Endodontic Practice US Fall 2021 Vol 14 No 3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Fall 2021 – Vol 14 No 3 • endopracticeus.com

Endodontic treatment of the immature permanent necrotic teeth with open apices

ENDODONTICS Endodontic predictability Dr. John West

Drs. Tony Tataro and Mohammad Sabeti

Corporate spotlight Endo1 Partners

Practice profile Christopher Sabourin, DDS, MS, MSD

Improving root canal disinfection and endodontic outcomes with irrigants Dr. Eshwar Arasu

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

CELEBRATING 25 YEARS OF ENDODONTIC EXCELLENCE!

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PROMOTING

See Page 5

My patients and referring doctors are experiencing the

GentleWave Difference. ®

They’re happy with the

one-visit* procedure protocol and even happier with the opportunity

to reach expedited clinical outcomes. RYAN FACER, DDS GentleWave® Doctor since 2018

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

Trust in what’s been proven by your peers and approved by their RCT patients. Discover the GentleWave® System. SONENDO.COM/TRUST

PRE-GENTLEWAVE® PROCEDURE RETREATMENT (CBCT)†

3-MONTH RECALL POST-GENTLEWAVE® PROCEDURE (CBCT)†

* GentleWave Procedures are typically performed in one session. † Photo and images courtesy of Ryan Facer, DDS © 2021 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo and SAVING TEETH THROUGH SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: www.sonendo.com/intellectualproperty. MM-1071 Rev 01

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

The year of endodontic training that you missed

’ve had the opportunity to speak with many residency classes over the past year, and I am struck by how the new generation of endodontists is so different. Due to the unbelievable level of education debt they carry (and the nearly prohibitive level of additional debt that comes with a practice acquisition), recent new endodontists must be more focused than ever on the “business” side of endodontics. They recognize they must navigate through the start-up phase and quickly close the knowledge gap created by the missing year of business education that every endodontist should have but no one gets. This thirst for rapid business knowledge is so acute among new endodontists that Endo Mastery has created a Dr. Albert Goerig tailor-made program combining clinical and business coaching to get them up to speed and successful as quickly as possible. It’s paying off because the determination of new endodontists in the program is resulting in them achieving much more productivity and practice growth than many of their more experienced colleagues who have been practicing for a decade or more. The average endodontist completes about 3 to 4 cases per day, working 4 to 5 days per week — an insightful statistic about the current state of endodontic business practices. Given the advances in clinical techniques and technology, most endo cases can be completed clinically in less than an hour if the doctor remains efficient and focused. What is the rest of the time spent on? In an 8- or 9-hour day, doctors should be able to comfortably and easily complete 6 to 7 cases per day on average without stress and with plenty of time remaining for the other doctor essentials that need to occur daily. That level of productivity would also more than double take-home income, which would quickly eliminate financial stress and transform their lives. It seems like a high incentive for doctors to invest in improving their clinical efficiency and business systems, yet many remain unchanged in their comfort zone without making progress. I’ve met many doctors with 20 or more years of experience in endodontics, but when I look at their numbers, I see 1 year repeated 20 times. Lack of true growth (above fee increases and inflation) for years in a row is the symptom of doctors who have not put all the clinical and business components of their practices together in an effective way. The heart of practice growth is team-driven clinical efficiency. It is my favorite part of the coaching process to work with doctors and reveal to them how to optimize their clinical techniques and treatment process for better patient outcomes and better business outcomes that naturally follow. Combining that with improved referral marketing, team productivity, and business systems results in practices shedding their comfort zone and doctors experiencing the best that endodontics can offer at all levels. Dr. Albert Goerig

Lisa Moler (Publisher) Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

© 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.

Albert Goerig, DDS, MS, is a Diplomate of the American Board of Endodontics and a sought-after speaker who has lectured extensively in the field of endodontics and practice success throughout the United States, Canada, and abroad. He is the author of over 100 published articles and a contributing author to numerous endodontic textbooks. Dr. Goerig has a private endodontic practice in Olympia, Washington, in the top 1% nationwide for practice profitability. He has almost 40 years of experience as an endodontic educator and practice coach to nearly 1,000 endodontists.

ISSN number 2372-6245

Volume 14 Number 3

Endodontic practice 1

INTRODUCTION

Fall 2021 - Volume 14 Number 3

TABLE OF CONTENTS Publisher’s perspective Off the roller coaster — a positive outlook, fresh goals, and renewed focus on success Lisa Moler, Founder/Publisher, MedMark Media................................ 6

Practice profile Christopher Sabourin, DDS, MS, MSD

Dedicated to fully defined, interconnected business processes

Webinar roundtable Bioceramics: Promising New Frontier or Wild West? Drs. He and Nasseh provide a look into a webinar on bioceramics......... 14

Practice spotlight John Collier, DMD, and Franklin Kimbell, DMD Combining experience and improving patient care with HighFive................ 19

Clinical Endodontic management of a maxillary lateral incisor with Oehlers Type IIIB dens invaginatus

Corporate spotlight

Drs. Gonzalo García, Claudia Judkin, Denise Alfie, Ariel Lenarduzzi, and Pablo Alejandro Rodríguez discuss treatment of a complex dental anomaly ......................................................20

Endo1 Partners The fastest-growing endodontic partnership organization that helps you prosper on your terms

Industry news................ 23 ON THE COVER Cover image courtesy of Dr. John West. See article on page 37.

2 Endodontic practice

Volume 14 Number 3

Making Endodontics Fun Again.

You’re already on top of your game; we’re just helping you raise the bar. We bring 60+ years of healthcare chops and a squad that pushes the limits. From billing to marketing, compliance to maintenance, we’re the swiss army knife of healthcare management and an entirely new level of collaboration.

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.

Practice Management With cloud-based solutions at our fingertips, we convert systems, communications, best practices and corporate backend procedures into metrics that track gaps and opportunities within your business.

The Digital Experience From online appointment scheduling to check out, we leverage tech innovation to make the patient experience easy, streamlined and secure.

We are artists of healthcare management. Tending to the tedious so you don’t have to

TABLE OF CONTENTS

Case study Restorative-driven endodontics for more conservative outcomes Dr. Gregori M. Kurtzman combines endodontic and restorative goals to achieve clinical success................... 24

Continuing education Endodontic treatment of the immature permanent necrotic teeth with open apices Drs. Tony Tataro and Mohammad Sabeti discuss and illustrate an alternative treatment........................32

Endodontic perspective Endodontic predictability Dr. John West explores “The Set Up” .......................................................37

Product profiles Next-generation gutta-percha cones Advance your technology and your patients’ health................................42

Continuing education

Improving root canal disinfection and endodontic outcomes with irrigants

Dr. Eshwar Arasu discusses approaches to activating irrigants for effective endodontic treatment

Eradicating the endodontic enemy — bacteria — utilizing ZEISS microscopy and EndoHandle

Small talk How to coach your team to peak performance

Dr. Lauren E. Kuhn discusses her bacteria-battling techniques............. 44

Drs. Joel C. Small and Edwin McDonald discuss ways to effectively develop your team.............................. 47

Coming soon! Triton all-in-one irrigation solution by Brasseler USA®..........................46

Service profile U.S. Endo Partners...................... 48

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

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

4 Endodontic practice

Volume 14 Number 3

CELEBRATING 25 YEARS OF ENDODONTIC EXCELLENCE AND FINANCIAL FREEDOM!

TRANSFORM YOUR PRACTICE — TRANSFORM YOUR LIFE!

“You are not going to find anyone more genuinely dedicated to your success in endodontics than Ace Goerig and the Endo Mastery team. Even though my practice is achieving higher profits than I ever imagined, it’s more than just money. Endo Mastery transformed my life.” DR. MICHAEL FELDMAN • LONG ISLAND NY

SCHEDULE A FREE PRACTICE ANALYSIS AND TRANSFORMATION ROADMAP TODAY!

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PUBLISHER’S PERSPECTIVE

Off the roller coaster — a positive outlook, fresh goals, and renewed focus on success

n looking back, most of us felt that last year was a roller coaster ride. We got shoved into that buggy, fastened our seat belts, and hung on. Dentists hurtled around all of the new rules and regulations that were unveiled each day. You skidded around corners that held unknown aerosol dangers, careened past roadblocks to business operations, and avoided the twists and turns of offering emergency care to patients when the definition of emergency care was still evolving. It was a white-knuckle ride, for sure. But through the highs and lows and learning curves, we emerged definitely wiser and more resilient. Here at MedMark, even at the height of the pandemic, Lisa Moler we brought you the most up-to-date information on how to Founder/Publisher, MedMark Media protect your patients and staff and prepare for reopening. We anticipated and tracked the new trends and technologies that patients would be expecting. We checked on our readers and authors through emails, texts, and Zooms. We saw you calmly focus on keeping in touch with patients through teledentistry, informative texts, and website updates. You prepared protective equipment to be able to provide emergency care, consulting, and treatment plans for when the crisis was over. Now we are joyfully hearing about your safe returns to business. And our articles reflect our goal of helping you flourish in the future. In his CE, Dr. Eshwar Arasu discusses root canal disinfection and approaches to activating irrigants for better endodontic outcomes. Drs. Tony Tataro and Mohammad Sabeti illustrate an alternative treatment when traditional treatment may not be possible because of trauma or infection. In his article, Dr. Gregori M. Kurtzman combines endodontic and restorative goals to achieve clinical success. Dr. Gonzalo Garcia and colleagues manage the complex dental anomaly of a tooth with Oehlers Type IIIB dens invaginatus. In his perspective, Dr. John West explores endodontic predictability by staying focused, keeping it simple, and having fun while recognizing your endodontic potential. With this fall issue, the new view from the top is exciting. We are thrilled to be able to say that we made it. We’re no longer anticipating what is coming around each bend. And we are ready to take a new plunge — into the future. I’m proud and amazed at the perseverance and courage that we all saw in the dental profession. With a positive outlook, fresh goals, and renewed focus on success — the MedMark team is bracing for new adventures! To your best success, Lisa Moler Founder/Publisher MedMark Media

Published by

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

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

6 Endodontic practice

Volume 14 Number 3

PRACTICE PROFILE

Christopher Sabourin, DDS, MS, MSD Dedicated to fully defined, interconnected business processes

r. Christopher Sabourin is the founder of Endodontic SuperSystems (ESS/a FlowPatterns Company) — the SaaS platform offering to help endodontic offices reduce the daily stress with a whole new layer of workflow organization, including management and marketing. With standards that were developed and tested over the past 16 years, ESS offers a playbook for on-boarding that provides team empowerment, consistency, and stages (ranging from 4 to 13 treatments per day) while drastically decreasing doctor exertion and keeping your team and practice modern.

What can you tell us about your background? I graduated from Fresno State with a degree in psychology. This has proven invaluable in both helping create the most comfortable environment possible as well as guiding our patients through their experience. After this, I earned a Master’s degree in Human Physiology from Loma Linda University. People have always fascinated me. I moved up to San Francisco to study Dentistry at University of California San Francisco (UCSF). I was fortunate to serve as the school vicepresident and then president, receiving several awards, including a commendation from the Governor of California as well as the esteemed Pierre Fauchard award for 2004. During my time at UCSF, I founded the undergraduate endodontics certificate program. After completing dental school, I began my specialty training and was accepted into the University of Washington, Seattle, for the Master’s degree in Endodontics. I am a proud father and husband and the oldest of seven siblings. I like to keep moving. When the doctor is in the chair, it’s go time!

What training have you undertaken? As an endodontist, I have advanced training in diagnosis as well as root canal treatment, microsurgery, and other related procedures geared to save natural teeth. Additionally, I am certified to offer Pediatric and Adult Oral Conscious Sedation (DOCS). While I no longer offer these services, I have also had training in IV sedation (USC) and surgical implant coursework (Misch Institute), and received a Fellowship from the 8 Endodontic practice

ICOI. I have patented/patent-pending work and published in the Journal of Endodontics (JOE). Outside of clinical skills, I have done creative work in my passions — leadership, futurism, and business workflow systems.

Is your practice limited solely to endodontics, or do you practice other types of dentistry? Solely. Endodontics is the best!

Christopher Sabourin, DDS, MS, MSD Volume 14 Number 3

Yes, all our patients are referred from local general dentists as well as referring offices from surrounding counties, approximately 200 in total.

Professionally, what are you most proud of? Business insights and step-by-step developments with our root canal specialty office — specifically, the workflow side. Eliminating gaps and overlapping team member responsibilities made our days so much more enjoyable and productive. This is what led to Endodontic SuperSystems. The daily death by a thousand cuts and no clear direction forward can be tiring. When starting out, I

wish I had a clearer way to grow. I am most proud of sharing something I wish I had in the past — a team that is kept fresh and engaged with routines so that we might all enjoy flowing as well as more predictable days that grow out of a fully defined, interconnected business processes.

What do you think is unique about your practice? There might be very little unique to my practice other than we have a “true north,” the resource that we train and retrain quarterly on. It keeps us focused and gives us standards that undergo vetted improvements. Being that organized looks a little like a synchronized flow to patients, and they take serious notice.

What has been your biggest challenge? Starting a business without industrial management experience, and then testing step-by-step how to run a practice with complete team coordination at the most detailed level possible. What I found was that everything generally came to the dentist owner, resulting in bottlenecks and frustration. But there was not an easy alternative. Often this dynamic results in friction between team members and the endodontist, with each group pointing at the other. It is difficult to operate a practice. There are a large number of practice improvement directions and very little clarity on what is the right way to improve. Also, we are doing root canals during the day, so the team needs maximum clarity on their step-by-step. I have even heard of great practitioners selling their offices out of frustration.

What is the future of endodontics and dentistry? Fully interconnected smart business. Endodontic business is about to change — big time. And those who choose to work without tools for empowering their team with digital workflows (and new insight into time bottlenecks) will be left behind. I see people looking for marketing or management pieces to solve the pain, but every part of the business impacts the other. What good is increasing marketing if the practice is not prepared to double production? What good is management without the specific insights

Above top: RDH administering anesthesia; ESS empowers employee growth and performance. Above bottom: Happy staff, happy life Volume 14 Number 3

RDA taking on a leadership role with treatment of patients Endodontic practice 9

PRACTICE PROFILE

Do your patients come through referrals?

PRACTICE PROFILE to keep a team running cohesively? With ESS, the vast majority of the pieces of the business are available for learning (Learn) for rocket-fast on-boarding. The software component shows exactly where time waste occurs (Do), and employees submit ideas for improvement (Improve), as well as insights into team member sentiment level. Learn, do, improve. No gaps, no overlapping work. And time visuals. We are dubbing this new tech branch ExecuTech.

What are your top tips for maintaining a successful specialty practice? Endodontic SuperSystems (patent pending). Get going with ESS, it’s like buying a subscription to the future of small business. Learn, do, improve. For the life of your business.

What advice would you give to a budding endodontist? You can have it easier than prior practitioners who used to wish for a “business-ina-box” to help run their office. Endodontic SuperSystems is the cutting edge for your new team. Imagine saving 5 to 8 years to

Because you don’t become a top 0.1% practice overnight — we learn, do, improve — the mantra of our ESS continuous circle of improvement

Top ten favorite books for small business leaders 1. Mastering the Rockefeller Habits by Verne Harnish 2. Unstoppable Teams by Alden Mills 3. Good to Great by Jim Collins 4. Think in Systems by Zoe McKey 5. The Wisdom of Crowds by James Surowiecki 6. Leaders Eat Last by Simon Sinek 7. The Power of a Positive Team by Jon Gordon 8. Leading Change by John P. Kotter 9. Bringing Out the Best in People by Aubrey C. Daniels 10. Extreme Ownership by Jocko Willink and Leif Babin

10 Endodontic practice

Above top: We consider the mental and physical aspects of a patient’s well-being to provide next-level care. Above bottom: Real-time insights help staff to coordinate and control the schedule

Our ability to save natural teeth is enhanced through consistency, efficiency, and technology

fully develop your team. Focus on what you love — endodontic care and the best parts of owning your own business. Develop a team that can work by processes and take on the day-to-day weeds that you, as the endodontist, are too valuable to spend time on. ESS is a transgenerational model where you start from day one with the best workflow routines and improve from there. Why reinvent the wheel, when you can start with an amazing wheel and just keep improving it?

working in areas that are not very visible. The specialty felt magical to me, and I remain eternally grateful for the opportunity to be a member of our amazing profession.

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

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

Spending time with my beautiful family, reading (hundreds of books a year), skydiving, watching gastrophysics stuff, economics, developing business systems, and spelunking. Imagining.

Who has inspired you? Jim Collins, author of Good to Great and other books about what makes great companies thrive.

What would you have been if you didn’t become a dentist? Corporate CEO, industrial psychologist, or ER physician.

When did you become a specialist, and why? I chose dentistry because I feel passionate about providing pain relief while also having a family life and my own business to run. Why endodontics? Growing up I had (correctable) extremely poor vision, so I felt right at home

Why did you decide to focus on endodontics? I spent a lot of time choosing a profession, and endodontics was just the perfect fit at so many levels. I love what we all do. So happy.

I have been practicing endodontics for more than 17 years.

What is the most satisfying aspect of your practice? The most satisfying aspect of my practice is the opportunity to help provide opportunities and challenge my team to try new things while also seeing what I can do to make their day-to-day smoother and smoother.

Tell us some of the details about your practice I have two offices that have four operatories each. (We only practice at one location at a time and need another endodontist now.) We employ six dental assistants, one extended function, four patient coordinators, one manager, one marketing liaison, and one endodontist! Learn more about Dr. Sabourin and ESS by visiting https://endosuper systems.com/. EP Volume 14 Number 3

CORPORATE SPOTLIGHT

Endo1 Partners The fastest-growing endodontic partnership organization that helps you prosper on your terms

ndo1 Partners is the original and fastest-growing Endodontic Partnership Organization (EPO) dedicated to supporting endodontists. The EPO offers a full suite of business and operational support services that reduces administrative burden, increases efficiency, and fuels growth for partner endodontists. Endo1 Partners was founded and is led by practicing endodontists Matthew Haddad, DMD; Daryl Dudum, DDS; Mark Haddad, DDS; and Darron Rishwain, DDS. These industry-leading professionals came together to form the first-of-its-kind EPO after finding that existing dental service organizations (DSOs) did not truly understand the specific needs and challenges of endodontists. Established in October 2019 with just six locations and operations in Texas and California, Endo1 Partners experienced rapid growth across several markets during its first full year in operation. The EPO now supports more than 70 practices and over 100 specialists across 15 states — and expects to continue this impressive growth trajectory by adding 50 locations to its network in 2021. If you are interested in partnering with a DSO, Endo1 Partners boasts a unique model that empowers you to achieve your goals and allows you prosper on your terms.

