM photos of root surfaces after closed-system negative pressure irrigation4 was run through the canal of this upper cuspid tooth. EDTA was used during instrumentation with a 30-.08 file to finish, then 30 minutes of NPI with 6% NaOCl, with a 15 second final rinse with EDTA. Contrary to other researcher’s findings, irrigating with NaOCl after EDTA showed no excessive etching or apparent weakening of dentin. The smooth dentin surfaces show no evidence of overetching by NaOCl because a final rinse with EDTA was used, leaving clean, smooth, and structurally intact dentin walls

Figure 4: Clear research simulation block (designed by the author) printed in two halves, placing thin-sliced porcine tissue (pulp analog) in the isthmus space between adjacent simulated canals before block halves are assembled with light-cure adhesive. After assembly, a platform for the multisonic technology was built on top of the pulp chamber, and cleaning was done as video footage was shot through a microscope. This qualitative research model offers insights about relative speeds of pulp dissolution in isthmus spaces between canals when different irrigation methods are used

of the 5-minute NaOCl cycle, pulp analog remained. Watching playbacks of the video recording through the clear isthmus block,

as the prosciutto captured between the block halves was irrigated and digested by NaOCl, fascinated me, especially when I realized I could watch how different variables like Endodontic practice 25

CONTINUING EDUCATION

Several factors obfuscate diagnoses of irrigation failures. Start with the fact that pain referred from inflamed pupal remnants may refer to any teeth on the same side of the patient’s face, while percussing the offending tooth may elicit a different awareness at most. The first big tip-off — if you did thorough thermal pulp testing before entry — is the knowledge that treating the tooth alleviated the patient’s thermally induced pain, leaving the patient with continuing spontaneous pain that can be severe. The surprising aspect is how long pulp remnants can stay alive, a function of their close proximity to the rich periradicular blood supply. There will seldom be PR lucencies visible in CBCT volumes, and they won’t get even slightly better on the most effective antibiotics like Augmentin or clindamycin. The diagnosis is made by reviewing the patient’s history and finding notation of severe pulpitis before the emergency access. Give the patient 400 mg of naproxen (Aleve®), wait 40 minutes, and if the pain has been relieved, schedule the patient for the retreat. And do a better job of irrigating the second time.

CONTINUING EDUCATION concentration, temperature, and the surprise variable-aeration-enhanced the dissolution efficacy of sodium hypochlorite (Figures 5-7). From a 40-minute time to dissolve the pulp analog with 6% NaOCl EndoVac irrigation (much of that time spent unclogging the EV needles), dissolution times were progressively

shortened: 40 minutes to 30 minutes simply by reversing the direction of fluid flow, simultaneously eliminating the clogging problem inherent to using irrigation needles as vacuum pipes; 30 minutes reduced to 20 minutes by increasing the concentration of the NaOCl solution from 6% to 12% or by heating the

solution to 109º F, and the dog-bites-man story of how simply aerating the solution halved the time to dissolution as air bubble cavitation exploding out the ends of the catheters imparting significant shear forces throughout the length of the canal.6

Applying all variables to shorten the time Finally, I did a block test combining all four of those factors — concentration, the direction and volume of fluid flow, temperature, and aeration (Figure 9) — bringing the time to digest all the way through the isthmus pulp analog down to 10 minutes. This led to joining forces with Vista Dental to develop what we call the multi-canalar PulpSucker (PS) Closed-System Vacuum-Drawn Irrigation System (Figure 10).

Conclusion Figure 5: The multisonic technology procedure digests the pulp analog in the isthmus space in 7.5 minutes of NaOCl irrigation time. The image (fourth from the left) shows pulp analog remaining after the 5-minute NaOCl GW cycle. As this unit’s 2-minute EDTA cycle and its 45-second distilled water cycles followed, none of the pulp analog was digested or affected in any way. When another molar procedure Instrument was brought in, the 1.5-minute vacuum check with distilled water (with full multisonic energy applied) did not further the removal either. It wasn’t until the NaOCl cycle came on for another 2.5 minutes that the remainder of the pulp analog was removed

This new irrigation system and method has the following advantages: 1. PS Irrigation supports MIE canal shapes and single visit RCT for all cases.

Figure 6: Isthmus research blocks showing the difference in pulp analog dissolution times btn 6% (left) and 12% (right) NaOCl. Doubling the concentration increased the speed of dissolution by 33%

Figure 7: Isthmus research blocks showing the difference in pulp analog dissolution times btn NaOCl at 70º F (left) and NaOCl heated to 106º F (right). Increasing the temperature by 33% increased the speed of dissolution by 33%

Figure 8: Isthmus research blocks showing the difference in pulp analog dissolution times between NaOCl with no air bubbles (left) and NaOCl with air bubbles (right). Aerating the NaOCl doubled the speed of dissolution — the most surprising results of these isthmus block studies

Figure 9: Isthmus research blocks showing the difference in pulp analog dissolution times between room temperature NaOCl without aeration (left) and heated NaOCl with aeration (right). Heating and aerating the NaOCl tripled the speed of pulp analog dissolution when applied in a closed-system vacuum-drawn irrigation method of action

26 Endodontic practice

Volume 14 Number 2

CONTINUING EDUCATION Figure 10: This extracted tooth was entered through five separate 1 mm access openings, one for each of four canals and a fifth opening directly into the pulp chamber as a setup for the obturation to follow and was mounted in a TrueJaw printed replica (DELabs) with impression material. A stage was luted to the tooth with a light-cure polymer, catheters were placed to ideal length in each of the four canals plus the fifth catheter into the pulp chamber through its separate side port, and the top plate was luted to the stage after X-ray confirmation of catheter position. The catheter manifold was hooked up to an IV bag of NaOCl, the line out of the Top Plate was hooked into the chairside vacuum system, and it was left to run for 15 minutes after which the canal system was obturated and the access openings restored. This is minimally invasive endodontics at its best

Figure 11: The canals in this lower molar were minimally cut to 13-.03 MiniKUT File shapes, irrigated with the PS System for 18 minutes, and obturated, revealing a 6 mm mid-mesial canal exiting its own furcal POE. This canal was never entered with an instrument

