Endodontic Practice US Winter 2021 Vol 14 No 4 by MedMark, LLC

EXCELLENCE

The Endodontic Triad: dead or alive? Dr. John West

ENDODONTICS Maintenance and retention of dental records Dr. Bruce H. Seidberg

Group practices Special section

Practice spotlight Cumberland Endodontics: Coming out stronger! A practice that wouldn’t stop

The five best dental job interview questions to ask to build an outstanding team Ali Oromchian, JD, LLM

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In the world of Endo, patient comfort rules the day and saving the natural tooth is king. Mining the innermost anatomy of a tooth is tricky business. Lucky for you, we’re here to

clinical articles • management advice • practice profiles • technology reviews

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Focus on receiving the gratitude

EDITORIAL ADVISORS Dennis G. Brave, DDS David C. Brown, BDS, MDS, MSD L. Stephen Buchanan, DDS, FICD, FACD Gary B. Carr, DDS Arnaldo Castellucci, MD, DDS Gordon J. Christensen, DDS, MSD, PhD Stephen Cohen, MS, DDS, FACD, FICD Samuel O. Dorn, DDS Josef Dovgan, DDS, MS Luiz R. Fava, DDS Robert Fleisher, DMD Marcela Fridland, DDS Gerald N. Glickman, DDS, MS Jeffrey W Hutter, DMD, MEd Syngcuk Kim, DDS, PhD Kenneth A. Koch, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI Joshua Moshonov, DMD Richard Mounce, DDS Yosef Nahmias, DDS, MS David L. Pitts, DDS, MDSD Louis E. Rossman, DMD Stephen F. Schwartz, DDS, MS Ken Serota, DDS, MMSc E Steve Senia, DDS, MS, BS Michael Tagger, DMD, MS Martin Trope, BDS, DMD Peter Velvart, DMD Rick Walton, DMD, MS John West, DDS, MSD

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

s endodontists, we love to give! We freely give so much of ourselves — our skills, our compassion, our effort, our energy, and our care to others. We give to our families, teams, friends, communities, and profession readily and without hesitation. As empathic humans, we find this giving to be true to our nature and training. Endodontists are givers! However, the skill we all should endeavor to master is receiving! Givers often have a harder time learning to receive the love, gratitude, and expressions of thanks that come back to us. The impact of endodontic treatment on our patients is often lifesaving. We not only save a patient’s natural tooth, but also often “save the day” as orofacial pain can stop someone’s life in its tracks, rendering Dr. Brett E. Gilbert the person unable to move forward until the pain is alleviated. This life-changing gift of root canal therapy that we provide often stokes a visceral feeling of gratitude and thanks within our patients. They, as humans, desire to express that to us in a variety of ways. As givers, we often don’t quite know how to fully accept and process the praise and sentiments that are sent back to us. However, the truest form of giving is to receive what others are sending YOU! We all feel great when we give to others, so we must also realize that for others to feel great giving, we must receive the gifts they are giving back to us. For me, receiving has been not only one of the most difficult skills to strengthen, but also one of the most rewarding and uplifting tools I have in my life. Receiving from others lifts me up, fills my cup, and allows me to appreciate the positive impact I can have as an endodontist and human being. As we close this year and look forward to a new start, let’s focus on receiving the gratitude and love that those around us (family, teams, and patients) so graciously want to extend to us! Burnout shows up without much warning as it is so easy to get caught up in the procedural aspects of root canal treatment and the self-judgment and stress that come with being skilled dental specialists who hold themselves to near perfectionist standards. If we broaden our focus to the entire patient experience, we can start to see the magnitude of the impact our practices and our skills as clinicians have on our patients’ (and teams’) lives. Our cups are much fuller when we can look beyond the clinical cases and recognize and receive how much our patients appreciate us and all that we have done to help them (despite how much we like the final radiograph of the case). In this ever-expanding battle to maintain our mental and emotional health as clinicians, business owners, partners, and respected members of our communities in such stressful and uncertain times, the true antidote to burnout may just be the awareness and allowance of us to RECEIVE all of the gratitude that so many others are trying to send back to us. I once had a coach ask me to visualize a huge balloon full of all of the gratitude that others had felt and extended to me over the years since I have been in practice. As I added up the years, the procedures, the patients, the situations, and the effort behind it all, I realized that the balloon was gigantic and overflowing. This brought a great sense of pride and grace as I started to realize that by receiving all of that gratitude and love — I have so much more to give! Dr. Brett E. Gilbert

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.