You retain control of your business Partnering with Endo1 Partners allows you to receive all the benefits of joining a

“The fact that Endo1 Partners is endo-owned and endo-run makes a huge difference. If I have a clinical problem, the founders are only one call away. As practicing endodontists, they get it and are happy to help anytime. This regular communication makes me feel like a valued member of the organization.” – Dr. Rowshan Ahani, Bayside Endodontics larger group of dental professionals, while maintaining control of your business. Unlike what happens in similar organizations, partners retain a considerable amount of equity in their practices and remain in control of their practice’s brand, culture, and team. Most importantly, you will have complete clinical autonomy. Plus, you tell us what you need — not the other way around. Endo1 Partners does not mandate that partners use all services. You have the flexibility to choose which services your practice needs to drive success.

Patient care is our primary focus Imagine being able to solely focus on the “practice” part of your endodontic practice. As a member of the Endo1 Partners network, you will have access to best-inclass services, resources, and more that will help you streamline your practice so you can focus on what matters most — providing high-quality care to patients.

We don’t have a corporate feel Endo1 Partners operates more like a tight-knit family than a corporation or company. The founding partners personally visit with potential partners to ensure a good fit and stay in touch even after partners have been integrated. This personalized touch and caring culture is part of what makes Endo1 Partners unique.

Join the Endo1 Partners Network Endo1 Partners is looking to partner with more specialists in building a world-class organization they can count on for bestin-class resources and support. Contact Endo1 Partners at info@endo1partners. com, or call 305-206-7388 to partner with a network of like-minded dental professionals you can trust. EP Founders, Endo1 Partners 12 Endodontic practice

This information was provided by Endo1 Partners.

Volume 14 Number 3

70+ PRACTICES

100+ SPECIALISTS

15 STATES

Imagine soley focusing on the “practice” part of your endodontic practice. We partner with endodontists nationwide to empower them to do just that, while helping you to achieve your goals. Endo1 Partners supports our endodontic partners by implementing business best practices to reduce administrative burden, increase efficiency, and prioritize growth.

THE ONLY ENDODONTIC PARTNERSHIP LED BY ENDODONTISTS

305-206-7388

Endo1partners.com

WEBINAR ROUNDTABLE

Bioceramics: Promising New Frontier or Wild West? Drs. Jianing (Jenny) He and Allen Ali Nasseh provide a look into their recent Endodontic Practice US webinar focused on bioactives and bioceramics Learning Objectives • Understand the properties of the “bioceramics” and “bioactives” used in endodontics. • Understand the knowledge gaps regarding research and clinical outcomes for newer materials versus the established bioceramics on the market. Dr. He: The terms bioceramics and bioactives are being used at an everincreasing rate in endodontic circles. Let’s discuss these two terms as they relate to products used in endodontics. Dr. Nasseh: Bioceramics are essentially any inorganic, ceramic material (refractory polycrystalline compounds) used in medicine and dentistry. There are various categories of bioceramics used for various applications. They are highly biocompatible materials that (by design or selection) should have similar physical characteristics to the tissue that they are replacing or repairing. They are chemically stable, non-corrosive, and are able to withstand interfacial interactions with surrounding organic tissue without triggering a significant immune response. In endodontics, we have a few different types of bioceramics that can be generally categorized by: 1. Composition a. “Pure Bioceramics” contain only bioceramic components b. “Hybrid Bioceramics” contain bioceramics in addition to resins or metals

2. Setting Mechanism a. Premixed hydrogels (no mixing required, set in the presence of moisture in dentin) b. Non-premixed powders and liquids (mixed or triturated to achieve set) 3. Absorbable or non-absorbable Dr. He: There is certainly some overlap between materials that are considered “bioceramics” and those considered “bioactives.” While the term “bioceramics” describes the composition of the material, the term “bioactives” describes the properties of the material. If a material has the ability to release biologically active compounds and elicit a response from the tissue it is placed in, it is considered bioactive. In the field of dentistry, this definition covers two main groups of materials. The first group includes fluoride-releasing materials such as glass ionomers and resin-modified glass ionomers. The fluoride released from these materials helps to maintain or remineralize dentin or enamel. EndoSequence® BC Liner™ also belongs to this group of nonbioceramic bioactives. The other group of bioactive materials include those that can interact with the tissue they are placed in, mostly through the release of calcium and hydroxyl ions, such as the bioceramics used in endodontics. One good example of such materials is EndoSequence® BC Sealer™. During the hydration process, the calcium silicates in the material interact with water in the

Dr. Jianing (Jenny) He, DMD, PhD, received her dental degree from West China University of Medical Sciences in 1996 and a certificate in Endodontics and a PhD in Oral Biology from the University of Connecticut Health Center in 2003. Dr. He has been actively involved in endodontic education, research, and clinical practice. She is a Diplomate of the American Board of Endodontics and a fellow of American College of Dentists. She has published over 50 manuscripts in peer-reviewed journals and has served on The Research and Scientific Affairs committee for the AAE and the scientific advisory board of the Journal of Endodontics. Dr. He also served as the President of DFW Metroplex Endodontic Society and Dallas Asian Dental Association. Dr. He is currently a Clinical Associate Professor at Texas A&M University College of Dentistry and maintains a full-time private practice limited to Endodontics in Dallas, Texas. Allen Ali Nasseh, DDS, MMSc, received his dental degree from Northwestern University Dental School in Chicago, Illinois, in 1994 and completed his postdoctoral endodontic training at Harvard School of Dental Medicine in 1997, where he also received a Masters in Medical Sciences (MMSc) degree in the area of bone physiology. He has been a clinical instructor and lecturer in the postdoctoral endodontic program at Harvard School of Dental Medicine since 1997 and the Alumni Editor of Harvard Dental Bulletin. Dr. Nasseh is the endodontic advisor to several educational groups and study clubs and is endodontic editor to several peerreviewed journals and periodicals. He has published numerous articles and lectures extensively nationally and internationally in surgical and nonsurgical endodontic topics. Dr. Nasseh is in solo private practice (MSEndo.com) in downtown Boston, Massachusetts. Dr. Nasseh is the President and Chief Executive Officer for the endodontic education company Real World Endo® (RealWorldEndo.com).

14 Endodontic practice

environment to first form calcium hydroxide, which further interacts with the calcium and phosphate components in the tissue fluid to form hydroxyapatite-like precipitates on the material surface. Hydroxyapatite is highly biocompatible. As it forms at the material/ pulp or material/periapical tissue interface, it helps to promote healing and induce new mineralized tissue formation. Hydroxyapatite can also form a chemical bond with dentin, which helps improve the sealing ability of the material. Therefore, there are many benefits in using a bioactive bioceramics for root filling and to induce tissue repair and regeneration. Dr. Nasseh: Some examples of bioceramic materials include ProRoot MTA, Biodentine®, EndoSequence BC Sealer, and BC RRM™ Paste and Putty. There are several new brands of MTA materials, which have recently been introduced. But the materials I mentioned first are the only ones that have been thoroughly tested and proven over time. The main difference between those three materials is that MTA and Biodentine require mixing or trituration, and MTA contains a bismuth oxide, which is staining to teeth. I personally prefer the premixed EndoSequence Bioceramics because of the extensive clinical track record coupled with their superior handling and the fact that we at Real World Endo helped develop simple clinical techniques for their surgical and non-surgical use. Dr. He: I am very excited for the future of endodontics as it relates to the “premixed bioceramic materials,” but I am hesitant to generalize all of the various products as being more or less the same. Recently, during my lectures, I have been getting a lot of questions from students and clinicians about my opinion of one brand of premixed bioceramic sealer or root repair material versus another brand. Materials like MTA, Biodentine, BC Sealer, and RRM are considered “proven” materials because they have a long track record of clinical use and very well documented success. They have been thoroughly tested and researched. In contrast, many of the newer materials have very little independent research or data published in peer-reviewed journals to support their use. We can all think of a few examples where the latest and greatest endo sealer ended Volume 14 Number 3

WEBINAR ROUNDTABLE

Figure 1: Biological properties

Figure 2: Antibacterial properties

up failing after a few years. These types of unproven products can undermine the entire endo specialty, and so I tread lightly when selecting a material that will remain within the patient for possibly the rest of their life. Dr. Nasseh: I have noticed that many of these new materials that are marketed as “bioceramics” include some components that I would not categorize as pure bioceramics. Many of these newer materials contain ingredients not found in EndoSequence BC sealer or RRM, such as resins, calcium aluminate, calcium sulfate, iron oxide, and even mineral oil. At this time, we don’t yet have any studies to show how these components might affect the properties of the materials. The presence of aluminum compounds has also raised some concern due to the possible association between aluminum exposure and certain neurological degenerative diseases. However, it needs to be recognized that there is no evidence that the aluminum content in these materials can leach out and cause any significant accumulation in other organs. Nevertheless, clinicians may want to be cautious while using aluminum-containing materials especially when aluminum-free alternatives are available. I do think there is a place for hybrid bioceramics because pure bioceramics have the inherent drawbacks of not being light curable and not having enough strength and wear characteristics for certain applications. An example of a hybrid composition “bioactive” material that shows beneficial Volume 14 Number 3

Figure 3: In vitro sealing ability

bioactive properties while interacting with pure bioceramics is EndoSequence BC Liner. I use this product as a liner, an orifice barrier over the furcation floor, as a long-term provisional during vital pulp therapy, and in cervical resorption and transgingival reparative defects. I would encourage the reader to watch the Endodontic Practice US Webinar under this same title, to learn more about the clinical applications of this product. Dr. He: I would strongly recommend that clinicians review the SDS documents as well

as the third-party research for any materials that they are considering to incorporate into their armamentarium. The guiding principles of evidence-based dentistry ask us to consider our professional judgment, clinical circumstance, scientific evidence, and patient preference when we make clinical decisions. I have been actively following research in the field of bioceramic materials and have participated in some studies as well. I would like to review some of what I consider the most relevant research that supports the efficacy Endodontic practice 15

WEBINAR ROUNDTABLE of the EndoSequence Bioceramics, which are the materials that I use clinically and are most familiar with. There have been over 150 independent studies on EndoSequence Bioceramics since these materials came to the market over 14 years ago. Due to space limitations, I am only able to review a few of the most important studies. Therefore, I would encourage the reader to search PubMed for additional literature support.

In vitro studies (Figures 1-3)

For an endodontic material that is intended to be used for root canal obturation, tissue repair, and regeneration, the properties most relevant to their functions include biocompatibility, antibacterial properties, and sealing abilities. Regarding biocompatibility, although these materials may have some initial cytotoxicity due to their high pH, overall, they support and encourage cell attachment and growth (Chen, et al., 2016), and promote osteogenic and odontogenic differentiation (Zhang, et al., 2010; Rifaey, et al., 2016; Giocomino, et al., 2019). The antibacterial properties of a root filling material are beneficial as they enable the material to inhibit the growth of any remaining bacteria that are present in the canal at the time of obturation. Studies have shown that both EndoSequence BC Sealer and BC RRM are effective against Enterococcus faecalis and Enterococcus faecalis biofilms (Lovato, et al., 2011; Wang, et al., 2014; Bukari, et al., 2019). MTA and EndoSequence BC RRM have also been shown to have antifungal properties (Alsalleeh, et al., 2014). Results from in vitro studies on the sealing ability are less consistent, mainly due to the limitations of the in vitro models and the variations in methodology used in different studies. Many of these studies show the materials to have less leakage (Ballullaya, et al., 2017), higher bond strength (DeLong, et al., 2014) and better dentin tubule penetration (Wang, et al., 2018) compared to traditional materials like AH Plus®. However, we do need to be aware of the limitations of the in vitro models and not to over-interpret the in vitro data.

Figure 4: Animal and clinical studies on vital pulp therapy

Figure 5: Clinical case report on vital pulp therapy

Clinical studies on obturation (Figure 6) Evidence from clinical studies is considered more important because it is more relevant to our clinical practice. However, clinical studies on obturation with a meaningful sample size are difficult to do. As a result, not many of them are available. We published the first outcome study on BC-based obturation technique in 2018 (Chybowski, et al., 2018). 16 Endodontic practice

Figure 6: Clinical studies on obturation Volume 14 Number 3

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B-5471-EP-09.21

WEBINAR ROUNDTABLE

Figure 7: Clinical studies on root-end surgery

This study was a retrospective case series, which included over 300 cases treated in our private practice. Both initial treatment and retreatment cases were included. The majority of the cases were posterior teeth (92.2%); about half of the cases had pre-op periapical lesions, and the average follow-up time was around 30 months. All the included cases were treated in a single-visit and obturated with the hydraulic condensation technique using BC sealer. We found an overall success rate of close to 91%, which is well within the range of success rates reported in the literature. Dr. Nasseh also has some preliminary data on the cases treated at his office that shows a survival rate of greater than 97%.

Clinical studies on root-end surgery (Figure 7) There have been at least five studies published in the past 6 years on the clinical success of EndoSequence BC RRM as a root-end filling material in endodontic microsurgery. The first of these studies reports a success rate of 92% in a series of more than 100 cases treated at our office with a minimum 1-year follow-up (Shinbori, et al., 2015). This data was later confirmed by another study that retrospectively compared the outcome between MTA and BC RRM used in surgery cases treated by our postgraduate endodontic residents (Chan, et al., 2020). No significant difference was found between the two materials (MTA-92.1%, BC RRM-92.4%). Two randomized controlled trials have been published that corroborate our findings and show no difference between MTA and BC RRM with both materials showing a success rate above 92% (Zhou, et al., 2017; Safi, et al., 2019). Dr. Thomas von Arx recently published another case 18 Endodontic practice

series that reports an overall success rate of 94.1% at 1-year follow-up (von Arx, et al., 2020). Based on these studies, it appears EndoSequence BC RRM offers consistent, predictable success similar to that achieved with MTA, which has been considered the “gold standard” for apical surgery. Dr. Nasseh and Dr. He: It is clear that bioceramics and bioactive materials have positively impacted clinical endodontics. While bioceramics have excellent clinical properties, clinicians must be diligent to research and select clinically proven materials, backed by research, to help improve the efficacy and safety of their care. We also want to encourage you to watch the Endodontic Practice US Webinar on this topic as it includes more clinically relevant information that was omitted in this article due to space limitations. EP REFERENCES 1. Zhang W, Li Z, Peng B. Effects of iRoot SP on mineralization-related genes expression in MG63 cells. J Endod. 2010;36(12):1978-1982. 2. Rifaey HS, Villa M, Zhu Q, et al. Comparison of the Osteogenic Potential of Mineral Trioxide Aggregate and Endosequence Root Repair Material in a 3-dimensional Culture System. J Endod. 2016;42(5):760-765. 3. Wang Z, Shen Y, Haapasalo M. Dentin extends the antibacterial effect of endodontic sealers against Enterococcus faecalis biofilms. J Endod. 2014;40(4):505-508. 4. Bukhari S, Karabucak B. The Antimicrobial Effect of Bioceramic Sealer on an 8-week Matured Enterococcus faecalis Biofilm Attached to Root Canal Dentinal Surface. J Endod. 2019;45(8):1047-1052. 5. DeLong C, He J, Woodmansey KF. The effect of obturation technique on the push-out bond strength of calcium silicate sealers. J Endod. 2015;41(3):385-388.

6. Wang Y, Liu S, Dong Y. In vitro study of dentinal tubule penetration and filling quality of bioceramic sealer. PLoS One. 2018;13(2):e0192248. 7. Alsalleeh F, Chung N, Stephenson L. Antifungal activity of endosequence root repair material and mineral trioxide aggregate. J Endod. 2014;40(11):1815-1819. 8. Lovato KF, Sedgley CM. Antibacterial activity of endosequence root repair material and proroot MTA against clinical isolates of Enterococcus faecalis. J Endod. 2011;37(11):1542-1546. 9. Ballullaya SV, Vinay V, Thumu J, et al. Stereomicroscopic Dye Leakage Measurement of Six Different Root Canal Sealers. J Clin Diagn Res. 2017;11(6):ZC65-ZC68. 10. Liu S, Wang S, Dong Y. Evaluation of a bioceramic as a pulp capping agent in vitro and in vivo. J Endod. 2015;41(5):652-657. 11. Rao Q, Kuang J, Mao C, Dai J, et al. Comparison of iRoot BP Plus and Calcium Hydroxide as Pulpotomy Materials in Permanent Incisors with Complicated Crown Fractures: A Retrospective Study. J Endod. 2020;46(3):352-357. 12. Ricucci D, Grande NM, Plotino G, Tay FR. Histologic Response of Human Pulp and Periapical Tissues to Tricalcium Silicate-based Materials: A Series of Successfully Treated Cases. J Endod. 2020;46(2):307-317. 13. Chybowski EA, Glickman GN, et al. Clinical Outcome of Non-Surgical Root Canal Treatment Using a Single-cone Technique with Endosequence Bioceramic Sealer: A Retrospective Analysis. J Endod. 2018;44(6):941-945. 14. Shinbori N, Grama AM, Patel Y, Woodmansey K, He J. Clinical outcome of endodontic microsurgery that uses EndoSequence BC root repair material as the root-end filling material. J Endod. 2015;41(5):607-12. 15. Zhou W, Zheng Q, Tan X, et al. Comparison of Mineral Trioxide Aggregate and iRoot BP Plus Root Repair Material as Root-end Filling Materials in Endodontic Microsurgery: A Prospective Randomized Controlled Study. J Endod. 2017;43(1):1-6. 16. Safi C, Kohli MR, Kratchman SI, Setzer FC, Karabucak B. Outcome of Endodontic Microsurgery Using Mineral Trioxide Aggregate or Root Repair Material as Root-end Filling Material: A Randomized Controlled Trial with Conebeam Computed Tomographic Evaluation. J Endod. 2019;45(7):831-839. 17. Chan S, Glickman GN, Woodmansey KF, He J. Retrospective Analysis of Root-end Microsurgery Outcomes in a Postgraduate Program in Endodontics Using Calcium Silicate-based Cements as Root-end Filling Materials. J Endod. 2020;46(3):345-351. 18. von Arx T, Janner SFM, Haenni S, Bornstein MM. Bioceramic root repair material (BCRRM) for root-end obturation in apical surgery. An analysis of 174 teeth after 1 year. Swiss Dent J. 2020;130(5):390-396.