2. It is multi-canalar and works in all 1-5 canals simultaneously. 3. It takes 2-4 minutes of hands-on to stage. 4. It takes 8-15 minutes of hands-off irrigation run time. 5. Vacuum-drawn irrigation with 8% NaOCl is 100% safe. 6. There are no capital costs; no maintenance costs. 7. These are single-use, completely disposable devices. EP REFERENCES 1. Hess W, Zurcher E, Dolamore WH. The Anatomy of the Root Canals of the Teeth of the Permanent Dentition. London: J. Bale Sons and Danielsson; 1925. 2. Nixdorf DR, Law AS, John MT, Sobieh RM, Kohli R, Nguyen RH; National Dental PBRN Collaborative Group. Differential diagnoses for persistent pain after root canal treatment: a study in the National Dental Practice-based Research Network. J Endod. 2015;41(4):457-63. 3. Retamozo B, Shabahang S, Johnson N, Aprecio RM, Torabinejad M. Minimum contact time and concentration of sodium hypochlorite required to eliminate Enterococcus faecalis. J Endod. 2010;36(3):520-3. 4. Schoeffel GJ. The EndoVac method of endodontic irrigation: Part 2—efficacy. Dent Today. 2008;27(1):82,84,86-87. 5. Haapasalo M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour M. Tissue dissolution by a novel multisonic ultracleaning system and sodium hypochlorite. J Endod. 2014;40(8):1178-81.

Figure 12: Close-up radiography shows a remarkable apical delta system at the end of the distal canal. Seeing 1-3 lateral canal aberrations filled is commonplace, seeing five lateral canals filled in the apical 2 mm of the roots is the ultimate proxy for irrigation efficacy Volume 14 Number 2

6. Buchanan LS. Closed System Negative Pressure Endodontic Irrigation: A Serious Inflection Point in Root Canal Cleaning. Dent Today. April 2020. https://www. dentistrytoday.com/endodontics/10666-closed-systemnegative-pressure-irrigation-a-serious-inflection-point-inroot-canal-cleaning

Endodontic practice 27

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To provide feedback on this 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 judgement of a trained healthcare professional.

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Endodontic irrigation: optimizing pulp dissolution from complex root canal systems BUCHANAN

1. Irrigating canals aside, diagnosing irrigation failures can be very mysterious, and patients unlucky enough to have an incompletely treated tooth containing inflamed pulp remnants are also at great risk of receiving ________ if a diagnostic failure follows. a. unnecessary RCT b. extractions c. fractures d. both a and b 2. A study showed ________ of patients in pain who saw an endodontist were not relieved of their pain within 6 months. a. 11% b. 22% c. 33% d. 44% 3. Several factors obfuscate diagnoses of irrigation failures. Start with the fact that pain referred from inflamed pupal remnants may refer to __________. a. any teeth on the opposite side of the patient’s face b. any teeth on the same side of the patient’s face c. just the “offending tooth” d. just the “offending tooth” and the tooth adjacent to it 4. The surprising aspect is how long pulp

28 Endodontic practice

remnants can stay alive, a function of ________. a. their proximity to the nerve b. their resistance to bacteria c. their close proximity to the rich periradicular blood supply d. the patient’s dental hygiene. 5. There will ________, and they won’t get even slightly better on the most effective antibiotics like Augmentin or clindamycin. a. seldom be PR lucencies visible in CBCT volumes b. always be PR lucencies visible in CBCT volumes c. never be PR lucencies visible in CBCT volumes d. never be PR lucencies visible in 2D radiography 6. (The author writes) The diagnosis of irrigation failure is made by _______ before the emergency access. a. reviewing the patient’s history b. finding notation of severe pulpitis c. visual examination d. both a and b 7. According to this author, the diagnosis of irrigation failure is made by reviewing the patient’s history and finding notation of severe pulpitis before the emergency access. Give the patient _____, wait 40

minutes, and if the pain has been relieved, schedule the patient for the retreat. a. 400 mg of naproxen (Aleve®) b. 500 mg of Augmentin c. 500 mg of clindamycin d. an injection of lidocaine 8. The author did a block test combining all four of those factors — concentration, the direction and volume of fluid flow, temperature, and aeration — bringing the time to digest all the way through the isthmus pulp analog down to _______. a. 10 minutes b. 20 minutes c. 30 minutes d. 1 hour 9. The author’s new irrigation system and method lists this as one of the advantages: Vacuum-drawn irrigation with ______ NaOCl is 100% safe. a. 5% b. 6% c. 8% d. 10% 10. The irrigation system and method developed by the author are _______ devices. a. single-use, completely disposable b. multi-use, non-disposable c. not minimally invasive d. none of the above

Volume 14 Number 2

CE CREDITS

ENDODONTIC PRACTICE CE

Drs. Brett E. Gilbert and Richard Mounce discuss techniques and materials that lead to effective endodontic treatment

his article was written to demonstrate that the application of proven literature and/ or evidence-based endodontic principles leads to excellent clinical results, irrespective of the materials used. We will describe the key points to achieving excellent results in initial nonsurgical endodontic treatment in the key areas of diagnosis, shaping, irrigation, obturation, and restoration. Assessing “proven” and “literature/ evidence-based” techniques and materials is easier said than done. While a number of excellent endodontic meta-analysis and systematic reviews have been completed in the recent scientific literature, not many high-level studies can definitively validate a number of key treatment strategies. For example, we cannot prove by high-level studies that warm obturation is better than cold lateral condensation, nor can we prove that activated irrigation is superior to passive cold irrigation, among the host of other such clinical questions. However, lower levels of evidence in studies certainly lead us to adopt new techniques, but without the confidence that the efficacy can be proven without doubt to

Brett E. Gilbert, DDS, graduated from the University of Maryland Dental School in 2001 and completed his postgraduate training in endodontics from the University of Maryland Dental School 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 is a past president of the Illinois Association of Endodontists. Dr. Gilbert is Board-certified, a Diplomate of the American Board of Endodontics. He was named a top ten young dental educator in America by the Seattle Study Club in 2017. In 2019, he was named to Academic Keys Who’s Who in Dentistry Higher Education (WWDHE). Dr. Gilbert lectures nationally and internationally on clinical endodontics. He has a full-time private practice limited to Endodontics in Niles, Illinois. He can be contacted online at www.drbrettgilbert.com. Richard Mounce, DDS, practices endodontics in Eagle River, Alaska. He has lectured globally and is widely published. He can be reached at RichardMounce@MounceEndo.com.