Brett E. Gilbert, DDS, graduated from the University of Maryland Dental School in 2001 and completed his postgraduate training in endodontics from the University of Maryland Dental School in 2003. He is currently a clinical assistant professor in the Department of Endodontics at the University of Illinois-Chicago, College of Dentistry and on staff at Presence Resurrection Medical Center in Chicago. He is a past president of the Illinois Association of Endodontists. Dr. Gilbert is Board-certified, a Diplomate of the American Board of Endodontics. He was named a top ten young dental educator in America by the Seattle Study Club in 2017. In 2019, he was named to Academic Keys Who’s Who in Dentistry Higher Education (WWDHE). Dr. Gilbert lectures nationally and internationally on clinical endodontics. He has a full-time private practice limited to Endodontics in Niles, Illinois. Dr. Gilbert is a partner in U.S. Endo Partners. He can be contacted online at www.drbrettgilbert.com.

ISSN number 2372-6245

Volume 14 Number 4

Endodontic practice 1

INTRODUCTION

Winter 2021 - Volume 14 Number 4

TABLE OF CONTENTS

Publisher’s perspective With a gladiator’s determination Lisa Moler, Founder/Publisher, MedMark Media................................ 6

Case report

Practice spotlight Cumberland Endodontics: Coming out stronger! A practice that wouldn’t stop

Drs. Adam Davis, Jonathan Uhles, and Eshwar Arasu show resilience in challenging circumstances

Retreatment with GentleWave® of teeth that did not respond to traditional multi-visit treatment: a case series of five patients Dr. Rick Schwartz discusses retreatment of five cases with varying outcomes........................................16

Technique The GEMS method Drs. Hamid R. Abedi and Farzad Foroughi explain a novel approach for flapless endodontic surgery............. 20

Continuing education Maintenance and retention of dental records

Clinical 12

Dr. Bruce H. Seidberg discusses legal obligations of dentists for record keeping...........................................24

The reciprocal effect of electronic apex locators and implantable cardiac defibrillator Drs. Roy Gadassi, David Keinan, Ritz Shlomi, and Iris Slutzky-Goldberg study the impact of electronic dental devices on the function of pacemakers and ICD ON THE COVER Cover image courtesy of Dr. John West. See article on page 37.

2 Endodontic practice

Volume 14 Number 4

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.

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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 Practice management Solving endo’s Catch-22 lifestyle gap Dr. Albert (Ace) Goerig discusses an effective method of providing essential care.................................................33

Continuing education

The five best dental job interview questions to ask — and two to avoid — to build an outstanding team

Special section Cornerstone Dental Specialties................................... 34 Endo1 Partners..........................35 U.S. Endo Partners....................36

Endodontic perspective The Endodontic Triad: dead or alive? Dr. John West shares colleagues’ perceptions on improving performance and increasing endodontic predictability.................................... 37

Ali Oromchian, JD, LLM, offers suggestions to find out about your potential new hires without legal concerns

Service profile

U.S. Endo Partners

Endo1 Partners

Dr. Eric Young discusses operating his practice with the help of fully informed, data-based decisions......................42

A partnership organization focused on patient and partner satisfaction.........46

Product profile Triton — All-in-one irrigation solution........................................44 ®

Small talk How to create your best year ever Drs. Joel C. Small and Edwin McDonald discuss how to develop a team of peak performers....................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 4

GET BACK ON TRACK! GET BACK ON TRACK! Don’t let another year go by! Don’t let another year by! Love your practice andgo life Love yourgoals practice and life with new for 2022! with new goals for 2022!