We invite you to watch the full Endodontic Practice US Webinar on this topic at https://endopracticeus.com/webinar/bioceramics-promising-new-frontier-or-wildwest/, and you can take the quiz to earn 1 free CE credit.

Volume 14 Number 3

Combining experience and improving patient care with HighFive What can you tell us about your background? Dr. Collier: I am a graduate of Samford University, University of Alabama (UAB) School of Dentistry, and University of Alabama endodontic program. Dr. Kimbell: I went to college at Spring Hill College in Mobile, dental school at UAB (’88), did my Endodontic residency at UAB (’90) training under Dr. Robert Barfield, joined Endodontic Associates immediately after completing my endo residency (July of ’90), and joined HighFive approximately a year ago.

Do your patients come from referrals? Dr. Collier: We have a mix of return patients who need treatment on other teeth and new patient referrals from a great group of general practitioners. Dr. Kimbell: We’re honored that they’ll trust us to take care of their patients.

What is unique about your practice? Dr. Collier: It is extremely fulfilling to our team to help someone in need and to continually strive to exceed our patients’ expectations. Our ultimate goal is to have every patient feel loved and cared for. We send every patient a survey following treatment; the team gets such positive gratification with each positive review. Dr. Kimbell: Joining HighFive has definitely made us a unique practice. We’re able to use each other’s experiences to help us choose each patient’s best treatment path.

We just simply have a greater pool of knowledge and experience.

Professionally, what are you most proud of? Dr. Collier: Seeing improvement in the patient experience. The new technology in 3D CBCT and improved armamentarium have allowed endodontic treatment to become better than ever. Dr. Kimbell: I’ve always tried to treat every patient as though they were a family member — spending the time required to take care of them to the absolute best of my ability.

What do we most enjoy about HighFive? No doubt about this one. We have learned so much from all the other doctors — so much experience and so many different ways of approaching treatment. We feel like we’re doing the best endo that we’ve ever done

What is your most satisfying or challenging aspect of your practice? Dr. Collier: It is challenging when patients have to wait for an open appointment. Patients should have access to quality endodontic care in a reasonable amount of time instead of having to wait a week or more in discomfort. Dr. Kimbell: I am most satisfied when I know that I’ve really helped my patient.

What is your perception of the future of endodontics? Dr. Collier: With new technology and materials, we can treat patients more efficiently with more confidence. This will lead to better patient experience and care. Hopefully, this will change how people view root canals. Dr. Kimbell: New instruments and equipment are always being developed, and new philosophies of treatment are always being discussed. If endodontists will continue to focus on what’s best for the patient, endodontics will continue to be a great field of dentistry.

What is your advice to budding endodontists? Dr. Collier: Have as many experienced advisors as possible when determining patient needs and treatment. Also, to remember how fortunate they Volume 14 Number 3

are to be able to help people who are in pain and in need. Dr. Kimbell: Don’t think that you’ll be practicing the same way for your whole career. Philosophies will change, and tools will change. Be open to all of this, but strive to see the difference between a vendor trying to sell you something and someone trying to help you better treat your patient.

What are your tips for maintaining a successful specialty practice? Dr. Collier: You need a team of likeminded, loving, caring staff who will help you provide the care you desire for your patients. Also, find a like-minded experienced peer group to share ideas and treatment decisions with. Don’t try to do it alone. Dr. Kimbell: Treat your patients as you would like to be treated.

What is your favorite aspect of being a part of HighFive? Dr. Collier: The collaboration with so many other excellent doctors. It is truly amazing how much you can learn from other clinicians. I’m so blessed to be a part of this family. Dr. Kimbell: I have learned so much the other doctors’ experience and many different ways of approaching treatment. I feel like I’m doing the best endo that I’ve ever done. I feel very blessed to be a part of the HighFive family. They’ve helped me be a better endodontist. EP Endodontic practice 19

PRACTICE SPOTLIGHT

John Collier, DMD, and Franklin Kimbell, DMD

CLINICAL

Endodontic management of a maxillary lateral incisor with Oehlers Type IIIB dens invaginatus Drs. Gonzalo García, Claudia Judkin, Denise Alfie, Ariel Lenarduzzi, and Pablo Alejandro Rodríguez discuss treatment of a complex dental anomaly Abstract The complex anatomy of an Oehlers Class IIIB dens invaginatus (DI) in a maxillary lateral incisor is a major endodontic challenge for the endodontist.

Method The case reported here is a 14-year-old male patient referred for clinical evaluation with a fistula associated with the maxillary lateral incisor. The crown had no signs of alteration, just slightly wider mesiodistally compared to its contralateral. Pulp testing showed negative results. The images obtained revealed an extensive apical radiolucency. The diagnosis was pulp necrosis with a periapical lesion in an upper lateral incisor with an image coincident with DI.

Results In this case, the endodontic treatment of the root canal system was performed in three sessions. Irrigation with 2.5% sodium hypochlorite plus the use of an activating device played a very important role in cleaning the DI. The endodontic obturation was performed with a dual thermoplastic guttapercha system to obtain an adequate threedimensional filling. The 3-year recall showed complete healing of the periapical tissues.

Conclusion Endodontic success in these cases can be achieved through correct planning, thorough cleaning of the internal anatomy, and adequate three-dimensional obturation.

Introduction Among dental malformations, dens invaginatus (DI) is one of the most frequent. This development anomaly arises from the invagination of the internal epithelium of the Gonzalo García DDS, Claudia Judkin, DDS, Denise Alfie, PhD, Ariel Lenarduzzi, DDS, Pablo Alejandro Rodríguez, DDS, PhD, are from the Department of Endodontics, School of Dentistry, University of Buenos Aires, Argentina. Disclosure: The authors deny any conflicts of interest related to this study.

20 Endodontic practice

enamel organ within the dental papilla before the calcification of the tissues. Affected teeth may present, in the crown and/or roots, variations in shape and size.1 Radiographically, this presents an invagination of the enamel and dentin that can reach the pulp chamber, the root, and in some cases, even the apex. This alteration is usually asymptomatic and in many cases, its detection is a random radiographic finding. DI was first described in 1856 by a dentist called Socrates.2 Mühlreither in 1873 reported ... “anomalous cavities in human teeth.” Baume in 1874 and Busch in 1897 also published this malformation.3-5 In 1897, Tomas describes DI in his textbook, A System of Dental Surgery.1-3 DI can occur in any dental group and in temporary or permanent teeth; however, it occurs more frequently in the upper lateral incisor. Forty-two percent of reported cases are linked to that tooth. Its incidence in the population ranges from 0.04% to 10%,6 being more frequent in men.7 Probably the percentages observed in the literature are so variable because the studies were conducted in different population groups, and the diagnostic criteria used were not equal.8 Various treatment modalities have been proposed to address the pathologies associated with DI. These procedures range from prophylactic restorations to endodontic treatments, complementary surgery, or even extraction.9-11 Undoubtedly, the clinical resolution of a DI, which requires nonsurgical endodontic treatment, represents a great challenge for the specialist.

Classification of dens invaginatus Different classifications have been suggested to describe DI. The first was published by Hallet in 1953.14 However, one classification of Oehlers, proposed in 1957, is the most used.12-13 This author divided the DI into three categories according to the depth of penetration and communication with the periapical tissues and the periodontal ligament. Type I: The invagination is small, communicates with the enamel, is limited to the

crown of the tooth, and does not exceed the level of the cementoenamel junction. Type II: The invaginated depth of the enamel reaches the root, remaining hidden inside it. It may or may not have communication with the pulp tissue, but it does not have it with the periodontal ligament. Type IIIA: The invagination penetrates through the root and communicates apically or laterally in the foramen, sometimes refers to a second foramen in the root. Normally, there is no communication with the pulp. Type IIIB: The invagination extends through the root and communicates with the periodontal ligament in the apical foramen. Normally, it has no communication with the pulp.

Case report A 14-year-old male was seen at dental school of the University of Buenos Aires in December 2015, referred by the orthodontic specialist. Clinical examination revealed the presence of a sinus tract at the level of the right upper lateral incisor. The crown of the tooth was complete, and it was slightly wider than the crown of the contralateral tooth. On the periodontal examination, no abnormal depth pockets were found. A panoramic radiograph shows unusual dental anatomy and a radiolucency image surrounding the apex. To determine the origin of the sinus tract, a gutta-percha cone was placed along its path, and a periapical radiograph was taken. The image obtained confirmed that the tooth No. 1.2 was the cause of the infection and allowed to visualize the presence of a distal root canal of normal configuration and a larger pulp space toward the mesial. (Figures 1A and 1B, Figure 2) A cone beam computed tomographic imaging (CBCT) was captured for a more precise diagnosis. The images obtained confirmed the presence of an Oehlers Class IIIB DI (Figure 3). Informed consent was obtained from the parents to carry out the treatment, and at the first appointment, conventional access was performed under local infiltrative anesthesia (Totalcaina Forte; Laboratorios Bernabo, Buenos Aires, Argentina) and rubber dam isolation. Volume 14 Number 3

Figure 2: CBCT preoperative image Volume 14 Number 3

The final obturation of the DI was done by thirds using a thermoplastic guttapercha system. The Calamus® Dual system (Dentsply-Sirona) was used for this purpose in the apical third using the continuous wave of obturation technique after adjusting a No. 60 gutta-percha point. The remaining canal was back-packed with the Calamus Flow handpiece (Figure 4).The sealer used was AH Plus. The access was restored with Ionofil Molar. Clinical and radiographic controls were performed initially every 3 months and, after the second recalls, every 6 months until

the complete reparation of the periapical tissues was confirmed. Periapical radiography (Figure 5) and CBCT were performed in the 3-year recall. Both images showed complete apical healing, and the patient was asymptomatic.

Discussion DI is always a challenging case for endodontic treatment since such teeth always have a complex root canal morphology.1-14 Various treatment options have been reported in the literature including

Figures 1A and 1B: Figure 1A. Gutta-percha cone in the sinus tract (color). Figure 1B. Preoperative radiograph image with the gutta-percha cone in the sinus tract

Figure 3: Postoperative radiograph immediately after root canal filling

Figure 4: Three-year follow-up radiograph showing satisfactory healing of the periapical lesion Endodontic practice 21

CLINICAL

After the access, the distal canal was negotiated, and purulent drainage occurred spontaneously. An electronic apical locator (Root ZX®; J Morita Corp.) was used to determine the working length and confirmed radiographically. The main canal was cleaned and shaped with K-files (Dentsply Sirona) with a stepback technique up to a No. 50 apically and irrigated with 2.5% of sodium hypochlorite. After the use of paper points, calcium hydroxide mixed with distilled water was used as intracanal dressing and a temporary sealing with Ionofil Molar glass ionomer (VOCO, Cuxhaven, Germany) was placed on the access cavity. In a second appointment, 15 days later, clinical examination revealed that the sinus tract had disappeared, and the final obturation of the main canal was performed with lateral compaction technique of gutta-percha points (Meta-Biomed, Korea) and AH Plus® sealer (Dentsply Sirona) In the same appointment, the DI was located using an operative microscope (OPMI pico, ZEISS). Profuse drainage of pus occurred again during the access. The working length was verified through the use of an apex locator and a periapical radiographic image; 2.5% sodium hypochlorite was used as irrigation and activated with EndoActivator® (Dentsply Sirona). At the end of this appointment, an intracanal dressing based on calcium hydroxide and a temporary sealing with Ionofil Molar were placed. In a third appointment, the calcium hydroxide dressing was removed with copious irrigation, and the removal was completed with the XP endo-Finisher file (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland). The apical gauge of the DI was confirmed with a No. 60 K-file. Finally, irrigation was carried out with 2.5% sodium hypochlorite for 5 minutes and dried with paper points.

CLINICAL preventive restorations, endodontic treatment, a combination of endodontics and surgery, intentional reimplantation, or extraction. The decision to choose one of them is related to the type and extent of the invagination.10,15,16 The clinical case treated in this article was Oehlers Class III Type B DI in a superior lateral incisor with periapical lesion.12 An accurate radiographic examination is necessary for the detection of the DI. However, periapical radiographs and/or panoramic images may not reveal details of the type and extent of invagination.17,18 Texeiro, et al., noted that the use of CBCT has become a very valuable tool, not only for diagnosis, but also for planning and treatment. Nonetheless, its use requires higher doses of radiation, so its indication must be precise and applied correctly in each patient.19,20 The images obtained in this case allowed the analysis of the internal morphology, and confirmed the existence of independent foramen at the apex and the size of the invagination and the periradicular lesion. These anomalies have a high incidence of infection and pulp degeneration, which is why its early detection is very important to establish preventive behaviors and avoid pulp necrosis and periapical inflammation.13 Not detecting and not treating these malformations can promote pulpal alterations in a short time after dental eruption even when the apex is not yet developed.21-23 In the present case at the first appointment, a sinus tract was detected clinically. The crown did not show alterations due to caries or pre-existing restorations. However, the literature mentions that the pathology can develop due to the presence of communicating canals between the invagination and the root space. This communication would occur because the enamel coating is incomplete.24,25 When a Type III DI is accompanied by an apical lesion, the indicated treatment in the first instance is conventional endodontic treatment. Its therapeutic management can be difficult due to the internal configuration of the root canal system, which makes cleaning and shaping arduous beyond the use of manual or mechanized techniques.7 Endodontic instruments are designed to clean and shape the dentin, but it is impossible to remove the enamel with them. In cases of Type III DI where the invagination is partially or completely covered with adamantine tissue, the conventional instrumentation will not be effective.26-27 On the other hand, the volume and shape of the DI make it very difficult for the instruments to reach the dentin surface. In this case, irrigation solutions and their activating 22 Endodontic practice

systems play a very important role due to their ability to clean and disinfect the cavity. The use of intermediate medication in endodontic treatment is a matter of debate in the literature because of the difficulties for its removal. Undoubtedly, this situation is even more complex in DI cases because of the presence of a large, irregular, and retentive cavity. In this case, when the access was performed in the DI, drainage occurred that required the placement of an intracanal dressing based on calcium hydroxide. Several publications have reported success rates in removing calcium hydroxide with various techniques and devices such as sonic, ultrasonic irrigation, or even negative pressure systems (PUI).28-31 In this case, a sonic device, the EndoActivator, was used to activate sodium hypochlorite, and XP endo-Finisher was used to remove the intermediate medication. Due to its design and kinematics, XP endo-Finisher allows a larger internal surface of the root canal to be addressed, achieving better contact with the dentin wall.32 The combination of both systems made it possible to achieve a more efficient cleaning and removal of the intermediate medication. Finally, achieving a three-dimensional seal becomes the last therapeutic challenge. In general, such wide-rooted spaces require the use of techniques that involve hot gutta percha even with the risk of overfilling. Injection systems are usually those of choice.33 In this case, a combined obturation technique was performed. Cold lateral condensation was used in the distal canal. In the DI, the Calamus Dual System, which combines two hot gutta-percha techniques, was used. The apical third was obturated with the continuous wave technique after achieving a correct fit of No. 60 gutta-percha cone and the middle and coronal thirds with the injection technique.

6. Rotstein I, Stabholz A, Heling I, Friedman S. Clinical considerations in the treatment of dens invaginatus. Endod Dent Traumatol.1987;3(5):249-254.

Conclusion

26. Stamfelj I, Kansky AA, Gaspersic D. Unusual variant of Type 3 dens invaginatus in a maxillary canine: A rare case report. J Endod. 2007;33(1):64-68.

The treatment of a Type III DI is a big challenge for the specialist. Nonsurgical endodontic treatment is always considered as the first choice, no matter the size of the apical lesion. EP REFERENCES 1. Hülsmann M. Dens invaginatus: etiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J. 1997;30:79-90. 2. Schulze C, Gorlin RJ, Goldman HM. Thomas Oral Pathology. 6th ed. Vol. 1. St. Louis: CV Mosby; 1970. Developmental abnormalities of the teeth and jaws. 3. Tomes J. A System of Dental Surgery. 3rd ed. London, UK: J.& A. Churchill. 4. Oehlers F. Dens Invaginatus (dilated composite odontome): I-variations of the invaginatus process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol. 1957; 10: 1204-1218. 5. Cole G, Taintor J, Garth, J. Endodontic therapy of a dilated dens invaginatus. J Endod. 1978;4(3):88-90.