Volume 14 Number 2

Educational aims and objectives

This self-instructional course for dentists aims to describe the key points to achieving excellent results in initial nonsurgical endodontic treatment in the key areas of diagnosis, shaping, irrigation, obturation, and restoration.

Expected outcomes

Identify preplanning procedures.

•

Realize some efficient anesthesia options.

•

Identify the benefits of CBCT for managing complex anatomy.

•

Discover a variety of instrumentation systems.

•

Identify various methods of efficient irrigation.

be an improvement over older techniques. An example is a study by Gutarts, et al., 2005, that showed that 1 minute of ultrasonic activation of irrigant solution resulted in significantly cleaner canals histologically in the mesial root of mandibular molars. This is a low level of evidence (in vivo/ex vivo, low N) but certainly compelling and a valid justification to adopt the technique.1 We will incorporate many of these references, but we want to emphasize that Level 1 studies are not in place to validate these techniques to the highest possible evidence levels. The preceding notwithstanding, regardless of philosophies and corporate relationships, it is the overwhelming preference of endodontists globally to use warm obturation techniques and activated irrigation. (Concepts discussed in greater detail follow.) Specialist preferences also are hedged by the “eyeball test” and the visual evidence that is observed in treatment in comparison to prior techniques. Hence, this article will focus on key technique objectives that universally are agreed upon. As a starting place, before ever picking up a syringe, the two single greatest ingredients to creating excellent endodontic results are time and comprehensive treatment planning. It is essential that the clinician has enough time to carry out the treatment in a relaxed but productive environment — in essence, practicing with high efficiency.

All procedures must be carefully preplanned. Such treatment planning includes performing high-level imaging and a thorough clinical examination to determine a definitive diagnosis. Preoperative treatment planning includes informed consent, assurance of restorability, profound pain control (local anesthesia), visualization and magnification (surgical microscopes), instrumentation (stainless and nickel titanium), irrigation and disinfection protocols, obturation, and coronal seal strategies prior to endodontic access. A lack of treatment-planning strategies is the harbinger of endodontic misadventure (Figures 1-3). While a discussion of each principledriven step required in a first-time endodontic procedure would fill a textbook, there are a

Figure 1: Sodium hypochlorite accident postoperatively, extraoral. (All images provided by Brett Gilbert, DDS, and Richard Mounce, DDS) Endodontic practice 29

CONTINUING EDUCATION

Evidence-based endodontic principles

CONTINUING EDUCATION number of key features of well-treated cases that are showcased in this article. (Please see the caption that accompanies each case and describes its application of the principles discussed.) As a starting place, assuming a thorough examination and indication for treatment in addition to detailed informed consent, the most difficult gateway to comfortable patient treatment is anesthesia for the “hot lower molar.” Fluency with the Gow Gates injection as well as intraosseous anesthesia (X-Tip, Dentsply) will in large measure eliminate shortcomings in anesthesia when standard block injections do not profoundly anesthetize an anxious patient with a severely inflamed pulp.

Managing complex anatomy is much simpler if the clinician has a preoperative road map. The CBCT provides the road map, and the surgical microscope provides the lens (literally) for visualization of the anatomy. Aside from a relaxed patient who is profoundly numb, being able to visualize anatomy by taking a preoperative (and possibly intraoperative) using CBCT scanning and a surgical microscope during treatment has no substitutes. They are the current “gold standard.” 3D imaging shows the clinician the true reality of a clinical situation as opposed to the suggestion gained from a 2D radiograph. Proper interpretation of imaging prior to and/or during endodontic treatment goes a long way in taking the guesswork out of identifying canal location and other anatomical complexities as the procedure unfolds. In a 2014 study by El Fayad and Johnson, it was determined that when having a preoperative CBCT as compared to 2D

radiographs alone, the treatment plan was modified 62% of the time. This is a huge game changer to realize that the information learned from 3D imaging changed the treatment plan more than 6 times out of 10 (Figure 4).2 While many preoperative clinical features need to be considered prior to starting treatment, the key preoperative decision points are the patients’ medical and dental history, their anxiety level, the position of the tooth, space limitations to reaching the tooth, and the canal anatomy. A wide-open canal on tooth No. 9 can be immensely difficult on a noncompliant patient. Alternatively, a distal lingually inclined upper right second molar on a relaxed patient without access limitations and distinct canals can be relatively straightforward, especially for a righthanded clinician using a surgical microscope. In any event, it is incumbent on the clinician to assess every aspect of the case prior to initiating treatment and to give the patient a detailed assessment of what treatment is being recommended. Access should be big enough to allow visual and tactile control, but not so large as to structurally weaken the tooth. Only as much dentin as required to allow adequate cleaning and shaping should be removed, but no more with effort being expended to always debride the tissue from the pulp horns and other hidden anatomy within the coronal portion of the tooth. Neelakantan, et al., 2018, determined that orifice-directed dentin conservation access design (ninja access) had significantly compromised debridement of the pulp chamber. Therefore, common sense is the best guideline when access design is considered, assuring that the pulp chamber and all pulp horns are debrided.3

Figure 2: Sodium hypochlorite accident approximately 5-months post-op, intraoral (different patient than that shown in Figure 1)

Figure 3: Calcium hydroxide extruded into the mandibular canal through a perforation

Imaging and visualization

30 Endodontic practice

Instrumentation Generally, tooth anatomy indicates how much time will be required using hand files for canal negotiation, especially with calcified canals. Calcification requires fluency with ultrasonics to know which tips and units are required to allow the clinician to remove restrictive dentin. For example, in a C-shaped lower second molar, using a bur in the furcation predisposes the canal to a future fracture. Alternatively, using the appropriate ultrasonic tip preserves tooth structure and allows a precise removal of tooth structure. There are literally dozens of instrumentation systems available globally at this time. One author uses the Twisted File (KaVo Kerr) (BG) and the other Bassi Logic™ (Bassi Endo) (RM). This notwithstanding, the goals of canal shaping are identical regardless of the instrumentation system used — patency is always sought during canal scouting and instrumentation. Clinicians can debate the relative merits of reciprocation versus rotary motion, optimal Af temperatures (austenite transformation temperatures that control whether a file undergoes the martensitic transformation), controlled memory files ground by CNC machines versus twisting nickel titanium in R phase, along with a multitude of different similar clinical issues. Regardless of these nuances, it is the adherence to basic principles of canal preparation that files create a pathway from coronal to apical to allow irrigant to flow into all of the canal ramifications, which clean the root canal system and optimize clinical success. Goals of canal preparation include keeping the canal centered in its original

Figure 4: Cleared tooth showing the true complexity of the anatomy within this molar tooth. (Courtesy of Dr. Sergio Rosler) Volume 14 Number 2

Figures 5 and 6: Chlor-Xtra and SmearOFF (Vista Dental) Volume 14 Number 2

and biofilm from the canal walls and dentinal tubules with antimicrobial solutions is the micro-cleaning. During preparation, it is axiomatic that debris should be removed as quickly as it is produced regardless of whether it is in the chamber or canals. Inserting a nickeltitanium file into a dry canal full of debris in an effort to make apical progress is the harbinger of blocked canals and separated files. This action packs the fine three-dimensional anatomy (apical deltas, fins, cul-desacs, isthmuses, etc.) of canals with debris, which can become much harder to remove later in the treatment process. Alternatively, irrigating after the insertion of every file and recapitulation with hand files is ideal to prevent the subsequent buildup of debris, to improve circulation of irrigant apically, and to optimize irrigant refreshment. Today’s rotary files are designed to funnel debris out of the canal in a coronal direction, further facilitating the debris removal.

Irrigation regimens Irrigation regimens differ widely, but the goal of removal of all organic and inorganic materials, bacteria, biofilm, and toxins from the root canal space is universal. After the canal is prepared, irrigation should be copious. The average volumes of sodium hypochlorite delivered during treatment at the specialty level are approximately 20 cc to 50 cc per case or more for a molar tooth. Volumes of liquid EDTA range anywhere from 5 cc to 10 cc per case or more for a molar tooth. The utilization of surfactants and enhanced solutions are common at the specialty level. For example, Chlor-Xtra™ (Vista), ChlorCid™ Surf (Ultradent), and HypoPure™ Pro (Kerr Endodontics) are pharmaceutical grade NaOCL solutions that possess surfactants, which reduce solution surface tension

Figure 7: QMix (Dentsply)

and optimize canal wall wetting. Palazzi, et al., 2016, showed that sodium hypochlorite with the addition of surfactant had better penetration into dentinal tubules than sodium hypochlorite alone.4 Surfactants also improve tissue dissolution and oxidizing potential. Sodium hypochlorite solutions are only chemically effective against the organic component of canal debris, and so EDTA, a chelator, is also used to remove the inorganic component of canal debris, including the smear layer. SmearOFF™ (Vista) is a 17% EDTA solution, which also contains surfactants as well as chlorhexidine (a powerful antibacterial solution). A commercial alternative to SmearOFF is QMix. Unlike QMix (which contains chlorhexidine and EDTA), SmearOFF can be mixed with Chlor-Xtra without a rinsing step as no unwanted precipitates are produced by their mixture (Figures 5-7). Clinicians should know where they are in the canal at all times when irrigating. Recommended needle gauges vary depending on the size of the initial and prepared final canal shape. For the majority of canals, a 27-gauge needle is adequate, but in fine canals, a 31-gauge needle can be appropriate. Needle tip designs can include side-ported and close-ended or side-vented among many possible configurations. The placement of a sodium hypochlorite solution — e.g., ChlorXtra to remove bacteria and organic material and SmearOFF to remove the smear layer and inorganic debris using a 27- or 31-gauge needle approximately 2 mm from the apex — ensures penetration of these irrigants into the apical third. Irrigation needles should never be locked by the canal walls. Irrigant delivery is always passive, and the needle is moved gently, slowly, and vertically a few millimeters at a time during extrusion. Under the surgical microscope, irrigant delivery, as described, occurs with precise control. It is noteworthy that larger syringes (10 cc to 12 cc) require more pressure to extrude

Figures 8 and 9: Voyager Tip and AutoSyringe (Vista Dental) Endodontic practice 31

CONTINUING EDUCATION

position within the root structure and keeping the apical foramen at its original position and size. One of the hallmarks of all the cases illustrated is that the apical foramen has been respected. Specifically, it has not been moved, transported, zipped, and/ or altered in any way. The apical foramen might be thought of as the “North Star” in endodontics. Reaching the apical constriction without transporting the canal and eliminating all debris from the canal and providing a tapering funnel from orifice to apex are key canal preparation objectives. The final prepared canal shape should be large enough to irrigate and obturate, but not so large as to structurally weaken the tooth. For practical purposes, while treatment philosophies differ, the minimum guidelines for final prepared taper should be .04 and the minimum apical diameter a 30 (depending on the initial size of the foramen). Given the advent of controlled-memory nickel titanium, there is little indication for larger tapers, especially in fine three-dimensional apical curvatures. As mentioned, patency is essential because its obtainment means that the clinician can always reach the apex during every phase of treatment, and its loss means that tissue, toxins, and bacteria can remain despite irrigation procedures, especially in the apical third. Apical debris is the harbinger of iatrogenic events. Including, but not limited to, canal transportation, zipping, irrigant extrusion, and a lack of optimal canal cleaning. Conceptually, root canal system cleansing can be divided into a macro-phase and a micro-phase. Debridement with files is the macro-cleaning. Removal of bacteria

CONTINUING EDUCATION the solution relative to a 3 cc syringe. It is imperative that clinicians appreciate how much pressure they are using on the plunger. One unique alternative to plastic syringes is the AutoSyringe (Vista) device, which accepts any luer-lock needle tip and extrudes irrigant at various speeds depending on the setting selected. One author (RM) uses it routinely (Figures 8 and 9).