7. Sousa S, Bramante C. Dens Invaginatus: treatment choices. Endod Dent Traumatol.1998;14(4):152-158. 8. Pallavi Reddy Y, Karpagavinayangam K, Subbarao C. Management of dens invaginatus diagnosed by spiral computed tomography: a case report. J Endod. 2008; 34(9):1138-1142. 9. Nostrat A, Scheineder C. Endodontic Management of a Maxillary Lateral Incisor with 4 Root Canals and a Dens Invaginatus Tract. J Endod. 2015;41(7):1167-1171. 10. Hovland EJ, Block RM. Non-recognition and subsequent endodontic treatment of dens invaginatus. J Endod. 1977;3(9):360-362. 11. Ridell K, Mejare I, Matsson L. Dens Invaginatus: a retrospective study of prophylactic invagination treatment. Int J Clin Pediatr Dent. 2001;11(2):92-97. 12. Tagger M. Nonsurgical endodontic therapy of tooth invagination. Report of a case. Oral Surg Oral Med Oral Pathol. 1977;43(1):124-129. 13. Lindner C, Messer HH, Tyas MJ. A complex treatment of dens invaginatus. Endod Dent Traumatol. 1995;11(3):153-155. 14. Hallet GE. The incidence, nature, and clinical significance of palatal invagination in the maxillary incisors teeth. Proc R Soc Med. 1953;46(7):491-499. 15. Oehlers FAC. The radicular variety of Dens Invaginatus. Oral Surg Oral Med Oral Pathol. 1958;11(11):1251-1260. 16. Agrawal P, Wankhade J, Warhadpande M. A Rare Case of Type III Dens Invaginatus in a Mandibular Second Premolar and Its Nonsurgical Endodontic Management by Using Cone-Beam Computed Tomography: A Case Report. J Endod. 2016;42(4):669-672. 17. Patel S. The use of cone beam computed tomography in the conservative management of dens invaginatus: a case report. Int End J. 2010;43:707-713. 18. Mishra S, Mishra L, Sahoo SR. A Type III Dens Invaginatus with Unusual Helical CT and Histologic Findings: A Case Report. J Clin Diagn Res. 2012; 9: 1606-1609. 19. Kfir A, Telishevsky-Strauss Y, Leitner A, Metzger Z. The diagnosis and conservative treatment of complex Type 3 dens invaginatus using cone-beam computed tomography (CBCT) and 3 plastic models. Int End J. 2013;46(3):275-288. 20. Abella F, Teixido LM, Patel S, et al. Cone-bean computed tomography of the root canal morphology of maxillary first and second premolar in the Spanish population. J Endod. 2015;41(8):1241-1247. 21. Serota K. Cone-Beam computed tomography: How safe is CBCT for your patients? Dental Economics. January 2011. https://www.dentaleconomics.com/science-tech/ article/16394714/cone-beam-computed-tomographyhow-safe-is-cbct-for-your-patients. Accessed August 9, 2021. 22. Durack C, Patel S. Cone beam computed tomography in endodontics. Braz Dent J. 2012;23(3):179-191. 23. Nik-Hussein NN. Dens invaginatus: Complications and treatment of non-vital infected tooth. J Clin Pediatr Dent. 1994;18(4):303-306. 24. Chen RJ, Yang JF, Chao TC. Invaginated tooth associated with periodontal abscess. Oral Surg Oral Med Oral Pathol. 1990;69(5):659. 25. Ferguson FS, Friedman S, Frazzetto V. Successful apexification technique in an immature tooth with dens in dente. Oral Surg Oral Med Oral Pathol. 1980(4);49:356-359.

27. Pai SF, Yang SF, Lin LM. Nonsurgical endodontic treatment of dens invaginatus with the large periradicular lesion: a case report. J Endod. 2004;30(8):597-600. 28. Narayana P, Hartwell G, Wallace R, Nair P. Endodontic clinical management of dens invaginatus case by unique treatment approach. A case report. J Endod. 2012;(38)8:1145-1148. 29. Kenee DM, Allemang JD, Johnson JD, Hellstein J, Nichol BK. A quantitative assessment of efﬁcacy of various calcium hydroxide removal techniques. J Endod. 2006;32(6):563-565. 30. Lambrianidis T, Kosti E, Boutsioukis C, Mazinis M. Removal efﬁcacy of various calcium hydroxide/chlorhexidine medicaments from the root canal. Int Endod J. 2006;39(1):55-61. 31. Pabel AK, Hülsmann M. Comparison of different techniques for removal of calcium hydroxide from straight root canals: an in vitro study. Odontology. 2017;105:453-459. 32. Keshin C, Sariyilmaz E, Sariyilmaz Ö. Efficacy of XP-endo Finisher File in Removing Calcium Hydroxide from Simulated Internal Resorption Cavity. J Endod. 2017;43:(1)126-130. 33. Mangani F, Ruddle CJ. Endodontic treatment of a “very particular” maxillary central incisor. J Endod. 1994;20(11):560-561.

Volume 14 Number 3

Introducing Endodontic SuperSystems (ESS) Too often large businesses buy and consolidate smaller businesses. The problem with this big-business phenomenon is that it makes starting up a small business increasingly difficult for others. Individuals must now compete with large, organized corporations with ample resources. Meanwhile, these larger companies struggle to maintain quality and are heavily affected by economic shifts. Endodontic SuperSystems (ESS) eases problems that all small business owners face. The next generation of professional support, ESS offers a reproducible system to ease training and recruitment while focusing human resources and optimizing the customer experience. This kind of purposeful transformation is universal to all owners and can spark growth from any starting point. Focus on what you know, endodontic treatments, and easily empower a team that can work by process and take on the day-to-day tasks. For more information, visit Endosupersystems.com, or call 855-294-3671.

BIOLASE and EdgeEndo® announce plans to develop new EdgePRO™ Laser-Assisted Microfluidic Irrigation device BIOLASE, Inc., and EdgeEndo have announced the codevelopment of EdgePRO™ — a next-generation laser-assisted microfluidic irrigation device for endodontists. This device is being developed to offer a solution for endodontists seeking more from their current cleaning and disinfection techniques such as NaOCl, EDTA, chlorhexidine, or 2-in-1 or 3-in-1 irrigation solutions. BIOLASE anticipates submitting a premarket notification — 510(k) to the Food and Drug Administration for the co-developed device in the second quarter of 2021. The device is not currently available for sale in the United States. The EdgePRO Laser-assisted microfluidic irrigation device will build upon BIOLASE’s patented and proven platform, which has been shown to significantly improve debridement, cleaning, and disinfection up to 99%, and removes smear layer and biofilms using the most advanced laser light sound technology with traditional irrigation solutions. For more information, visit at www.biolase.com.

Volume 14 Number 3

Sonendo®, Inc., developer of the GentleWave® System, announced the appointment of Michael Smith as its Chief Commercial Officer. He brings more than 20 years of international experience working across a range of medical device and healthcare technology companies. Prior to joining Sonendo, Smith served as Vice President of Global Product, Marketing and Innovation at Align Technology, manufacturer of the Invisalign® system. In this role, he was responsible for the end-to-end development and commercialization of a range of the company’s new products and programs, in addition to leading its global orthodontic channel. Prior to that role, he was Align’s Director of Sales for Europe, the Middle East, and Africa. For more information about Sonendo, visit www.sonendo.com.

New Elevate™ multi-specialty dental chair ASI’s new Elevate™ dental patient chair provides advanced treatment capabilities. A combination of features allows the patient positioning to be optimized for specialized procedures, including endodontics to implants, while providing full restorative treatment. Smooth-acting swivel features allow side-to-side movement with a 60° range. The traverse movement allows the chair to glide forward and backward. For more information on the dual articulation headrest, backrest, programmable membrane chair control, and more, visit https:// asidental.com/asi-elevate-multi-specialty-dental-chair.

Endo1 Partners adds 34 practices and expands national footprint Endo1 Partners, an Endodontic Partnership Organization (EPO), continues to build on the fiscal success of 2020, with the announcement of an array of new affiliations that will give the company a strong presence across the nation. Since January, Endo1 Partners has expanded into seven new states, adding Connecticut, Georgia, Illinois, New Hampshire, North Carolina, North Dakota, and Wisconsin. The company formed partnerships with 34 new practices and added 42 new specialists to its network from these states. Given this rapid growth during the first and second quarters, Endo1 Partners expects to exceed its goal of adding 50 new locations to its network in 2021. Currently, Endo1 Partners supports more than 70 practices and over 100 specialists in 15 states. For more information, please visit www.endo1partners.com.

Endodontic practice 23

INDUSTRY NEWS

Sonendo® appoints Michael Smith as Chief Commercial Officer

CASE STUDY

Restorative-driven endodontics for more conservative outcomes Dr. Gregori M. Kurtzman combines endodontic and restorative goals to achieve clinical success Introduction Endodontic treatment has trended to more conservative access as well as canal instrumentation to preserve as much tooth structure within the root and, specifically, the cervical region of the tooth, taking on a restorative-driven approach. Treatment outcome, especially long term, is dependent not only on identifying the canals, instrumenting them, and obturating those canals to the apex, but also on restoration of that tooth to allow functional loading over time without structural failure. Those goals — the endodontic and restorative aspects — are not mutually exclusive. With proper planning and treatment, they complement each other in achieving long-term clinical success. Teeth when loaded either by loads along the tooth’s long axis (longitudinal) or off-axis lead to concentration of those loads in the cervical region of the tooth1 (Figure 1). This occurs in teeth with no structural deficiencies (absent of restorative material or caries) or those that have compromised tooth structure in the cervical region of the tooth. Stress distributions in cervical region reported that tensile stress is mainly concentrated on the mesiobuccal

Dr. Gregori M. Kurtzman, DDS, MAGD, FAAIP, FPFA, FACD, FADI, DICOI, DADIA, is in private general dental practice in Silver Spring, Maryland. He is a former Assistant Clinical Professor at University of Maryland in the department of Restorative Dentistry and Endodontics and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. Dr. Kurtzman has lectured internationally on the topics of restorative dentistry, endodontics and implant surgery and prosthetics, removable and fixed prosthetics, and periodontics. Dr. Kurtzman has published over 760 articles globally, several ebooks, and textbook chapters. He has earned Fellowship in the AGD, American College of Dentists (ACD), International Congress of Oral Implantology (ICOI), Pierre Fauchard, ADI, Mastership in the AGD and ICOI and Diplomat status in the ICOI, American Dental Implant Association (ADIA), and International Dental Implant Association (IDIA). Dr. Kurtzman is a consultant and evaluator for multiple dental companies. He has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006 and was featured on their June 2012 cover. Dr. Kurtzman can be reached at jdr_kurtzman@ maryland-implants.com Disclosure: Dr. Kurtzman has received honoraria from SS White for lectures and articles.

24 Endodontic practice

Figures 1 and 2: 1. Finite element analysis when the tooth is loaded under function by either longitudinal or off-axis forces leads to concentration of those forces in the cervical region of the tooth. (Courtesy of Dr. Gene McCoy). 2. Taper comparison of a size 25 file with a 08 taper between the ExactTaperH DC file and competitive files (WaveOne, ProTaper Gold, and ProTaper Next) with relation to how much root structure would be removed in a coronal direction from the apex

aspects of the root and the root furcation in multirooted teeth.2 So preserving coronal dentin, especially in the cervical region utilizing conservative endodontics, significantly reduces the concentration of tensile stress and the potential for structural failure at the cervical aspect of the tooth. But the goals of endodontics still require adherence to achieve clinical success with that portion of treatment on the affected tooth. Those include removal of any remnants of pulpal tissue within the canal system as well as bacteria that may be present in the pulp or dentinal tubules and creating a shape that can then be obturated to seal the canal system from the apex coronally. File taper determines how much dentin is removed, especially in the cervical region of the tooth. Depending on the manufacturer, files will have either a constant or a variable taper. With a constant taper, the file taper is the same as it moves from the files tip toward its shaft. A variable taper file will taper typically in the apical half, and then the remainder of the instrument either does not taper or has a lesser degree of taper. Clinically, what this means is when instrumentation is completed, a greater amount of cervical root dentin will be removed with a constant taper file than with a variable taper file, potentially weakening the cervical tooth structure. When we compare taper between several constant taper files that are commonly used (Wave One®, ProTaper Gold, and ProTaper Next; Dentsply Sirona) and a variable taper

file (ExactTaperH DC™, SS White Dental), we are able to observe that for files with the same apical size, greater amounts of dentin are removed as the cervical is approached (Figure 2). So utilization of a variable taper file aids in conservation of tooth structure and yields when instrumentation is completed. A tooth is stronger cervically due to preservation of more pericervical dentin. When looking at the files in the ExactTaperH DC, a variable taper system, we can see that at different distances from the file’s tip, the taper varies for each of the files in the system (Figure 3). Additionally, variable taper files tend to be less stiff (more flexible) than constant taper files due to the narrower diameter of the file in the middle and coronal aspect of the fluted portion of the files. The ExactTaperH DC also by design has a 33% smaller maximum flute diameter than the constant taper files mentioned. This allows a more passive ability to follow the canal’s curvature without trying to straighten the curved canal as may present with stiffer files, providing “root form appropriate shaping.” One potential drawback to a constant taper file is when a portion of the file engages in the canal wall or its anatomy. A “suck down” effect happens where the file threads itself further into the canal as more of the file flutes engage more canal wall, which can increase the potential for file separation.3,4 This is much less likely with a variable taper file as there is a minimized engagement of the file against the canal wall. Volume 14 Number 3

CASE STUDY

Endodontic phase of treatment Following isolation of the tooth and access of the pulp chamber with identification of the canal orifices, the canals are explored with a file to establish a glide path to the working length (WL) as measured on the radiograph. When the canal is visible to the apex radiographically, the glide path (GP) rotary NiTi file (ExactTaperH DC), which is equivalent to a size 14 file with a .03 taper (Figure 1), is taken to WL to ensure a lack of obstructions is present that may hamper advancement of the subsequent files to be used. If the canal is not clear radiographically, or the GP rotary file does not advance to WL, a No. 6, 8, or 10 hand file is taken to WL and then followed up with the GP file. When the canal orifice presents as narrow or impedes advancement of the GP file or hand files, an orifice opener is useful to allow easier progression with other files. The SX orifice opener rotary NiTi file (ExactTaperH DC) is a size 15 with an .09 taper (Figure 4) and is intended to only be utilized in the coronal and middle one-third of the canal and not taken to WL. Rotary NiTi files should be kept in constant rotational motion before entering the canal and until withdrawn from the canal to aid in prevention of the file binding in the canal. An in-and-out motion is used while brushing the canal walls while the canal system is filled with an appropriate irrigant, which aids in removal of debris within the canal while limiting potential for file binding. Should the file not be able to advance without applying apical pressure, the canal should be recapitulated with the prior used file to WL and then file size progression continued until the final file completes canal instrumentation. Most canals will be completed with an F3 ExactTaperH DC file

Figures 3 and 4: 3. Width of the different ExactTaperH DC files at different distances from the instrument’s apical tip on these variable taper files. 4. File sequence utilizing the ExactTaperH DC files

(Figure 4), which is a size 30 with an .06 taper. Some canals — e.g., maxillary molar palatal canals, mandibular distal canals, maxillary and mandibular canines, and maxillary central incisors — may require a large file instrumentation. The F4 ExactTaperH DC file (Figure 4) with a size 40 and .06 taper is an appropriate final instrument in those canals. Should the canal be wider then the F4, the file is a loose fit. Using the F4 file with a brushing motion along the canal walls will remove any tissue and allow the irrigants to act on the canal walls in preparation for obturation. Utilizing a brushing motion is done on the out-stroke from the canal, as using that on the in-stroke may cause the file tip to bind and separate in the canal. This technique also works well in those canal shapes that are irregular or ribbon shaped in the coronal half of the canal system. Narrow canals may be found in mandibular incisors, maxillary laterals, and premolars with two canals or in older patients where some narrowing of the canals has occurred due to secondary dentin with aging. In that case, final instrumentation can be done with the F2 file (Figure 4), which has a size 25 with a .06 taper.

Instrumentation is just a part of endodontic treatment and is complemented by the obturation phase. Utilization of a single-cone obturation technique, where the gutta-percha cone matches the final file used for instrumentation, allows an intimate fit of the cone with the prepared instrumented canal minimizing the amount of sealer in the canal in comparison to gutta percha.5 With this cold technique, there is no shrinkage of the gutta percha that is found when warm obturation techniques are employed.6,7 When combined with a bioceramic sealer, which when set does not have the potential for dissolution that has been reported with ZOE- and CaOH-based sealers, the result is long-term stable endodontic treatment.8

Case 1 A 76-year-old female patient presented with pain on teeth Nos. 7 (maxillary right lateral incisor) and 11 (maxillary left canine). Clinical exam noted the coronal breakdown of both teeth without any discernable mobility. Radiographs were taken, and it was noted that tooth No. 7 presented with periapical pathology and caries connection with the

Figures 5-8: 5. Tooth No. 7 presented with large portion of the MBLI missing on tooth with pulpal involvement as evidenced by a moderate periapical area. 6. Presentation of tooth No. 11 with caries on the ML and hot sensitivity and pain reported by the patient. 7.Final obturation following instrumentation of tooth No. 7 with ExactTaperH DC files and resolution of the apical area utilizing Vitapex as an intracanal medicament between appointments. 8. Tooth No. 11 following instrumentation with ExactTaperH DC files and obturation with a single-cone GP matching the final file size and Bioceramic Root Canal Sealer Volume 14 Number 3

Endodontic practice 25

CASE STUDY pulp (Figure 5). Tooth 11 did not present with periapical pathology, but pulpal exposure was noted clinically (Figure 6). Endodontic treatment of both teeth was recommended followed by restoration with a fiber post, resin core, and full-coverage crown. The teeth were isolated by rubber dam, and caries removed with burs and hand instruments. The canal was explored with the GP rotary file to WL. This was followed by instrumentation to the F3 ExactTaperH DC file in tooth No. 7 and the F4 ExactTaperH DC file in tooth No. 11. The canals were irrigated by alternating between NaOCl 3% (Vista Apex) and 17% EDTA solution (Vista Apex) during instrumentation and at completion. Due to the periapical pathology, it was decided to fill the canals with a CaOH medicament (Vitapex®, Neo Dental International) to the apex to allow apical healing prior to obturation of the canal systems. The teeth were sealed by placement of GC Fuji® Automix LC (GC America) as a temporary restoration until endodontic completion. The patient returned after 2 weeks indicating all pain and sensitivity that had been present prior to treatment were completely resolved. The teeth were again isolated, and the provisional restorations removed. The canals were instrumented with the final file sizes used at the last visit and irrigated with 17% EDTA solution to remove the CaOH placed at the last appointment and dried with paper points (ExactTaperH DC) matching the size of the final file used. Bioceramic Root Canal Sealer (SS White) was mixed and dispensed on a pad. A gutta-percha cone (ExactTaperH DC) matching the final file size was coated in the sealer, and both canals were obturated in a single-cone technique. The excess cone was cut off at the canal orifice, and isolation was removed to take a final radiograph to document canal obturation (Figures 7 and 8). A temporary restoration was placed into both teeth using the GC Fuji® Automix LC, and the patient was appointed to restore the two teeth.

Case 2 A 37-year-old male new patient presented with the complaint of pain with hot foods and beverages on teeth Nos. 14 (maxillary left first molar) and 15 (maxillary second molar), which had been increasing the past 6 months since he had restorations placed by a prior dentist due to decay. The past treatment occurred before he had relocated to my area. A radiograph was taken, and slight apical widening was noted on both teeth (Figure 9). Both teeth were responsive to testing with 26 Endodontic practice

Figures 9 and 10: 9. Patient presented with complaint of pain on chewing on teeth Nos. 14 and 15 with increasing sensitivity to hot. 10. Instrumentation performed with ExactTaperH DC files and obturation with a single cone of GP and Bioceramic Root Canal Sealer completing endodontic treatment

heat and cold that lingered for a minute or two after the stimulus was removed. Both teeth also tested to slight responsiveness to percussion stimuli. The patient was informed that based on what presented, it was recommended that both teeth were moving toward needing endodontic treatment, or we could adjust the occlusion and see if that helped with symptom improvement. The patient indicated due to the increasing sensitivity to hot foods and beverages, he would prefer to initiate endodontic treatment at this time. The teeth were isolated, and access performed with canal orifice identification. The SX file (ExactTaperH DC) was utilized to enlarge the canal orifice and aid in further file instrumentation. The canals were then instrumented to WL with the GP file. Each canal was instrumented with ExactTaperH DC files starting with the S1, then S2, followed by the F1, F2, and F3 in the mesial-buccal and distal-buccal canals in both molars. The palatal canals in both teeth were competed with the F4 file. The canals were irrigated by alternating between NaOCl 3% (Vista Apex) and 17% EDTA solution (Vista Apex) during instrumentation and at completion. Canals were dried with paper points (ExactTaperH DC) matching the size of the final file used. Bioceramic Root Canal Sealer (SS White) was mixed and dispensed on a pad. A guttapercha cone (ExactTaperH DC) matching the final file size for each canal was coated with sealer, and each canal was obturated in a single-cone technique. The excess cones were cut off at the canal orifice, and obturation was completed (Figure 10). A temporary restoration was placed into both teeth using the GC Fuji® Automix LC, and the patient was appointed to restore the two teeth.

Conclusion Endodontics has transitioned to being more conservative in preserving tooth structure and becoming restoratively driven. Longterm success can be linked to how much natural tooth structure is present following

endodontic treatment in the cervical area of the tooth as under functional loading that is where stress is concentrated. A variable taper NiTi file system such as the ExactTaperH DC provides a flexible file with a minimum number of files to complete instrumentation, so a change in the practitioner’s current technique is not required. The system provides files to allow glide path formation through instrumentation with shaping and completing with finishing, plus an orifice opener when needed. The ExactTaperH DC system is paired with paper points and guttapercha cones that correspond to the files size and taper allowing single-cone obturation to be performed. A single-cone obturation technique allows minimization of sealer in the obturation so sealer-setting shrinkage is minimized, and the single cone matching the size and shape of the final file is able to drive sealer into the adjacent canal anatomy and dentinal tubules within the canal system. When combined with the Bioceramic Root Canal Sealer, a durable seal of the canal system is achieved, and restoration of the tooth yields preservation of necessary tooth structure improving long-term overall treatment success. EP REFERENCES 1. Palamara D, Palamara JE, Tyas MJ, Messer HH. Strain patterns in cervical enamel of teeth subjected to occlusal loading. Dent Mater. 2000;16(6):412-419. 2. Wang Q, Liu Y, Wang Z, et al. Effect of access cavities and canal enlargement on biomechanics of endodontically treated teeth: a finite element analysis. J Endod. 2020;46(10):1501-1507. 3. Agarwal S, Nagpal R, Singh UP. NiTi endodontics: contemporary views reviewed. Austin J Dent. 2018; 5(4):1112. 4. Diemer F, Calas P. Effect of pitch length on the behavior of rotary triple helix root canal instruments. J Endod. 2004;30(10):716-718. 5. El Sayed MA, Taleb AA, Balbahaith MS. Sealing ability of three single-cone obturation systems: An in-vitro glucose leakage study. J Conserv Dent. 2013;16(6):489-493. 6. Gurgel-Filho ED, Feitosa JP, Gomes BP, et al. Assessment of different gutta-percha brands during the filling of simulated lateral canals. Int Endod J. 2006;39(2):113-118. 7. Lottanti S, Tauböck TT, Zehnder M. Shrinkage of backfill gutta-percha upon cooling. J Endod. 2014;40(5):721-714. 8. Hegde V, Arora S. Sealing ability of three hydrophilic single cone obturation systems: An in vitro glucose leakage study. Contemp Clin Dent. 2015;6(Suppl 1):S86-S89.

Volume 14 Number 3

WELCOME TO THE

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CONTINUING EDUCATION

Improving root canal disinfection and endodontic outcomes with irrigants Dr. Eshwar Arasu discusses approaches to activating irrigants for effective endodontic treatment

he chemomechanical preparation of the root canal system represents the most important phase of orthograde endodontic treatment. Reliance strictly on mechanical canal opening and fluid chemistry may be insufficient in achieving successful long-term endodontic outcomes. This article was written to review the clinical value of activating endodontic irrigants and the various technologies available to accomplish that task. Instrumentation of the canal space is intended to create a pathway large enough for the penetration of endodontic irrigants to the apical portion of the root. While hand and rotary files can enable the operator to machine a tunnel that incorporates the main root canal system, mechanical instrumentation alone often fails to address the anatomic complexities of that system. Anastomoses, fins, lateral canals, and apical deltas are common examples of those hardto-reach morphological traits of root canal systems seen in every tooth type. Failure to adequately debride these mechanically inaccessible areas has been shown to result in endodontic failures.1,2 The chemistry of endodontic irrigants facilitates the removal of microbes and inorganic smear layer that contribute to the disease of endodontics — apical periodontitis. Although a number of chemical agents have been studied and deployed for endodontic treatment, sodium hypochlorite (NaOCl) reigns as the most commonly used irrigant for tissue dissolution and microbial Eshwar Arasu, DMD, MSD is a private practice endodontist in Nashville, Tennessee. Dr. Arasu obtained his dental degree from the Harvard of School Dental Medicine and completed his postdoctoral endodontic training through the residency program at Virginia Commonwealth University. He was awarded a Master of Science in Dentistry for his thesis on the volumetric analysis of surgically treated endodontic lesions via cone beam computed tomography. As of 2019, Dr. Arasu is a Diplomate of the American Board of Endodontics (ABE). Disclosure: Dr. Arasu has received compensation from Sonendo® for lecture presentations showcasing the GentleWave®.

28 Endodontic practice

Educational aims and objectives

This self-instructional course for dentists aims to review several available methods for activating irrigants to improve root canal disinfection and endodontic outcomes.

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: •

Recognize the limitations of chemomechanical debridement without activation.

•

Identify the relationship between canal disinfection and endodontic clinical outcomes.

•

Detail the mechanisms of action underlying heat, laser, negative pressure, and acoustic activation of irrigants.

•

Compare relative efficacies of activation techniques in categories of tissue dissolution, biofilm disruption, and smear layer removal.

Figure 1: The main (A) and lateral (B) canals of a maxillary incisory with necrotic pulpal tissue and dense bacterial biofilm1

disinfection. While its tissue dissolution efficiency increases commensurate with concentration and contact time, NaOCl solution delivered passively into the canal system via conventional needle irrigation has been shown to be only moderately effective in disrupting biofilms adherent to radicular dentin.3 As seen in the histologic sections of Figure 1 adapted from a study by Ricucci, et al., these resilient biofilms may be the putative etiology for persistent apical disease. Ethylenediaminetetraacetic acid (EDTA) — a metal-chelating agent — is a common irrigation agent used for removal of the smear layer that serves as a nutritive substrate for intracanal microbes. EDTA also demonstrates

limited efficacy in smear layer removal when introduced to the canal system via needle irrigation exclusively. One scanning electron microscopy study assessing root cleanliness of extracted mandibular molars concluded that conventional needle irrigation inadequately addressed the smear layer in the middle and apical thirds of the root.4 The use of intracanal medicaments such as calcium hydroxide in staged root canal treatment can promote pulpal tissue dissolution and canal disinfection. Even with interappointment medication, investigators have identified residual bacteria in apical ramifications, isthmuses, and dentinal tubules.5 If the operator intends to complete endodontic Volume 14 Number 3

CONTINUING EDUCATION Figure 2: Micro-CT volumetric representations of a complex isthmus system are presented here with instrumented canals before irrigation (A), change in affected volume after PIPS irrigation/ removal of debris (B), and the superimposition of pre- and post-altered canals (C)11

treatment in a single appointment where no unremitting apical drainage is noted, activation of irrigants may be a powerful treatment adjunct capable of facilitating a successful clinical outcome. Broadly, activation of endodontic irrigants is defined by the application of kinetic energy to procedure fluids. The following content will review activation via 1) thermal heating, 2) laser, 3) negative pressure, and 4) acoustic techniques

1. Thermal heating Studies have demonstrated that heating NaOCl solution enables faster pulpal tissue dissolution. Specifically, intracanal hypochlorite warmed to its boiling point via System B™ heat source (Analytic Endodontics) can achieve tissue disintegration approximately 210 times faster than room temperature solution.6

2. Laser The use of the laser in endodontics dates back to the 1970s with studies published since then that have reported on the capacity of lasers to vaporize pulpal tissue and disrupt the smear layer.7 Beyond irradiating dentin, investigators have developed laser-activated irrigation (LAI) for tubular dentin disinfection and smear layer removal. LAI technologies available to clinical operators include, but are Volume 14 Number 3

not limited to, carbon dioxide, mid-infrared erbium (Er:YAG), and neodymium (Nd:YAG) lasers.8,9,10 The bactericidal capability of the laser depends on its wavelength and the resultant thermal effect on disrupting bacterial cell walls. One subset activation technique relies on a Er:YAG laser with subablative energy and short pulses to create intracanal cavitation. In a phenomenon called photoninduced photoacoustic streaming (PIPS), the resultant shockwaves have been shown to disrupt biofilms.3 While most LAI techniques rely on tips advanced in the canal within 5 mm of the apex, PIPS-specific tips are positioned over the orifices and may bypass the need for significant enlarging of the canal spaces with instrumentation. As seen in Figure 2, amended from a study by Lloyd, et al., PIPS permits deep penetration of irrigants into complex pulpal anatomic systems.11

3. Negative pressure Positive pressure irrigation relies on delivery of a syringe tip near the working length (WL) and expression of irrigant toward the root apex before evacuation with a suction tip. While this method is common, conventional needle irrigation inadequately disinfects complex canal anatomy and also may lead to hypochlorite extrusion accidents. Negative pressure irrigation, by contrast, begins with irrigant delivery inside the pulp

chamber and a narrow cannula suction tip advanced to the WL pulls the fluid into the canal. This approach taken by EndoVac™ (Kerr) has been shown in vitro to possibly mitigate irrigant extrusion.12 However, due to lack of standardization of protocols and laboratory models that may not represent in vivo conditions, comparison for efficacy of negative and positive pressure irrigation has not yielded a definitive victor.13 Potential confounders include irrigation volume, delivery time, and fluid flow rates.

4. Acoustic techniques Several clinical technologies acoustically activate endodontic irrigants and do so by operating at select frequencies. Sonic activation (1-8 kHz) has been shown to be capable of removing intraradicular biofilms and debris.14 Moreover, sonic activation of irrigants has been found to yield better disinfection of the canal system relative to manual agitation with endodontic files. Relative to ultrasonic (25-40 kHz) or laser activation, sonic agitation may be less effective in achieving canal disinfection.3 Ultrasonic tips likely facilitate canal debridement via acoustic streaming — the process in which high frequency oscillations lead to mixing of irrigant and shear stresses on radicular dentin walls. One study on comparative safety of intracanal irrigation systems concluded, however, that Endodontic practice 29

CONTINUING EDUCATION

Figures 3A and 3B: Post-op radiographs of cases treated with the GentleWave® with minimal instrumentation and obturation via thermoplasticized gutta-percha injection (Courtesy of Dr. Jonathan Uhles)

sonic agitation via EndoActivator™ (Dentsply) yielded less apical extrusion of irrigant relative to ultrasonic activation.15 Multisonic activation — innovated by the GentleWave® System (Sonendo®) — refers to an acoustic field of broadband frequency that occurs as a result of hydrodynamic cavitation in the pulp chamber. This field of sonic energy travels through the fluid into the root canal system, dissolving pulpal tissue, disrupting microbial biofilms, and stripping the smear layer packed into dentinal tubules.16,17 In the system, multisonic activation is also accompanied by fluid degassing and negative pressure, which allow for irrigant penetration into anatomic complexities without obstructive vapor lock and for minimal apical extrusion risk, respectively.18 The synthesis of these fluid dynamic principles allows for safe endodontic treatment of complex, mechanically inaccessible root canal systems with minimal instrumentation as seen in Figures 3A and 3B.

including host immune response, conservation of tooth structure, and coronal seal. The quality of endodontic therapy is largely in the hands of the clinical provider, and adequate disinfection of the root canal system remains a core tenet for treatment success. Discussed in this article are several technologic adjuncts available to clinicians to optimize this critical disinfection phase of treatment. Methods of irrigation activation should be assessed on the merits of safe tissue, biofilm, and smear layer removal efficacy and efficiency throughout the entire root canal system. EP REFERENCES 1. Ricucci D, Siqueiria J. Fate of the tissue in lateral canals and apical ramifications in response to pathological conditions and treatment procedures. J Endod. 2010;36(1):1-15. 2. Siqueiria J. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J. 2001;34(1):1-10. 3. Ordinola-Zapata R, Bramanta C, Aprecio R, Handysides R, Jaramillo D. Biofilm removal by 6% sodium hypochlorite activated by different irrigations techniques. Int Endod J. 2014;47(7):659-666.

7. Weichman J, Johnson F. Laser use in endodontics. A preliminary investigation. Oral Surg Oral Med Oral Pathol. 1971;31(3)416-420. 8. Takeda F, Harashima T, Kimura Y, Matstumoto K. A comparative study of the removal of smear layer by three endodontic irrigants and two types of laser. Int Endod J. 1999;32(1):32-39. 9. Peeters H, Suardita K. Efficacy of smear layer removal at the root tip by using ethylenediaminetetraacetic acid and erbium, chromium: yttrium, scandium, gallium garnet laser. J Endod. 2011;37(11):1585-1589. 10. George R, Meyers I, Walsh L. Laser activation of endodontic irrigants with improved conical laser fiber tips for removing smear layer in the apical third of the root canal. J Endod. 2008;34(12):1524-1527. 11. Lloyd A, Uhles J, Clement D, Garcia-Godoy F. Elimination of intracanal tissue and debris through a novel laser-activated system assessed using high-resolution micro-computed tomography: a pilot study. J Endod. 2014;40(4):584-587. 12. C Boutsioukis, Psimma Z, van der Sluis LW. Factors affecting irrigant extrusion during root canal irrigation: a systemative review. Int Endod J. 2013;46(7):599-618. 13. Konstantinidi E, Psimma Z, Chávez de Paz E, Boutsioukis C. Apical negative pressure irrigation versus syringe irrigation: a systematic review of cleaning and disinfection of the root canal system. Int Endod J. 2016;50(11):1034-1054. 14. Sabins R, Johnson J, Hellstein J. A comparison of the cleaning efficacy of short-term sonis and ultrasonic passive irrigation after hand instrumentation in molar root canals. J Endod. 2003;29(10):674-678. 15. Desai P, Himel V. Comparative Safety of Various Intracanal Irrigations Systems. J Endod. 2009;35(4):545-549.

4. Caron G, Nham K, Bronnec F, Machtou P. Effectiveness of different final irrigant activation protocols on smear layer removal in curved canals. J Endod. 2010;36(8):1361-1366.

16. Haapasalo M, Wang Z, Shen Y, et al. Tissue dissolution by a novel multisonic ultracleaning system and sodium hypochlorite. J Endod. 2014;40(8):1178-1181.

Conclusion

5. Vera J, Siqueira J, Ricucci D, Loghin S, Fernández N, Flores B, Cruz A. One- versus two-visit endodontic treatment of teeth with apical periodontitis: a histobacteriologic study. J Endod. 2012;38(8):1040-1052.

17. Choi H, Park S, Kang M, Shon W. Comparative analysis of biofilm removal efficacy by multisonic ultracleaning system and passive ultrasonic activation. Materials. 2019;12:3492.

Long-term clinical success in endodontic treatment relies on several important variables,

6. Woodmansey K. Intracanal heating of sodium hypochlorite solution: an improved endodontic irrigation technique. Dent Today. 2005;24(10):114-116.

30 Endodontic practice

18. Charara K, Friedman S, Sherman A, et al. Assessment of apical extrusion during root canal procedure with the novel GentleWave System in a simulated apical environment. J Endod. 2016;42(1):135-139.

Volume 14 Number 3

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit https://endopracticeus.com/subscribe/ to subscribe today.