Irrigant activation Figure 11: Finishing File (Tun Ultrasonics) Figure 10: Negative pressure irrigation (EndoVac, Kavo/Kerr) (Image courtesy of Dr. Gary Glassman)

Figure 12: EndoUltra (Vista Dental)

Figures 13A and 13B: Case treated with Chlor-Xtra, SmearOFF with EndoUltra activation. Note the excellent cone fit and apical control of obturation. (Courtesy of Dr. Sam Alborz)

Figures 14A and 14B: Case treated with Bassi Logic controlled memory nickel-titanium files. Note the visualization of the third root on this lower molar and conservative canal preparation shape. (Courtesy of Dr. Alex Chan) 32 Endodontic practice

At present there are many ways to deliver and activate irrigation for optimization, including these methods: apical negative pressure (EndoVac, Kerr)5, sonic (EndoActivator, Dentsply), ultrasonic (EndoUltra, Vista)6, multisonic (GentleWave®, Sonendo)7, laser-activated (PIPs, Fontana)8, and mechanical (Finishing File, Tun Endodontics) (Bassi Clean Files, Bassi Endo). All of the activation methods named enhance the antibacterial effects of irrigants and result in cleaner canals relative to passive syringe irrigation. In addition, activation removes the accumulation of air bubbles at the apex, which is otherwise known as vapor lock. Air bubbles left at the apex due to passive syringe irrigation diminishes the apical penetration of irrigants. One author (BG) utilizes a combination of ultrasonic activated and apical negative pressure techniques (EndoVac), and the other author (RM) utilizes ultrasonic energy (EndoUltra). Regardless of which method is utilized to deliver irrigation to the apical third, it is most critical that clinicians activate their irrigation and do not rely simply on cold passive syringe irrigation. While protocols vary, activating each primary irrigant (both SmearOFF and Chlor-Xtra, for example) 3 times in each canal for 20 seconds is a sound clinical strategy (Figures 10-12). Sonendo’s GentleWave deserves a special mention, as it is unlike the other activation systems available. GentleWave delivers a multisonically activated degassed solution (to remove air bubbles that dissipate energy) with negative-to-neutral pressure delivered via a handpiece over the access in a closed system. The literature basis supporting the system shows impressive cleansing of the root canal systems, but a definitive high-level study on improved healing has not been published to date. Its future application and expansion globally will be interesting to observe. And finally, the literature is conclusive that placing a post-endodontic coronal seal Volume 14 Number 2

CONTINUING EDUCATION Figures 15A-15G: Cased treated with photon induced photoacoustic streaming (PIPs). Note the orifice barrier placed in composite to protect the endodontic treatment from coronal leakage. (Courtesy of Dr. Paula Elmi)

Figures 16A and 16B: Case treated with a bioceramic master cone, sealer, and putty. Note the excellent apical control in this blunderbuss apex. (Courtesy of Dr. Rico Short)

Figures 17A and 17B: Case assisted with CBCT to determine anatomy preoperatively. Note the multiple cross sections moving apically and the correlation to the 2D view. Note also the conservative taper in relation to the root width. (Courtesy of Dr. Brett Gilbert)

Figures 17C-17F: Case assisted with CBCT to determine anatomy preoperatively. Note the multiple cross sections moving apically and the correlation to the 2D view. Note also the conservative taper in relation to the root width. (Courtesy of Dr. Brett Gilbert) Volume 14 Number 2

Endodontic practice 33

CONTINUING EDUCATION

Figures 18A-18C: Note the expert management of the apical constriction and the acute curvature of the MB root. (Courtesy of Dr. Nestor Cohenca)

Figure 19: Note the degree of penetration of sealer and gutta percha between the primary canals. Obturation of this space demonstrates both the macro- and micro-cleaning referred to in the article. (Courtesy of Dr. Nestor Cohenca)

at the time treatment is completed under the rubber dam is closely associated with endodontic success. Please note, all of the cases illustrated had some form of orifice barrier or buildup placed under the rubber dam at the time of treatment (Figures 13-18).

Figures 20A and 20B: Note the attention to detail required to locate all of the canals in this exceptional case done under the surgical microscope. (Courtesy of Dr. Adrian Silberman)

As a starting place, before ever picking up a syringe, the two single greatest ingredients to creating excellent endodontic results are time and comprehensive treatment planning. It is essential that the clinician has enough time to carry out the treatment in a relaxed but productive environment. REFERENCES

Conclusion This article has stressed literature-based proven treatment principles over a particular manufacturer’s devices or technique recommendations. Emphasis has been placed on an accurate diagnosis, conservative access, patency, minimal taper, activating irrigation, three-dimensional warm obturation, and the placement of a post-endodontic coronal seal at the time of treatment under the rubber dam. We welcome your feedback. EP 34 Endodontic practice

1. Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod. 2005;31(3):166-170. 2. Ee J, El Fayad MI, Johnson BR. Comparison of endodontic diagnosis and treatment planning decisions using cone-beam volumetric tomography versus periapical radiography. J Endod. 2014;40:910-916. 3. Neelakantan P, Khan K, Hei Ng GP, et al. Does the Orifice-directed Dentin Conservation Access Design Debride Pulp Chamber and Mesial Root Canal Systems of Mandibular Molars Similar to a Traditional Access Design? J Endod. 2018;44(2):274-279. 4. Palazzi F, Blasi A, Mohammadi Z, Del Fabbro M, Estrela C. Penetration of Sodium Hypochlorite Modified with Surfactants into Root Canal Dentin. Braz Dent J. 2016;27(2):208-216. 5. Nielsen B, Baumgartner J. Comparison of the EndoVac system to needle irrigation of root canals. J Endod. 2007;33:611-615. 6. de Gregorio C, Estevez R, Cisneros R, Heilborn C, Cohenca N. Effect of EDTA sonic and ultrasonic activation on the penetration of sodium hypochlorite into simulated lateral canals: an in vitro study. J Endod. 2009;35(6):891-895. 7. Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement using the GentleWave system. J Endod. 2015;41(10);1701-1705. 8. Peters OA, Bardsley S, Fong J, Pandher G, Divito E. Disinfection of root canals with photon-initiated photoacoustic streaming. J Endod. 2011’37(7);1008-1012.

Volume 14 Number 2

Evidence-based endodontic principles GILBERT/MOUNCE

1. Preoperative treatment planning includes informed consent, assurance of restorability, _______, irrigation and disinfection protocols, obturation, and coronal seal strategies prior to endodontic access. a. profound pain control (local anesthesia) b. visualization and magnification (surgical microscopes) c. instrumentation (stainless and nickel titanium) d. all of the above 2. In a 2014 study by El Fayad and Johnson, it was determined that when having a preoperative CBCT as compared to 2D radiographs alone, the treatment plan was modified ______ of the time. a. 32% b. 50% c. 62% d. 75% 3. The authors suggest that for practical purposes, while treatment philosophies differ, the minimum guidelines for final prepared taper should be .04 and the minimum apical diameter a _______ (depending on the initial size of the foramen). a. 30 b. 35

Volume 14 Number 2

c. 40 d. 45 4. Irrigation regimens differ widely, but the goal of removal of all _______ and toxins from the root canal space is universal. a. organic and inorganic materials b. bacteria c. biofilm d. all of the above 5. For irrigation regimens, the average volumes of sodium hypochlorite delivered during treatment at the specialty level is approximately _______ per case or more for a molar tooth. a. 5 cc to 10 cc b. 15 cc to 19 cc c. 20 cc to 50 cc d. 55 cc to 60 cc 6. For irrigation regimens, volumes of liquid EDTA range anywhere from ______ per case or more for a molar tooth. a. 5 cc to 10 cc b. 20 cc to 30 cc c. 40 cc to 50 cc d. 60 cc to 70 cc 7. According to the authors, when irrigating, for the majority of canals, a ________

needle is adequate, but in fine canals, a 31-gauge needle can be appropriate. a. 26-gauge b. 27-gauge c. 30-gauge d. 32-gauge 8. It is noteworthy that larger syringes (10 cc to 12 cc) require ______ to extrude the solution relative to a 3 cc syringe. a. more pressure b. less pressure c. the same pressure d. no pressure 9. (Regarding active irrigation) Activation removes the accumulation of air bubbles at the apex, which is otherwise known as _______. a. the “North Star” of endodontics b. macro-phase c. vapor lock d. chelation 10. Air bubbles left at the apex due to passive syringe irrigation ________ the apical penetration of irrigants. a. diminish b. increase c. equalize d. escalate

Endodontic practice 35

CE CREDITS

ENDODONTIC PRACTICE CE

PRODUCT PROFILE

Brasseler USA®: your trusted leader in bioactives

rasseler USA’s EndoSequence brand of materials consists of several different types of bioactives that are designed for specific clinical applications. This article will describe these different products along with their features, benefits, and indications for use. Prior to reviewing the products, it is helpful to understand the difference between pure bioceramic materials and bioactive materials. Bioactives are generally categorized as any product that elicits a positive biological response. In dentistry, the response is typically realized in the form of a release of beneficial calcium, phosphate, or fluoride ions. Bioactives can include non-bioceramic components, as they are defined by what they are designed to do and not by their composition. Bioceramics are different in that they are defined by both their composition and what they are designed to do. Bioceramics are essentially any inorganic, ceramic material (refractory polycrystalline compounds) used in medicine and dentistry. Brasseler’s bioceramics are pure calcium silicate, calcium phosphate-based bioceramics, which are designed to set hard in the presence of the moisture naturally present in dentin. It is important to note that according to these definitions, products consisting of metals and/or resins are not pure bioceramics. Table 1 lists each of the Brasseler bioactive products along with its primary active components, consistency, and applications.

bioceramics designed for maximum biocompatibility, healing, and optimal handling. These materials have been sold globally for over 13 years and have been used in over 50 million clinical cases. There are over 150 published research papers on these materials, including animal and outcome studies. These materials are void of any non-bioceramic components such as metals and resins.

Brasseler pure premixed bioceramic materials

Clinical applications

These materials include BC Sealer, BC Sealer HiFlow, BC RRM Paste and Putty. They are patented, premixed, calcium silicate, calcium phosphate-based

Figure 1: Applications for Brasseler’s full line of bioactive materials.

Brasseler hybrid bioactive materials These materials include BC Liner™ and BC Temp™. These materials contain some components that are not defined as bioceramics. The non-bioceramic components of these products were incorporated to overcome the inherent challenges of pure premixed bioceramics. BC Temp includes components that prevent the material from setting hard, which allows it to be easily removed (intracanal dressing). BC Liner includes components that allow for light curing and for optimal strength and wear characteristics. Both of these materials are bioactive and highly compatible with Brasseler’s pure premixed bioceramics. (BC Temp contains calcium silicates and releases calcium and hydroxyl ions, and BC Liner releases calcium, phosphate, and fluoride ions).

Figure 1 shows the applications for Brasseler’s full line of bioactive materials. • The BC Sealer and BC Sealer HiFlow are used for obturation (ortho- or retrograde as a root-end filling capped with

Table 1: Brasseler bioactive products Brand

Components

Consistency

Applications

BC Sealer HiFlow™

Dicalcium Silicate, Tricalcium Silicate, Calcium Phosphate, Calcium Hydroxide, Zirconium Oxide

Max flowability

Sealer (optimized for warm obturation)

BC Sealer™

Same as BC Sealer HiFlow

Flowable

Sealer (optimized for cold hydraulic condensation)

BC RRM™ Paste

Dicalcium Silicate, Tricalcium Silicate, Calcium Phosphate, Zirconium Oxide, Tantalum Pentoxide, Calcium Sulfate

Flowable (heavier bodied)

Perf repair, pulp capping, retrograde fill, apexification

BC RRM™ Putty (Jar)

Same as BC RRM Paste

Moldable putty

Perf repair, pulp capping, retrograde fill, apexification

BC RRM Fast Set Putty™ (Syringe)

Same as BC RRM Paste

Moldable putty (slightly softer)

Perf repair, pulp capping, retrograde fill, apexification

BC Temp™

Calcium Silicates, Calcium Aluminate, Calcium Oxide, Base Resin, Calcium Tungstate, Titanium Oxide

Flowable (resorbable)

Intracanal dressing

BC Liner™ (white & blue)

Methacrylates, Modified Polyacrylic Acid, Silica, Sodium Flouride

Less flowable with some stacking

Orifice barriers, base/liner, indirect pulp capping

36 Endodontic practice

•

a plug of putty). HiFlow is optimized for warm condensation methods, and BC Sealer is optimized for cold hydraulic condensation. BC RRM Paste is slightly thicker than BC Sealer and can be syringed into a site for perforation repair or pulp capping. BC Paste should be used for difficult to reach repair procedures where you would normally utilize the MAP system with MTA. BC RRM Putty/Fast Set Putty is used for all repair procedures where you would like to condense the material and where you need strong resistance to washout. It is ideal as pulp cap and retrofilling. BC Temp is an intracanal dressing that gradually releases hydroxyl and calcium ions maintaining a steady pH, and it is easily delivered and removed. BC Liner is a multifunctional, lightcurable, patented RMGI that is optimized for use with BC Sealer/RRM. It is extremely strong and has excellent wear characteristics. It can be placed over the top of unset BC RRM after repair of a perforation, resorptive defect, or pulpcapping procedure. The blue version is most often utilized as an orifice barrier, and for this application a bonding agent is not needed.