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.

n To receive credit: Go online to https://iendopracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 070 Date Published: September 3, 2021 Expiration Date: September 3, 2024

Improving root canal disinfection and endodontic outcomes with irrigants ARASU

1. Although a number of chemical agents have been studied and deployed for endodontic treatment, _______ reigns as the most commonly used irrigant for tissue dissolution and microbial disinfection. a. sodium hypochlorite (NaOCl) b. ethylenediaminetetraacetic acid (EDTA) c. calcium hydroxide [Ca(OH)2] d. YAG laser 2. One scanning electron microscopy study assessing root cleanliness of extracted mandibular molars concluded that conventional needle irrigation _______ the smear layer in the middle and apical thirds of the root. a. adequately addressed b. inadequately addressed c. should be the only choice for addressing d. destroyed 3. The use of intracanal medicaments such as calcium hydroxide in staged root canal treatment can promote ________. a. pulpal tissue dissolution b. canal disinfection c. biofilm d. both a and b 4. Even with inter-appointment medication,

Volume 14 Number 3

investigators have identified residual bacteria in _______. a. apical ramifications b. isthmuses c. dentinal tubules d. all of the above 5. Studies have demonstrated that heating NaOCl solution ________ pulpal tissue dissolution. a. has no effect on b. slows c. enables faster d. is detrimental to 6. In a phenomenon called ________, the resultant shock waves have been shown to disrupt biofilms. a. photon-induced photoacoustic streaming (PIPS) b. negative pressure irrigation c. positive pressure irrigation d. acoustic activation 7. While most laser-activated irrigation (LAI) techniques rely on tips advanced in the canal within ______ of the apex, PIPS-specific tips are positioned over the orifices and may bypass the need for significant enlarging of the canal spaces with instrumentation. a. 5 mm

b. 6 mm c. 7 mm d. 8 mm 8. ________ relies on delivery of a syringe tip near the working length (WL) and expression of irrigant toward the root apex before evacuation with a suction tip. a. Negative pressure irrigation b. Positive pressure irrigation c. Thermal heating d. Photon-induced photoacoustic streaming 9. ________ begins with irrigant delivery inside the pulp chamber, and a narrow cannula suction tip advanced to the WL pulls the fluid into the canal. a. Vapor lock b. Positive pressure irrigation c. Negative pressure irrigation d. Laser-activated irrigation 10. Multisonic energy travels through the fluid into the root canal system, dissolving pulpal tissue, ________ microbial biofilms, and stripping the smear layer packed into dentinal tubules. a. creating b. disrupting c. enlarging d. activating

Endodontic practice 31

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Endodontic treatment of the immature permanent necrotic teeth with open apices Drs. Tony Tataro and Mohammad Sabeti discuss and illustrate an alternative treatment Introduction The Hertwig epithelial root sheath (HERS) and the apical papilla interact epithelially and mesenchymally to mediate the root formation process.1 As stem cells move and develop into odontoblasts and fibroblasts, the pulpdentin complex is generated at the expense of the apical papilla, lowering the apical papilla size as the root matures. Unfortunate events such as trauma and infection can impede this sophisticated growth process and interfere with normal root development, resulting in insufficient root apex formation.2,3 Traditional root canal treatment is not a good option in these situations since dentin formation ceases when pulp vitality is lost, resulting in a tooth with open apices and thin dentin walls that is prone to fracture. An apical plug has typically been used to treat immature permanent necrotic teeth with open apices.4,5 This technique involves either the application of long-term calcium hydroxide or immediate placement of a mineral trioxide aggregate (MTA) plug. Despite the ability to provide a seal and allow obturation, these techniques do not result in increased root length or width development.6 An alternative treatment option for immature permanent teeth with open apices is regenerative endodontic therapy (RET). Dr. Nygaard-Ostby’s study paved the way for regenerative endodontics.7 He speculated that a blood clot could be the first stage in the healing of a damaged dental pulp, comparable to the role of blood clots in other healing processes (e.g., alveolar bone recovery after extractions).7 This strategy is based on the idea that induction of a blood clot will stimulate the pulpal stem cell to regenerate the pulp-dentin complex and enhance Tony Tataro, DDS, is an Endodontic Resident, Department of Preventive and Restorative Dental Science, Division of Endodontics, School of Dentistry at the University of California San Francisco, California. Mohammad Sabeti, DDS, MA, is a HS Clinical Professor, Department of Preventive and Restorative Dental Science, Division of Endodontics, School of Dentistry at the University of California San Francisco, California.

32 Endodontic practice

Educational aims and objectives

This self-instructional course for dentists aims to show information regarding endodontic treatment of the immature permanent necrotic teeth with open apices.

Expected outcomes

Realize why traditional root canal treatment may not be possible because of trauma or infection.

•

Realize some background of regenerative endodontic therapy (RET).

•

Identify some disadvantages of calcium hydroxide apexification.

•

Identify some advantages of MTA apexification.

•

Identify some disadvantages of MTA and bioceramic apexification.

•

Realize some science related to platelet-rich fibrin (PRF).

•

Observe a case report reflecting this technique.

the development and maturation of the root.8 The goal of this treatment alternative is not only to result in healing of any apical lesions, but also to gain root dentin thickness and restore the pulp dentin complex.

Apexification Calcium hydroxide apexification Apexification has traditionally been done with calcium hydroxide. This is a complex operation that takes from 5 to 20 months to complete and requires several appointments.3 The tooth is temporarily restored during this time and is vulnerable to fracture. In addition, after being exposed to calcium hydroxide for 5 weeks or longer, multiple in vitro investigations found that the mechanical characteristics of radicular dentin may be reduced.9 Disadvantages of calcium hydroxide apexification 1. The time required for formation of the calcified barrier (3 to 24 months). 2. Multiple appointments needed for reapplication of calcium hydroxide. 3. The effect of long-term (several months or more) calcium hydroxide on the mechanical properties of dentin, including increase risk of root fracture.10 4. Formation of a “swiss-cheese-like” apical barrier (which involves soft

tissue inclusions inside the hard tissue) that can lead to poorer seal. MTA apexification MTA (mineral trioxide aggregate) was first introduced in 1993 and has been widely researched since then. It is a great alternative to calcium hydroxide as an apical barrier in immature, nonvital teeth. MTA is a bioactive material that has great biocompatibility, sealing capabilities, and antibacterial characteristics.11,12 Advantages of MTA apexification 1. Consistent, more predictable apical barrier formation13 2. Fewer appointments to complete the treatment 3. Reduced follow-up appointments 4. Higher success rate (95%)14 MTA and bioceramic apexification disadvantages MTA has some drawbacks, including a long setting time, high cost, difficult handling properties, and dentin discoloration.11,12 Other bioactive materials that can be employed as apical barriers have been developed. These bioceramics include EndoSequence® Root Repair Material (ERRM) putty (Brasseler) and Biodentine® (Septanest® N, Septodont). The majority of articles describe beneficial features similar to MTA such as biocompatibility, bioactivity, Volume 14 Number 3

limited microleakage, and a low toxicity.15,16 In addition to these features, some added benefits have been described for these new bioceramics, including improved clinical handling capabilities and no staining.

MTA plug and extraradicular matrix Biological consequences The use of an extraradicular matrix for the treatment of immature teeth with open apices is justified by a number of challenges encountered in these cases. First, the canal is generally broader apically than coronally and thus a filling method, including softened filling material, is necessary, so it can mold and adapt to the shape of the apical part of the canal. There is no barrier to prevent this softened material from extruding from the apex leading to possible inflammatory reactions. Furthermore, the lack of an apical stop due to material extrusion rather than plug formation may result in an unsealed canal that is vulnerable to leakage.17 Another challenge is that these immature teeth have thin radicular dentin and are more prone to fracture during treatment. These issues are addressed by promoting the creation of a hard-tissue barrier to allow for efficient canal filling and by strengthening the weaker root against fracture during and after apexification.16,18,19 In addition, platelet-rich fibrin (PRF) releases the chemical and cellular components required for healing. The use of a biocompatible matrix is said to give the delivery of the apical plug better control. Several matrix materials such as demineralized freeze-dried bone, collagen sponges, calcium sulfate, and PRF have been suggested. The science of platelet-rich fibrin (PRF) A popular extracellular matrix material is PRF. Many of the chemical and cellular Volume 14 Number 3

components required for healing are found in whole blood. The main components of whole blood include plasma and three main types of cells: red blood cells, white blood cells, and platelets. Platelets recruit leukocytes and play an important role in innate immunity. These activities aid in tissue regeneration and repair. Technique A 10 mL sterile glass tube with no additives is used to draw venous blood. The blood should be centrifuged as soon as possible at 2700 rpm for 12 minutes. The blood will separate into three layers: red blood cells on the bottom, platelet-poor plasma (PPP) on top, and PRF fibrin clot in the middle (Figure 1). This high-density fibrin clot acts as a biological matrix, allowing cells to migrate and produce cytokines. PRF leukocytes operate as anti-inflammatory agents and play an important part in immunological control.20 The PRF clot can be compressed into a membrane and utilized whole, or it can be split into smaller pieces and used separately (Figure 2).

Clinical technique of using PRF as an apical barrier An apical plug can be used as a barrier outside the root, and the whole root is filled with MTA or any bioceramic materials (Figure 3). First appointment 1. Review the patient medical history and dental data and baseline radiographs. 2. Obtain anesthesia, and place rubber dam to isolate the tooth. 3. Once the tooth is accessible, determine working length.

Figure 3: PRF at and beyond the apex, MTA in the middle, and composite on top

4. After access, clean and shape the canal. 5. Irrigate the root canal system first with 1.5 NaOCl (20 ml/canal for 5 min) and then irrigate with saline.21 6. Slowly inject calcium hydroxide into the canal space to the working length. 7. Place the microsponges and temporary restoration consisting GC Fuji TRIAGE® in the access. Second appointment after 4 weeks Perform clinical exam to ensure that there are no signs or symptoms (moderateto-severe pain, pain on percussion, palpation, sinus tract, or swelling). If the patient presents with any symptoms or signs, repeat first appointment treatment.22 If not, proceed with the following steps: 1. Determine tooth shade by using the vita classical A1-D4 shade guide. 2. Obtain anesthesia with 2% lidocaine with 1:100,000 epinephrine. 3. Place rubber dam to isolate the tooth. 4. Re-access and remove the calcium hydroxide with 17% EDTA (20 ml/ canal for 5 min). 5. Perform a final flush with saline, and dry the canal with sterile paper points. 6. Draw blood using a 10-ml vacutainer without any additives and perform the following steps: a. Centrifuge at 2700 rpm for 12 minutes. The blood will separate into platelet-poor plasma, a PRF fibrin clot, and RBCs. b. Separate the fibrin clot by pulling in with tweezers and cut as necessary. c. Use a PRF box to compress the PRF clot. Endodontic practice 33

CONTINUING EDUCATION

Figures 1 and 2: 1. The blood separated into three layers: red blood cells on the bottom, platelet-poor plasma (PPP) on top, and PRF fibrin clot in the middle. 2. A fibrin clot is placed on a sterile instrument

CONTINUING EDUCATION 7. Cut the compressed PRF membrane to size, and insert into the root canal to the apex of the tooth. 8. Place multiple pieces until a firm apical barrier is formed.

9. Fill the canal with the MTA to the cementoenamel junction or 3 mm -5 mm from the radiographic apex, and obturate with gutta percha to the cementoenamel junction (CEJ).

Figure 4: Preoperative radiographs indicate decay on the distal surface of tooth No. 15

cold

EPT

>80

percussion

palpation

323-333

333-433

323-333

333-334

Figure 5: Clinical tests indicate tooth No. 15 had a necrotic pulp with symptomatic apical periodontitis

10. Place the composite restoration over the MTA.

Case report A 43-year-old female was referred from the predoctoral clinic. Her medical history was noncontributory. She said her chief complaint was “I had severe pain on upper left side,” pointing at tooth No. 15. Clinical and radiographical examination reveal that tooth No. 15 is necrotic with symptomatic apical periodontitis and has decay on the distal surface (Figures 4 and 5). Cone beam computed tomography indicates that tooth No. 15 has a periapical radiolucency and a mesiobuccal (MB) canal that is joining the palatal canal (Figure 6). After

Figure 6: CBCT shows an open apex on the palatal root and the MB canal joining the palatal canal

First appointment

Second appointment

Figure 7: Palatal and mesial canals were found and negotiated. Palatal apical size was 100. MB canal was cleaned and shaped to 35/.04 to the working length of 19.5 mm

Figure 8: MB canal obturated prior to MTA plug placement in the palatal canal

MTA plug

Figure 9: MTA plug was applied and packed 34 Endodontic practice

Figure 10: Final radiograph Volume 14 Number 3

Conclusion Necrotic immature permanent teeth can be managed by using an MTA apical plug. An MTA apical plug encourages the formation of a calcified barrier at the end of a root canal, which facilitates the vertical condensation of warm gutta percha. An MTA plug is effective and biocompatible, has great sealing ability, and can be performed in one single visit. EP REFERENCES 1. Xu L, Tang L, Jin F, Liu X-H, et al. The apical region of developing tooth root constitutes a complex and maintains the ability to generate root and periodontium-like tissues. J Periodontal Res. 2009;44(2):275-282. 2. Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta-percha. A retrospective clinical study. Endod Dent Traumatol.

1992;8(2):45-55. 3. Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: a review. Br Dent J. 1997;183(7):241-246. 4. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod. 2008;34(10):1171-1176. 5. Cvek M. Treatment of non-vital permanent incisors with calcium hydroxide. IV. Periodontal healing and closure of the root canal in the coronal fragment of teeth with intra-alveolar fracture and vital apical fragment. A follow-up. Odontol Revy. 1974;25(3):239-246. 6. Bose R, Nummikoski P, Hargreaves K. A retrospective evaluation of radiographic outcomes in immature teeth with necrotic root canal systems treated with regenerative endodontic procedures. J Endod. 2009;35(10):1343-1349. 7. Nygaard-Ostby B. The role of the blood clot in endodontic therapy. An experimental histologic study. Acta Odontol Scand. 1961;19:324-353. 8. Musson DS, McLachlan JL, Sloan AJ, Smith AJ, Cooper PR. Adrenomedullin is expressed during rodent dental tissue development and promotes cell growth and mineralization. Biol Cell. 2010;102(3):145-157. 9. Yassen GH, Platt JA. The effect of nonsetting calcium hydroxide on root fracture and mechanical properties of radicular dentine: a systematic review. Int Endod J. 2013;46(2):112-118. 10. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol. 2002;18(3):134-137. 11. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review--Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413. 12. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a

comprehensive literature review--Part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27. 13. Shabahang S, Torabinejad M, Boyne PP, Abedi H, McMillan P. A comparative study of root-end induction using osteogenic protein-1, calcium hydroxide, and mineral trioxide aggregate in dogs. J Endod. 1999;25(1):1-5. 14. Sarris S, Tahmassebi JF, Duggal MS, Cross IA. A clinical evaluation of mineral trioxide aggregate for root-end closure of non-vital immature permanent incisors in children-a pilot study. Dent Traumatol. 2008;24(1):79-85. 15. Ma J, Shen Y, Stojicic S, Haapasalo M. Biocompatibility of two novel root repair materials. J Endod. 2011;37(6):793-798. 16. Leal F, De-Deus G, Brandão C, Luna A, Souza E, Fidel S. Similar sealability between bioceramic putty readyto-use repair cement and white MTA. Braz Dent J. 2013;24(4):362-366. 17. Kerekes K, Heide S, Jacobsen I. Follow-up examination of endodontic treatment in traumatized juvenile incisors. J Endod. 1980;6(9):744-748. 18. Alhadainy HA, Abdalla AI. Artificial floor technique used for the repair of furcation perforations: a microleakage study. J Endod. 1998;24(1):33-35. 19. Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial leakage of mineral trioxide aggregate as a root-end filling material. J Endod. 1995;21(3):109-112. 20. Tsay RC, Vo J, Burke A, Eisig SB, Lu HH, Landesberg R. Differential growth factor retention by platelet-rich plasma composites. J Oral Maxillofac Surg. 2005;63(4):521-528. 21. Cvek M, Nord CE, Hollender L. Antimicrobial effect of root canal débridement in teeth with immature root. A clinical and microbiologic study. Odontol Revy. 1976;27(1):1-10. 22. Sjögren U, Figdor D, Spångberg L, Sundqvist G. The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. Int Endod J. 1991;24(3):119-125.

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(262) 501-0075 Endodontic practice 35

CONTINUING EDUCATION

cleaning and shaping of the canals, the MB was obturated with gutta percha (Figure 7). The palatal canal had an open apex, and thus it was decided to use MTA to create an apical plug. The remainder of the canal was obturated with gutta percha (Figure 10).