Summary Brasseler’s complete line of bioactive materials has been thoughtfully developed to cover all of your endodontic material needs while providing you with the best healing and handling characteristics. Thank you for making Brasseler your trusted leader in bioactives. To learn more and to read our extensive research bibliography, please visit BrasselerUSA.com, or contact Brasseler at 800-841-4522. EP This information was provided by Brasseler USA®.

Volume 14 Number 2

BY YOUR SIDE

NEW!

Bioceramic Intra-Canal Dressing Single or Less Frequent Application Highly Biocompatible Optimal pH Easily Removed High Radiopacity Non-staining

Initial X-Ray

Final X-Ray

Radiograph after initial placement of BC Temp

Radiograph after final obturation with BC Sealer

Images courtesy of Dr. Kely F. Bruno Universidade Federal de Goiás, Goiânia, GO, Brazil

B-5460-EP-06.21

PRODUCT PROFILE

SkyPulse® Endo Laser by Fotona

here are over 20 million root canal procedures being performed each year in the United States alone. For years, dental practitioners have used traditional methods to treat root canals, but today research studies are showing that root canal irrigation is more beneficial when completed with laser therapy instead. Why is a laser more beneficial? It all comes down to better cleanliness and patient comfort. “[Traditional root canal treatments] is not cleaning everything out. It’s only cleaning a small, tiny percentage of the dentinal tubules, leaving a ton of bacteria and toxins behind — but with the laser, you’re sterilizing cell layer by cell layer, and it’s really incredible.” says Board-certified endodontist, Dr. Valerie Kanter. “When you use a drill, there’s tons of air and water, and blasting it creates major pain and sensitivity into the tooth structure. However, you actually don’t even need anesthesia for a [root canal] treatment like this with the laser because it’s so gentle on the tooth structure.” With Fotona’s SkyPulse® Endo Laser, practices are able to add SWEEPS® to their treatment offering — a revolutionary method for chemically cleaning and debriding the root canal system using laser energy at subablative power levels. SWEEPS® harnesses the power of the Er:YAG laser to create photoacoustic shock waves within the cleaning and debriding solutions introduced in the root canal. The minimally invasive instrumentation preserves more of the natural tooth structure and thereby improve strength and integrity. Those can also be used for many different regenerative procedures and endodontics. Dr. Kanter says, “Lasers are making a huge wave in dentistry. With photobio-

Board-certified endodontist Dr. Valerie Kanter using Fotona’s SkyPulse® Endo Laser

“I use a Fotona erbium YAG laser, and my whole life has changed since I started incorporating this into my practice.” — Dr. Valerie Kanter modulation or a low-level laser, you can actually stimulate the mitochondria inside the tissues, upregulating ATP (adenosine triphosphate) production, collagen synthesis, and angiogenesis. We do these low-level laser procedures on every single patient who’s coming to see me, and it’s profound, the amount of healing and the reduction

of pain and inflammation that we can see with this.” By using synchronized pairs of ultrashort pulses, an accelerated collapse of laser-induced bubbles is achieved, leading to enhanced shock wave emission inside even the narrowest root canals. The precise waves of energy thoroughly clean the complex root canal system that traditional methods can sometimes miss. The containment of the shock waves thoroughly streams these solutions through the entire canal system, enhancing their effectiveness. “I think one of the top things that patients are looking for in a practitioner is which one is going to resonate with the things that they want — the answer is a dentist who offers some of these regenerative procedures and is using this laser therapy.” Dr. Kanter continues, “It’s becoming more and more popular, but only about 10% of dentists are using dental lasers right now. I use a Fotona erbium YAG laser, and my whole life has changed since I started incorporating this into my practice.” EP This information was provided by Fotona.

38 Endodontic practice

Volume 14 Number 2

Drs. Joel C. Small and Edwin McDonald discuss how leaders need to create a compelling vision

uch of our work at Line of Sight Coaching revolves around leadership development and creating optimal practice cultures. We believe that optimal organizational cultures are the byproduct of effective leadership. This is not to say that poor leadership does not produce a culture. In fact, whether we know it or not, each of our practices has a culture — good or bad. The theoretical concept of organizational culture can be somewhat vague and difficult to understand. This is due to the intangible nature of the concept. In practice, however, organizational cultures are powerful and potentially transformational. An organizational culture embodies the guiding principles that dictate how we work together as a team and how we interact with our patients, vendors, and anyone who has direct interactions with our practice. It embodies the expectations that we hold for ourselves and every other member of our team. It is our relational bible. We know, as coaches, that the very best and most productive clinical practices have strong cultures as their foundation. We also know those doctors who choose to disregard their practice culture do so at great risk. There are two distinct ways through which we create our practice culture. One way is through default leadership and emotional absenteeism. This occurs when the leader is disengaged and offers no direction, guidelines, or well-defined boundaries for team communication and interactions. Drs. Joel C. 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.

Volume 14 Number 2

It has been said that our leadership is defined by that which we tolerate, and disengaged leaders are prone to tolerate numerous forms of toxic behavior that severely diminish the quality of the practice culture. These doctors are what we call perpetual “problem solvers” because they are constantly dealing with problems that need solutions. Their staff has never been developed to think or act independently and therefore look to the doctor for even the simplest solutions. As a result, the doctors finds themselves bogged down in minutia and unable to utilize their time to its highest and best use. Furthermore, staff conflict is pervasive, and a practice with a poor culture and no guidelines has a weakened infrastructure and, like a house of cards, lacks resiliency and is prone to collapse when placed under stress. A more desirable way to create an optimal practice culture is through purposeful, conscious leadership and engagement. These leaders are what we refer to as “people developers.” They have provided the guidelines, direction, and well-defined boundaries that are the essential ingredients for an optimal culture. They have given their team the resources, knowledge, support, and authority to think and act independently within certain well-defined boundaries. They recognize that collaborating with their staff is the surest way to discover effective solutions and make the best possible decisions. They also recognize the profound negative effect of toxic behavior and are unwilling to tolerate these behaviors. These doctors are the ones who find maximum enjoyment and profit from their professional endeavors. Just as an optimal practice culture is the byproduct of effective leadership, peak performance is the byproduct of an optimal culture. Freeing ourselves from the burdens brought about by a negative culture allows us to concentrate on achieving goals and moving our entire team toward sustainable peak performance. An optimal culture promotes collaboration and team interactions that are no longer driven by ego

and/or jealousy. All team members clearly understand their roles in achieving sustainable peak performance and willingly subordinate their individual egos to the concept of team-driven success. Having an optimal culture that promotes a philosophy of abundance is another important step in achieving peak performance. Believing in abundance means that we are committed to making everyone on our team successful, and by doing so, we create something called “positive tension.” When we ensure our team’s success by giving them everything they need to be successful, we are allowing them to experience the satisfaction derived by a series of successes. As their challenges and successes become more significant, they begin to believe in their capabilities and ultimately adopt the mindset that no task is unachievable. This achievementoriented mindset proves invaluable when staff are presented with a compelling vision of a team working at a peak level, and they have a clear understanding of the tasks required to achieve this goal. The team that has a clear and compelling vision, a burning desire to make the vision reality, and confidence in its ability to make it happen has positive tension and will relentlessly pursue the team’s goal. The team becomes unstoppable. Given this scenario, it is our job to provide a compelling vision with the greatest clarity possible. We build the team’s desire to achieve the goal through tangible benefit statements, and we must offer the support and resources to provide the best possibility for the team’s success. As team leaders, we must believe that our teams are capable of achieving their goals. Research has shown that teams will perform to the level of the leaders’ expectations. Expressing our confidence to our teams in their capabilities will serve as a significant motivator. Using something we call a success formula allows us to distill these concepts to their simplest form: EFFECTIVE LEADERSHIP + AN OPTIMAL CULTURE = PEAK PERFORMANCE EP Endodontic practice 39

SMALL TALK

Peak performance is a byproduct of our practice culture

SERVICE PROFILE

Endo1 Partners The original and fastest-growing endodontic partnership organization, owned and led by endodontists

magine being able to solely focus on the “practice” part of your endodontic practice. Endo1 Partners empowers endodontists like you to do just that — and helps you to achieve all your business goals.

The only endodontic partnership organization led by endodontists Endo1 Partners is the original, fastestgrowing Endodontic Partnership Organization (EPO) dedicated to supporting endodontists. The EPO was founded and is led by practicing endodontists Matthew Haddad, DMD; Daryl Dudum, DDS; Mark Haddad, DDS; and Darron Rishwain, DDS. As an EPO that is endo-owned and endorun, Endo1 Partners understands the unique needs of endodontists. “We established Endo1 Partners in October 2019 with just six locations and operations in Texas and California, and after receiving great interest in 2020, we experienced rapid growth across multiple markets,” said Co-Founder and Co-Chief Executive Officer, Dr. Daryl Dudum. “We formed new partnerships with 31 endodontic practices, added 53 new endodontists to our platform, and expanded into six new states last year. Looking ahead, we expect to continue to grow our network.” Endo1 Partners hopes to add 50 locations to its network in 2021 and partner with more endodontists, in both new and existing markets, in building a world-class organization that they can count on for best-in-class resources and support. The first-of-its-kind EPO helps partners streamline, optimize, and improve their practices, so they can focus on what matters most — providing high-quality care to patients.

Run your practice in the most productive, advantageous way Endo1 Partners takes the stress of practice management off your plate, so you can spend more time doing what you love. The EPO offers a full suite of business and operational support services that will reduce your administrative burden, increase efficiency, and prioritize growth. Available services include accounting, billing and collection, business development, compliance, human resources, marketing, and payor negotiation. Endo1 Partners gives 40 Endodontic practice

Founders, Endo1 Partners

you the flexibility to choose which of these services you need to run a successful practice. Plus, their team will spend time with you and get to know you to determine how Endo1 Partners can support your success. “As a member of the Endo1 Partners network, you will have access to our centralized services and shared back-office support as well as group benefits and discounts,” said Founding Partner and Co-Chief Executive Officer, Dr. Matthew Haddad. “We also provide access to specialized training, credentialing, cutting-edge equipment, and the latest industry information, including best practices from endodontic practices just like yours.”

Continue to improve your skills and to enhance your practice Dr. Craig Hoffmann of Wichita Endodontics felt the access to innovative clinical materials and collaboration among a network of like-minded endodontists were key advantages that other partnership organizations did not offer. That is why he chose to partner with Endo1 Partners in December 2020. According to Dr. Hoffmann, “You can tie in cooperatively with any endodontist in the network for materials, new techniques, and new trends in the industry. You can also

discuss problems that you are having. I think it keeps you relevant in this age where everything is being consolidated, and it ensures you’re not going to be passed by.” Partnering with Endo1 Partners allows you to receive all the benefits of joining a larger group of dental professionals while maintaining control of your business. Partners retain a considerable amount of equity in their practices and remain in control of their practice’s brand, culture, and team. Most importantly, partners have complete clinical autonomy. With access to exclusive resources, shared services, and a wealth of support, you can prosper on your terms — with the support of other incredible partners — as you take your practice to the next level.

Let Endo1 Partners help you to succeed If you are an endodontist looking to partner with a network of like-minded endodontists you can trust, contact Endo1 Partners at info@endo1partners.com, or call 305-206-7388 to learn how the EPO can support you in your ongoing success. With the support of Endo1 Partners, there is nothing you can’t do! EP This information was provided by Endo1 Partners.

Volume 14 Number 2

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

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