Endodontic treatment of the immature permanent necrotic teeth with open apices TATARO/SABETI

1. Apexification is a complex operation that takes from ________ to complete and requires several appointments. a. 1 to 2 months b. 3 to 4 months c. 5 to 20 months d. 22 to 24 months 2. After being exposed to calcium hydroxide for _______ or longer, multiple in vitro investigations found that the mechanical characteristics of radicular dentin may be reduced. a. 1 week b. 5 weeks c. 7 weeks d. 8 weeks 3. ________ was first introduced in 1993 and has been widely researched since then. a. MTA (mineral trioxide aggregate) b. Calcium hydroxide c. Extracellular matrix material d. Lidocaine 4. The success rate of MTA apexification is ______. a. 56%

36 Endodontic practice

b. 75% c. 82% d. 95% 5. _______ has some drawbacks, including a long setting time, high cost, difficult handling properties, and dentin discoloration. a. MTA b. PRF c. Calcium hydroxide d. Sodium hydroxide 6. _______ releases the chemical and cellular components required for healing. a. MTA b. Platelet rich fibrin (PRF) c. Hertwig root sheath d. Calcium hydroxide 7. For PRF, the blood should be centrifuged as soon as possible at 2700 rpm for ______. a. 3 minutes b. 6 minutes c. 12 minutes d. 30 minutes 8. The blood will separate into three

layers: __________. a. platelet-poor plasma (PPP) on the bottom, red blood cells on top, and PRF fibrin clot in the middle b. red blood cells on the bottom, plateletpoor plasma (PPP) on top, and PRF fibrin clot in the middle c. PRF fibrin clot on the bottom, red blood cells on the top, platelet poor plasma (PPP) in the middle d. red blood cells on the bottom, PRF fibrin clot on the top, platelet poor plasma (PPP in the middle) 9. PRF leukocytes ________. a. operate as anti-inflammatory agents b. play an important part in immunological control c. create a hard-tissue barrier d. both a and b 10. The PRF clot can be ________. a. compressed into a membrane and utilized whole b. split into smaller pieces and used separately c. centrifuged a few days after being drawn d. both a and b

Volume 14 Number 3

CE CREDITS

ENDODONTIC PRACTICE CE

Dr. John West explores “The Set Up” Preparation When endodontics fails, it often fails before it even begins. In endodontics, technique isn’t everything. Your endodontic preparation (I call it “The Set Up”) is just as important as technique for becoming a highly skilled endodontic clinician and optimizing your endodontic predictability. The Set Up is, in fact, the start for the successful endodontic thought process of being prepared for that which you are not prepared. In being prepared, there are two distinct areas that require unique skills. Introducing a different terminology, I will call them simply the “Think Box” and the “Play Box.” The intent of this article is to explore the basics of the Think Box (internal and mental) and the Play Box (external and physical). The purpose of the proper Set Up is that it is a prerequisite for enriched endodontic predictability and possibility. In today’s dominant new technology narrative, the endodontic buzzwords have gotten off track. What really matters in creating exceptional endodontic outcomes are “The Fundamentals.”1-3

The context is decisive The context of today’s endodontic chronicles, education, and marketing is too often focused on a product’s features and benefits being the answer to better endodontic predictability rather than the basics of training and replicating the process of biologic, structural, and esthetic endodontic success. Two often overlooked ingredients for increasing the probability of predictably for successful endodontic outcomes are (1) precisely and intentionally planning for endodontic restorability and (2) starting with the answer. Endodontic success probabilities and tooth retention have the possibility to approach 100%. While success reports may have varied over the past 60 years within a range of 60% to 98%, the rationale and capacity for endodontic success remains at 100%. The rationale of and for predictably successful endodontics has always been that any endodontically diseased tooth can be predictably treated if the root canal system is eliminated (shaped, cleaned, and filled), the periodontal condition is healthy or Volume 14 Number 3

can be made so, and the tooth is restorable. But everyone knows the real percentage of endodontic success is not 100%. It is 100% minus some number. Let’s call that number X. So, 100 − X. What is the X factor? I have identified 3 X factors: (1) The clinician’s knowledge of what to do, (2) the clinician’s ability to do what is required, and (3) The clinician’s willingness to do so. Anything can work some of the time. In fact, that same thing might work more often than not. Endodontic predictability mandates something different. What is available to you, the dentist reading this, is for you to transform the expectations and experience of your endodontics. My personal Why for writing this article is to ultimately challenge the reader’s status quo, regardless of how presently predictable you may be with endodontic procedures. “If we keep doing the same thing over and over again expecting different results, we become insane” (Rita Mae Brown). Who wants to be an insane endodontic clinician? The key takeaway from the heart of this article is for each of us not only to improve our endodontic predictabilities, but also to identify how we want to experience ourselves before treatment, during treatment, and as we reflect back after the treatment. For most of us, the words and phrases used to describe our preferred experiences might include these examples: competent, masterful, in control, I can handle this; I am handling this; I got this; I am agile; I am resilient. You might even ask the ultimate critical question: Would I refer myself to me if I needed endo? Think about that for a second. I suggest you write down your own lists of “How I Want to Experience Myself Doing Endo” and “How Do I Want My Patients to Experience Me When I Am Doing Endo?” This little exercise can be vastly revealing. It may sound trite, but honestly, I feel I have done this exercise many times and discovered I have never really worked a day in my life. Our office is a playground. It is this way of thinking and being that is an essential, yet often missed, critical piece of the Think Box. When you think about any successful organization or domain such as endodontic predictability, four essential features are

Figure 1: A Think Box 3" x 5" cue card taped to the monitor is a reminder statement of the intentional result that I desire with this maxillary right second molar. Deliberately take 10 seconds to see, feel, and think (SFT) (i.e., visualize in your mind’s eye) the radiographic outcome

always present: (1) vision (intended outcome), (2) structure (a plan to get there), (3) by when (deadline), and (4) measurable milestones along the roadmap (accountability). Endodontic predictability has the same four distinctions, and The Set Up sets this up. Beginning to follow our roadmap is the context for the next successful step. Context is decisive!

The Think Box The Think Box is our brain, and this is the first essential part of The Set Up. The brain is made up of approximately 100 billion neurons. These nerve cells transmit electrochemical signals in what can be thought of like the gates and wires of a computer. The trick to mastering exceptional endodontic predictability is to harness our neurons to engender the endodontic experience and get the results that we want. The Olympic Gold Medal Mind is a perfect example. The gold medal is always on the Olympian’s mind. For example, when a female swimmer sets her sights on the Olympic gold medal, she visualizes herself on the Olympic podium receiving the gold John West, DDS, MSD, received his DDS degree from the University of Washington, where he is an affiliate professor. He is the founder and director of the Center for Endodontics in Tacoma, Washington and a clinical instructor at Boston University, where he earned his MSD degree and was honored with the Distinguished Alumni Award. Dr. West and his two sons, Drs. Jason and Jordan West, are in private endodontic practice in Tacoma. He can be reached via email at johnwest@centerforendodontics.com.

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Endodontic predictability

ENDODONTIC PERSPECTIVE

Figures 2A and 2B: Learning the 3D anatomy with 2D images. 2A. Bitewing and perpendicular views of a mandibular molar. The bitewing shows an obvious chamber that’s easy to locate. 2B. A perpendicular image implies the dimensions, sizes, and shapes of the canals. The mesial view reveals two mesial canals and one wide distal canal. The distal horizontal view confirms two mesial canals and one distal canal

medal around her neck with her country’s flag being raised, her anthem playing and tears of joy, and accomplishment streaming down her face. A little dramatic for endodontics? Well, let’s look a little deeper into this intentional imagery process and how it affects endodontic predictability. We all already do subconscious imagery in everything we do, whether we know it or not. It is the automatic pilot — the autonomic system working as its best. The trick is learning to recognize the made-up stories in our minds about the endodontic patient cases in front of us (bringing them into our consciousness) and then intentionally seeing the stories or outcomes that we want in our minds. Presto — magic! The outcomes we want and see become real. When this happens, we have applied our minds to produce intended outcomes. Now all we have to do is practice this until the practice itself, e.g., for the Olympic gold medalist, becomes second nature. Keep in mind that the vast majority of people have no idea that they are creating memories of the future (and their future goals) all the time. The trick is to intentionally fashion or guide the future desired memory into the present time. How do we do this using the concept of endodontic predictability as a perfect starting point? It’s time to take action! Once you decide that improving your endodontic predictability truly matters to you, you, like everyone else, will have your own penchants to unlearn. How can we remember to remember to nurture our newfound skills in order to immediately implement them in our practice of endodontics? The trick! Too often, dentists sabotage their intended successes by failure to take a few moments before, and frequently during treatment, to intentionally see, feel, and think (SFT) the desired endodontic outcomes: vividly seeing themselves overcoming what may first be perceived as obstacles, challenges, or temporary setbacks and instead producing perfect results with absolute imperturbability — feeling the desired outcomes in their guts and then thinking, “I am enough. I am 38 Endodontic practice

able” (briandesroches.com). Sometimes endodontic mistakes occur because the mental set up in The Think Box — namely, the pretreatment imaging of the posttreatment result — is insufficient or has not been practiced enough or at all (Figure 1). In order to understand the role of the brain in producing replicable endodontic predictability, a brief review about understanding how the brain works can be the difference that makes the difference.

Three essential brain facts 1. Hebb’s axiom “Neurons that fire together, wire together.”4 This clever phrase was first used in 1949 by Donald Hebb, a Canadian neuropsychologist known for his work in the field of associative learning. When a group of nerve cells are stimulated (fire together), a potential “neural network” of information and energy is formed (wired together). Firings happen with an emotion as the catalyst. Hebb’s axiom reminds us that every experience, thought, feeling, and physical sensation triggers millions of neurons, which form a neural network. When you repeat an experience over and over, the brain learns to trigger the same neurons each time: endodontic predictability. 2. Attention density Neural networks are created when nerve cells are fired enough for them to “wire” together. “Enough” is a function of focus, frequency, and intensity. Attention density is concerned with thoughts and emotions that accompany any action or intended result. If my thoughts about outcomes are embedded in a positive or negative state, and if I keep focusing on those thoughts and/or emotions, I will create a dense neural network with positive or negative contents (i.e., a memory). Along with love, this is perhaps our most powerful gift as humans: choice. Neuroscience and quantum physics research tell us if you focus long enough, hard enough, and often enough, you can change your neural pathways and brain circuitry to rewire your

brain. Attention density is how we make learning stick: endodontic predictability. 3. Neuroplasticity The brain can change, and we are the actual changers.5,6 You can change your brain by changing what you are focusing on. By managing my focus and using my mind to direct my focus on the outcomes and experiences I want, I can change my brain and strengthen the wiring of the SFT networks: the desired memories of the future brought into the present time, the now: endodontic predictability.

The endodontic practice-changing magic of SFT How does the endodontic clinician apply the above three basic brain facts, as mysterious and complicated as they are, to produce purposeful endodontic outcomes? The secret is SFT. The “see” part of SFT is the external-outcome component that is embedded within the neural network. The content of the SFT way of creating new neural networks are that it first enables us to first see what the root canal system is through multiview radiographs and ask: Is there a chamber? Where are the canals? How many canals are there? What are their sizes and shapes? Take a 3D CBCT scan to better see the anatomy, and/or take a bitewing and perpendicular, mesial, and distal periapical images (Figure 2). SFT is not hope, visualization, affirmation, positive thinking, kumbaya, or an endodontic cult. It is seeing (visualizing) the desired endodontic outcome as the point of focus or the North Star principles that guide you during the procedure. The “see” and “feel” have been wired into us since the beginning evolution of the survival of the fittest. Changing our neural networks does not happen overnight. Change requires attention density. The SFT skill has been used since our birth, and the good news is that we can harness this skill to produce our desired endodontic future now — right now — when treating your patient’s endodontic root canal system! Volume 14 Number 3

Figures 3A-3C: How the Think Box gets us into the game of endodontic mastery. 3A. A pretreatment image of the maxillary right second premolar with an S-curved root canal system configuration and imagining easily following the No. 10 manual file to length.8-10 3B. I imagined my desired S-shape finished. Sometimes I make some prints and practice drawing my maxillary-appropriate shape several times on the print itself. The imagined conefit is to the right. 3C. The imagined conefit and actual conefit side by side

The “feel” part of SFT is how I am experiencing myself doing the procedure and that I am “seeing” what I want in the theater of my mind: my mind’s eye; for example, “I am present, focused, and confident during my endo procedures, and I trust my skills and experience.” Hold this feeling for 10 seconds to fire and wire your new neurons. Do this every chance you get. The SFT practice will fire and wire your neurons to create the network of endodontic predictability. The principle of attention density reminds us that the more frequently we focus on the desired neural network for 10 seconds at a time, the stronger and more sustainable the wiring becomes.

Figures 4A-4M: 4A. An index card, stating “I make conefits to length.” 4B. The pretreatment periapical radiograph on the left and desired prep designs on the right. 4C. From left to right: the imagined palatal conefit, DB conefit, and MB conefit. 4D. On the left, all imagined conefits. On the right, the actual conefits. 4E. An index card reminder: “I make 3D obturations.” 4F. A pretreatment periapical radiograph of the maxillary right canine on the left; the sketched, desired canal preparation shape in the middle; and the imaginary conefit on the right. 4G. The actual conefit on the left, imagined downpack in the middle, and actual downpack on the right. Note that I did not imagine the void in the resorptive area of my actual downpack, nor were the exact locations of the obturated lateral portals of exit anticipated. 4H. The left image of the solid resorptive pack and the right image demonstrate the actual backpack finished with original resorptive void corrected. My index card roadmap was finally successful. 4I. On the left is a periapical radiograph of packed retreatment with several voids. On the right is the corrected void and final radiograph. 4J-4M. In order to correct this new, nagging void issue, I wrote on a new 3" x 5" memory card, “I make solid backpacks,” and pledged to correct this new error. I placed my remember-to-remember 3" x 5" cards in prominent places, so I could SFT my desired solid radiographic pack clinical treatment outcomes. It did not take too long, and this little temporary setback had vanished Volume 14 Number 3

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ENDODONTIC PERSPECTIVE

ENDODONTIC PERSPECTIVE The “think” part of SFT is the moment of realization when we give ourselves permission to believe that we are enough, even more than enough, to do the job. To think finds its origin from the Old English, referring to “causing to appear to one’s self; to conceive in the mind.” We are worthy of the endodontic accomplishment before us. Endodontic predictability is a state of mind. It is a state of thinking. It is a state of being. And we can evoke it on demand (Figure 3).

Application to an endodontic procedure Here’s my 3” x 5” index card trick. Back to how do we “remember to remember?” It is so easy to go out of the moment and listen instead to that constant voice in one’s head that is all about the past or future. This is the practiced skill difference that makes the difference. The index cards are placed in prominent locations where they cannot be avoided before, during, or after the endodontic treatment. The best way to train our neurons for what we want is to write what we want — for example, “I make conefits to length”— on an index card (Figure 4). While the external conditions of the endodontic challenge will vary from patient to patient, creating endodontic predictability through exceptional endodontic outcomes is the same. This is the SFT Gold Medal Mind. This “thinking” invites us to think differently: for example, “There are no problems in endodontics, only situations requiring smart thinking.”

simple rubber dam placement, clamp choice, and bur selection. Rubber dam clamps: You only need two: 2A for posterior teeth and 9A for anterior teeth. They should be almost universal, but they are not (Figure 5)! Rubber dam: The name of the game with the rubber dam is security! The rubber dam should be punched so that the tooth punch hole is in near the center of the rubber dam, allowing equal access from all angles. The rubber dam prevents the unintended

swallowing of an instrument, such as a manual file. The rubber dam also thoroughly seals the tooth from saliva leaking into the access and root canal system irrigants from leaking under the rubber dam and into the mouth. Rubber dam quality seems almost too basic to write about, but if proper attention is not given here, then our 1, 2, 3 Play Box checklist for endodontic predictability is already in jeopardy (Figure 6). Burs: Everyone has a favorite bur. In my practice, I have identified nine of my favorite

Figure 5: The Play Box setup (rubber dam, frame, and clamp)

The Play Box The Play Box is the physical component of The Set Up that is often overlooked or underperformed. In short, the three parts of the Play Box are (1) a rubber dam, (2) rubber dam clamps, and (3) an access bur selection. The importance of this 1, 2, 3 checklist can be underestimated. While every dentist reading this article has a different operatory design and infrastructure delivery system, there should be a consistent protocol for

Figures 6A-6G: The dos and don’ts of rubber dam placement. 6A. Pre-floss mesial and distal to the treatment tooth to be sure floss slides through easily and that there are no snakes or shape edges that could compromise the quality of the rubber dam seal. 6B. Punch a hole near the center of the rubber dam and slightly in the direction of the tooth (e.g., upper right of the middle square inch for a maxillary right posterior tooth). Place the hole halfway up or down, depending on if it’s a maxillary or mandibular anterior tooth. 6C. Do not leave a gap between the lip and rubber dam through which instruments can fall into the patient’s mouth. 6D. Correct rubber dam oral coverage. 6E. Prevent leakage gaps by tucking the rubber dam in properly. 6F. Take time to carefully floss the rubber dam to prevent leakage. 6G. Sealed and ready to go! 40 Endodontic practice

Volume 14 Number 3

way to the treatment finish line: endodontic predictability.7

Closing comments You now know the “intellectual knowledge” for producing endodontic predictability is “on demand.” You have your 3" × 5" remember-to-remember memory cards to provide frequent, significant visual support for experiencing sensory knowledge and for training your new endodontic predictability neural networks. It’s time to take action! Use this information when preparing for your next endodontic treatment and, even more importantly, during your next endodontic treatment. Remember, we are free to be (present in this nanosecond of a moment) and free to act. Whenever you are stuck — for example, on your way to the apex — rather than do more or less of the same, ask yourself, “What do I need to do differently?” Then, with your goal firmly in your mind, just get out of the way and observe as your hands do their magic! Along your endodontic treatment journey, you will want to minimize the variables, so

always remember that simple is better. It doesn’t mean easy. Stay focused on what is under your control. Learn to manage the variability of endodontics, and keep having fun while realizing and experiencing your full endodontic potential! EP REFERENCES 1. West JD. Anatomy matters only when it matters. Endodontic Practice US. 2013;6(5):14-16. 2. West JD. Endodontic predictability: “What matters?” Dent Today. 2013;32:108-113. 3. Brousseau C. Realize Your Golfing Potential. Sea Script Company; 2017. 4. Hebb DO. The Organization of Behavior: A Neuropsychological Theory. John Wiley & Sons: New York; 1949. 5. Doidge N. The Brain’s Way of Healing: Remarkable Discoveries and Recoveries from the Frontiers of Neuroplasticity. Viking: New York; 2015. 6. Nuwer R. The right stuff: the Olympic edge. Sci Am Mind. 2016. 7. West JD. The pendulum swings: “minimally invasive” vs “maximally appropriate.” Dent Today. 2019;38:8-10. 8. West JD. The endodontic Glidepath: “secret to rotary safety.” Dent Today. 2010;29:86-93. 9. West JD. Manual versus mechanical endodontic Glidepath. Dent Today. 2011;30:136-140. 10. West JD. Glidepath implementation: “return to the beginning.” Dent Today. 2011;30:90-97.

This article was reprinted with permission from Dentistry Today.

Figure 7: (from left to right) My most common burs for occlusal reduction or refinement are football-shaped diamond and gold burs. Next are round carbide burs followed by round diamond burs to penetrate and flare toward the chamber. The end-cutting “beaver” burs and diamond burs are used to rough out the access outline, followed by two tapered burs for smoothing access walls. Long shank burs of all these previously suggested burs may be required. Usually, only two to four burs are needed, sometimes fewer Volume 14 Number 3

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ENDODONTIC PERSPECTIVE

burs and their uses. If I include long shank burs, which are often needed, you can double the number of burs that I use! My point is that most dentists cutting an access cavity adapt to the bur. For more control, consider instead adapting to the access and using the bur that is needed. While some dentists may choose only one or two burs due to price sensitivity or perceived efficiency, I do not use all nine every time (Figure 7). The “less is more” concept applies here. The key part of the Play Box physical Set Up is a new bur. New-bur efficiency can be the subject of an entire article, but for now, here is a simple test to prove new bur versus used bur. I call this the new-bur challenge. For your next 10 endodontic accesses, use your favorite burs, but use new ones. After each of the first 10 patients, clean and sterilize each bur used, and then place them in a cup labeled “Used Burs.” When patient No. 11’s endodontic tooth is treated, use the burs from the “Used Burs” cup. Observe the difficulty of access with the used burs compared to the previous new-bur experience. Notice the loss of confidence. Dull burs show up when it is too late. It might not be the second time but maybe the third or fourth time. You never know exactly when; dullness is gradual and insidious. You now have to invest your time to first discover the dull bur, then you waste your time taking the bur out of the handpiece and placing a new bur into the handpiece and then returning to where you were in the procedure after having been distracted for perhaps up to a minute. Time is the most important factor in your overhead. Now honestly, as dentistry is crawling out of the world’s pandemic shock, efficiency may not be your current priority, but someday that will change back to normal with the desire to be as efficient as possible. The next step of the Play Box is designing a “maximally appropriate” access, followed by maintaining your mental game all the

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entsply Sirona’s mission is to empower dental professionals all over the world with the most optimal, innovative technology on the frontier of dental care. As the leading pioneer in the field, Dentsply Sirona holds itself accountable, as your partner, in providing you with the best, most innovative technology to aid your patients. In doing this, we all win because the quality of your patients’ lives improves, which is our number one goal. Our mission is to “deliver innovative dental product solutions to improve oral health worldwide.” Integrity, high performance, and accountability are our core values. In 2016, Dentsply and Sirona combined efforts to create the world’s largest manufacturer of professional dental solutions. Our legacy is that we spend over $150 million a year to advance dentistry. Our team of innovators is made up of 600 scientists and engineers. At any given time, we have 50 clinical studies going on to test safe, effective innovations that result in launches of more than 30 advancements in solutions every year.

Dentsply Sirona has operations in over 40 different countries and sells its products to more than 120 countries. This wide distribution reaches 6 million people daily around the world. One of our specialties is endodontics with a universal commitment toward innovation. In this particular article, we will spotlight our next-generation gutta-percha points, a recent innovation with which you can upgrade your practice and technology. Our injection molding process is far superior to the hand-rolled gutta percha of the past. Our new technique creates a much finer match between the master cone and the particular shape of your client’s file through the process of injection molding the cones. This bridges the gap of the traditional process that had created a lot of inconsistency in cone fit. Conform Fit™ uses state-of-the-art technology in its next-generation gutta-percha points. Traditionally, dentistry has been unable to create a perfect match between master cones and the shapes created by your files. Now Dentsply Sirona has achieved that by injection molding. With this technology, Dentsply Sirona is able to precisely match the shape of the

canal prepared with the corresponding file. There is a consistent 40% more consistent shape and fit* than traditional hand-rolled gutta-percha. Dentsply Sirona’s gutta-percha cones feature a variable taper to match the taper of the corresponding file used in the final shaping. Shapes reach the apex for a very snug fit, and the result of the superior apical fit provides an accurate tug-back response that can be felt even during the first application. The improvement is vast. With this technology, the heating is more consistent for a better flow. The transfer of heat through the gutta-percha cones reaches up to 4 mm beyond the heat source, reaching all the way to the apex. Patients benefit because the clinician can use a lower heat, thus there is less risk in doing harm to the periodontal ligament. It is also important to note a very important feature — the cones are not made from latex. Improving your technology improves your patients’ health. Call your Dentsply Sirona Endodontic Representative at 1-800662-1202 to achieve optimal results for your patients, or visit: www.dentsplysirona.com/ endo to find out more. EP *Source: Internal testing. Data available. This information was provided by Dentsply Sirona.

42 Endodontic practice

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Eradicating the endodontic enemy — bacteria — utilizing ZEISS microscopy and EndoHandle Dr. Lauren E. Kuhn discusses her bacteria-battling techniques

f endodontics were combat, endodontists would be highly decorated warriors. We need capable “boots on the ground” to win battles against bacteria. The war against bacterial colonization of the root canal system — and apical periodontitis — is comprised of many battles. To ultimately win the war, we need strategy, proper equipment, and vision. Here are some bacteria-fighting strategies.

Strategy 1: Get a bird’s eye view It’s hard to fight what you can’t see. After initial access, tilting the microscope head or objective lens aids in visualization. In my experience, ZEISS EXTARO® 300 simplifies these adjustments. Likewise, with the ZEISS OPMI® pico, the MORA interface allows me to tilt the objective lens left and right. Also, a clinician can scout inside the access without obstructions. The Universal EndoHandle (Vental Endo) grasps hand files and gives an unobstructed view. It’s like a DG-16 explorer and a hand file joined forces. After initial access, I focus with my microscope and deploy an EndoHandle to scout for symmetry, orifices, isthmuses, pulp tissue, etc. To see a perforation or open margin, I place the EndoHandle in the area and attach the apex locator to see if my file is in contact with the periodontium. The initial scouting is remarkably easier with a good view (microscope) and my hands out of the way (EndoHandle).

Strategy 2: Identify peripheral threats Bacteria are lurking in caries, as well as the canal system! On the EXTARO 300, Fluorescence mode and NoGlare mode aid in caries detection and viewing subtle details. On the ZEISS OPMI PICO, the MORA interface allows me Lauren E. Kuhn, DMD, MSD, is a graduate of the Harvard School of Dental Medicine (DMD) and Medical University of South Carolina (MSD in Endodontics). She is passionate about education and currently teaches part-time at the University of Minnesota School of Dentistry. She has published case-based research in the Southeast Case Research Journal and coauthored literature reviews in Dental Materials and The Journal of Advanced Prosthodontics. In addition, Dr. Kuhn’s research on patient motivation was featured in RDH Magazine in 2019. Aside from her research activities, Dr. Kuhn works as a full-time clinical endodontist.

44 Endodontic practice

Figures 1A and 1B: Images taken through microscope (ZEISS EXTARO 300). 1A. Extracted premolar with access preparation. Preparing to enter access with pre-curved size 10 C-File on Universal EndoHandle (Venta Endo). 1B. Tactile exploration of the access with size 10 C-File on Universal EndoHandle (Venta Endo)

Figure 2: Caries visualized during microscopic examination (ZEISS EXTARO 300)

to view the periphery without sacrificing ergonomics, by tilting the objective lens left and right. A.

Strategy 3: Identify bacterial strongholds To zoom in and identify critical bacterial fortresses, I adjust the microscope’s magnification and fine focus to get a high-definition view of the pulp chamber and orifices. The Universal EndoHandle (Venta Endo) allows exploration of the landscape without obstruction. Pre-curving the file on the EndoHandle gives precise and directed entry to the orifices(s). It’s a game changer for canals that require angular entry (such as MB of tooth No. 30) and for ambushing bacteria’s hiding places, such as fins, isthmuses, and additional canals.

Strategy 4: Ensure precision Achieving patency can be challenging on calcified or curved canals. In difficult skirmishes, I deploy lubricant (such as RC Prep). However, the lubricant often smears onto the walls and obstructs my view. To prevent this, I place a small drop of lubricant on a pre-curved file on the EndoHandle (Venta Endo) and precisely place the lubricant into the desired location. Longitudinal filing with

Figures 3A and 3B: Images taken through microscope (ZEISS EXTARO 300). 3A. Extracted maxillary molar. Exploring for MB1 canal. Debris visible in pulp chamber. 3B. Exploring for MB2 canal

the EndoHandle delivers the lubricant to midroot level.

Strategy 5: Seize remaining supplies The key to a successful battle is to attack from all angles. The aim is to mechanically (hand and rotary files) and chemomechanically (irrigation) remove and kill bacteria. But stragglers lurk in nearby crevices or caverns, and remaining supplies (pulp tissue) could nourish loiterers. It’s important make the environment inhospitable for occupation. My ZEISS microscopes allow me to adjust my focus down the canals. I identify remaining supplies (pulp tissue, debris), blockades (such as pulp stones), and channels (such as cracks) that could harbor bacteria. It’s hard to fight an enemy you can’t see. With proper vision, the war can be won. EP The opinions and techniques shown here are the recommendations of Dr. Kuhn. ZEISS does not dispense medical advice. Clinicians should use their own judgment in treating their patients. This article was supported by ZEISS.

Figures 4A-4C: Images taken through microscope (ZEISS EXTARO 300). 4A. Small drop of lubricant on file tip, attached to Universal EndoHandle. 4B. File and lubricant placed precisely into orifice of interest (radix paramolaris case). 4C. The EndoHandle is used in a longitudinal filing motion to deliver the lubricant into the canal Volume 14 Number 3

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Coming soon! Triton™ all-in-one irrigation solution by Brasseler USA®

rrigation is a critical step in performing successful root canal therapy. Unfortunately, the most popular and proven solutions that we use to clean root canals can be dangerous, and most opinion leaders suggest the use of multiple solutions to maximize the antibacterial effect. This requires extra steps and intermediate rinsing to avoid neutralization of the irrigation solution and/or dangerous chemical reactions. The biggest challenge is that sodium hypochlorite (NaOCl) is almost immediately neutralized when it comes in contact with dentinal debris. For this reason, many clinicians use full-strength NaOCl. To counter

this neutralization effect, we need to use EDTA to dissolve the inorganic debris and then quickly re-expose the canal to NaOCl. Unfortunately, the EDTA also neutralizes the NaOCl, so we have to use a high volume of irrigation solution or intermediate rinsing before we achieve an optimal cleansing effect. But now, there is a solution with Triton™. Triton is a patent-pending all-in-one irrigation solution that has been shown to kill the most virulent canal bacteria in one-half the time and with one-third of the steps of the current gold standard. Unlike traditional irrigants or other advanced 2:1 solutions, Triton works

“Triton addresses the most essential and fundamental needs of endodontic irrigation in one solution. The sodium hypochlorite component provides tissue dissolution and disinfection while the novel combination of gentle chelating agents and surfactants simultaneously provide inorganic debris dissolution, saponification, and lubrication. Triton provides soft tissue digestion, surface disinfection, and demineralization of the debris all at once making it a truly synergistic solution that greatly simplifies the irrigation process.” — Allen Ali Nasseh, DDS, MMSc; RealWorldEndo, Boston, Massachusetts

Chamber filled with Triton 46 Endodontic practice

Same chamber dried ready for obturation

Triton all-in-one irrigation solution

differently by avoiding the use of EDTA and chlorhexidine (CHX) altogether. The non-NaOCl components in Triton proactively dissolve the inorganic debris allowing for the safer concentration of NaOCl to be exposed to the surfaces of biofilms without as much buffering. This synergistic combination of dentinal debris dissolution and antimicrobial disinfection taking place at the same time allows for maximum clinical efficiency. By using a lower concentration of NaOCl and a proprietary blend of surfactants and gentle chelating agents, Triton is the first all-in-one irrigation solution to deliver all of the benefits of EDTA while at the same time delivering the antibacterial and tissue dissolution benefits of NaOCl. For more information, please contact Brasseler USA®. EP This information was provided by Brasseler USA®.

Volume 14 Number 3

Drs. Joel C. Small and Edwin McDonald discuss ways to effectively develop your team

f you ever played a team sport, you likely appreciate the necessity of coaching. A coach is that person who, like an orchestra’s conductor, keeps the team synchronized and harmonized. Coaches are the people who understand everyone’s individual and necessary contribution to a desired result. They also see the big picture and yet understand the many subtle nuances that move their team from average to peak performance. Coaching a healthcare team for peak performance is similar in many ways to coaching a team sport. At Line of Sight Coaching, we help doctors become more “coach-like” by teaching simple skills that have been proven to be very effective in creating and sustaining high performing teams. The following are some of the most important skill sets necessary for coaching a team to peak performance.

Leadership All good coaches are good leaders. The very act of coaching requires leadership skills. Leaders are realists who can provide unfiltered, honest assessments of their organization’s current status. They are also visionaries who see beyond the short term and communicate a long-term vision that is both compelling and motivating for the team. They provide the resources and support necessary for the team to beyond the status quo and toward a preferred future.

Self-awareness When 75 members of the Stanford Graduate Business School’s Advisory Council were asked to recommend the most important capability for leaders to develop, their answer was nearly unanimous — self-awareness. The same is true for coaches. Effective coaches have a high degree of self-awareness and emotional intelligence. They understand how their words and actions are perceived by their team. Armed with this vital knowledge, they are capable of “self-regulating” their interactions with their team to create an environment conducive to peak performance.

Vision What does peak performance look like? How will you know when you have achieved peak performance? These are critical questions that must be answered prior to initiating Volume 14 Number 3

a peak performance initiative. Like any goaloriented initiative, having a clear picture of what you are trying to achieve is critical to achieving the goal. Collaborate with your team when creating the vision. The more input they have, the more buy-in you will receive.

People developers One of the most critical tasks for any leader/coach is the development of human capital. Research has shown that the very best and most profitable businesses are those that have made significant investments in their people. There are two effective ways to develop your team. The first and more obvious way is to improve their technical skill set. This is often referred to as “horizontal development” and is an important step in creating high performing teams. The second and less obvious way to develop a team is to encourage them to think and act both independently and interdependently. This is referred to as “vertical development” and involves the development of the individual and team’s mental capacity and skill set. Developing a team’s capability to think and act both independently and interdependently, and understanding the distinction and value of each are foundational to achieving peak performance. Consider this: If we insist on making every decision in our practice, we become an unnecessary bottleneck, and we are unknowingly undermining our team’s ability to reach peak performance. Many of the nonclinical decisions can and should be made by our team. By allowing team members to think and act within predetermined guidelines, we are taking these burdens off our plate, removing unnecessary barriers to efficiency, and promoting individual and team confidence and growth. What is important is that each team member has the support and authority to act independently while considering the impact of their decisions on the entire team. This is when interdependent thinking, often requiring collaboration with other team members, is most important and most valuable. Simple coaching skills can be very effective in creating peak performing teams. Michael Bungay Stanier has written two excellent books that teach useful coaching skills for anyone wanting to take their team

to higher levels of performance. Stanier’s first book, The Coaching Habit, presents seven simple coaching questions that doctors will find invaluable when attempting to improve individual and team performance. His second book, The Advice Trap, serves as a primer for individual and team vertical development. Anyone interested in developing these vital skill sets should make it a point to read both books.

Reflection One of the best and most effective ways to achieve peak performance is through reflection. At the end of each day or the beginning of the next day, take a few minutes to reflect on the previous day. What went right? What could have been improved and why? What was a barrier to achieving peak performance? Again, using simple coaching skills and language will remove the team’s fear of offering an honest and unfiltered selfappraisal. These few minutes will prove to be one of the best team building techniques, and doctors will begin to see the staff improve their level of performance faster than they ever thought possible. In summary, becoming more coach-like does not require rigorous training or certification. All can learn simple skills that will prove invaluable in moving their organization to higher levels of productivity and profitability. More importantly, coaching your team is arguably the best way to sustain peak performance while simultaneously building an optimal practice culture. Do yourself a favor and read Michael Stanier’s books. You will be very glad that you did. EP 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.

Endodontic practice 47

SMALL TALK

How to coach your team to peak performance

SERVICE PROFILE

U.S. Endo Partners

.S. Endo Partners grew out of the idea that there is power in numbers. Together, endodontists can be a force for greater change. With their unsurpassed practice support, U.S. Endo Partners continues to drive change for good for their endodontists by increasing their purchasing power and amplifying their voice in the specialty while decreasing their time away from patients. Additionally, adding value to the lives of their partner endodontists makes up a large part of the DNA at U.S. Endo Partners. This includes putting experts in the right place to maximize their success and to continually put learning and educational opportunities at the forefront of their partnership. With adding value for their endodontists in mind, U.S. Endo Partners recently created the Operational Excellence Leader position. According to Dr. Jeremy Young, the first person to hold this title, it speaks directly to how much U.S. Endo Partners values their partner-clinicians and associates. “I’m an advocate for our doctors,” says Young, humbly. Jeremy Young has over 20 years of clinical practice experience. Young started as an associate. He has been a sole practice owner. And he has also been in a group practice. He understands many of the challenges endodontists face because he faced them himself. “I’ve experienced the breadth of what a clinician can experience,” said Young, “so I can relate to the doctors. I work on their behalf to make things as good as we can make them.”

48 Endodontic practice

“I’m an advocate for our doctors. I’ve experienced the breadth of what a clinician can experience.... I work on their behalf to make things as good as we can make them.” Dr. Jeremy Young, Operational Excellence Leader of U.S. Endo Partners

U.S. Endo Partners created this position to streamline responsiveness for their partners and associates by tasking Young with three primary missions. First, Young guides new associates. The partners have prioritized the experience for new associates. “We want to think about their experience,” says Young. He does this by monitoring their progress to keep their experience a positive one with the goal of retaining these starting endodontists from their first patient to their retirement. “We want to think about that process and what type of value U. S. Endo can bring them,” added Young. Second, Young focuses on the long-term implications for U.S. Endo. As practicing endodontists retire, recent endodontists look to ascend to their positions. This is the projection of a practice life cycle, says Young. “We want to think about who steps into their role as the managing doctor in their practice.” This includes offering additional education opportunities — specifically, teaching business acumen and leadership or reading a profit and loss statement. Anything a peer clinician might not have a chance to learn through the normal course of attending patients. Added Young, “We want to give opportunities for a junior doctor to learn

those things; this will make becoming a senior doctor easier.” Third, Young’s job is to foster collaboration between doctors. “How can we share ideas across our platform?” asks Young. The goal is not only to communicate ideas but also to foster a sense of community and partnership among all doctors under the U.S. Endo umbrella. Young says that no practice is an island. Everyone benefits by sharing the best ideas instead of learning the hard way by trial and error and having to go through all these processes. “If we can kind of capture the best ideas from the group and share them among all the partners,” says Young,” it’s a quicker way to success, and I think everyone wins when we do that.” U.S. Endo Partners supports excellence and provides value for their partners and associates. They believe in putting experts in positions to succeed. They prove this belief by putting an endodontist in charge of endodontist experiences. This drive for excellence informs all levels of the U.S. Endo Partners experience. From your first day with U.S. Endo Partners, they take away roadblocks to your success to put you in a position to achieve your success. EP This information was provided by U.S. Endo Partners.

Volume 14 Number 3

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If we capture the best ideas from the group and share them… everyone wins. – Dr. Jeremy Young, DDS, MMSC U.S. Endo Partners

U.S. Endo Partners seeks experts to maximize success at all organizational levels. U.S. Endo hired our first Operational Excellence Leader, Dr. Jeremy Young, to maximize the potential of our partners and associates. With each and every step forward, our partnership prospers. www.USEndoPartners.com/Success

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