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PUBLISHER’S PERSPECTIVE

With a gladiator’s determination

“I

am a gladiator! Winter is my season. This is my time. I will not be denied. … I will add more value than anyone else. … Give me your fears, give me your limitations, and I’ll give you results. I am a gladiator!” — Tony Robbins Welcome to our winter issue! The above inspirational message by Tony Robbins sums up how our MedMark team approaches your practices, your patients, and your future. Our goal is to add more value than anyone else. Through our publications, we inform you about trends in dentistry and provide articles that can help you grow clinically and professionally. Our CE articles educate you, and our webinars and podcasts bring amazing opportunities for growth. Our marketing expertise Lisa Moler spreads the word to audiences that are searching for insights Founder/Publisher, MedMark Media from leaders like you. This is your time, and we want to give you results! Throughout 2021, you have pushed past fears and muscled through limitations. We were courageous, creative, tenacious, and bold. Our focus was on not only getting back to normal, but also setting and surpassing new goals. We have heard of many triumphs since the beginning of 2021 — not just reopenings, but how you grew this year — with new technologies and techniques that improved patient care and expanded your capabilities. We are honored and thrilled to be a part of your continuing process. In this issue, our CE by Dr. Bruce H. Seidberg delves into maintenance and retention of dental records. Read about how proper storage and disposal of these essential records can help you in litigation, sale, or retirement. Our CE by Ali Oromchian, JD, LLM, discusses the art of the interview — how to build an outstanding team while avoiding legal pitfalls. Knowing what not to ask is often as important as asking the right questions! Our Practice Profile of Cumberland Endodontics features three endodontists who describe their ordeal after a tornado that devastated middle Tennessee destroyed their building, but not their resolve. And a Special Section on group practices features Cornerstone Dental Specialties, Endo 1 Partners, and U.S. Endo Partners — practices that demonstrate the power of strong partnerships. This coming year is going to be exciting. We are renewed, rejuvenated, revitalized, and ready to take the dental arena by storm. Winter is OUR season, and we are picking up the momentum for 2022 — ready to face the new year with a gladiator’s determination to empower our dental community! 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 NATIONAL ACCOUNT MANAGER 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 SALES ASSISTANT/CLIENT SERVICES 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 4

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PRACTICE SPOTLIGHT

Cumberland Endodontics: Coming out stronger! A practice that wouldn’t stop Drs. Adam Davis, Jonathan Uhles, and Eshwar Arasu show resilience in challenging circumstances Tell us a bit about your backgrounds Dr. Adam Davis: I am the youngest of four children. My mom was a dental assistant, and my dad was a Naval Officer. We had the opportunity to live in Florida, Rhode Island, Virginia, Hawaii, and Spain. In junior high school, golf became my passion and ultimately led me to play for Bethel College in McKenzie, Tennessee. After accepting the U.S. Navy Health Professional Scholarship Program (HPSP) scholarship for dental school and attending the University of Tennessee, my next 5 years were an adventure — serving my country and allowing me to explore all dental specialties. After completing my naval service and my endodontic residency at Virginia Commonwealth University, I returned home and opened Cumberland Endodontics. Dr. Jonathan Uhles: I grew up in Cookeville, a small town in the heart of middle Tennessee. I was fortunate to have parents who instilled in me the value of hard work from a young age. They believed in me and knew that I could do anything I wanted in life if I were willing to put in the work to make that dream a reality. I was fortunate to attend the University of Tennessee Health Science Center for dental school. Following graduation, I completed a fellowship with the Department of Endodontics and Operative Dentistry before entering and completing my postgraduate residency in Endodontics, where I received my MDS and certificate in Endodontics in 2014. Dr. Eshwar Arasu: I was born in India and immigrated with my family to the United States. After stints in Nevada and Hawaii, we eventually settled in Columbus, Ohio. I attended the University of Michigan to pursue a degree in Biomedical Engineering before enrolling in the Harvard School of Dental Medicine. After enduring winters in Ann Arbor and Boston, I welcomed the opportunity to complete my residency training at the Virginia Commonwealth University in Richmond where I was awarded an MSD and certificate in Endodontics. I joined Cumberland Endodontics as an associate in 2017, 8 Endodontic practice

Left to right, Dr. Jonathan Uhles, Dr. Adam Davis, and Dr. Eshwar Arasu stand at the site of their Mt. Juliet office — slated to re-open in 2022

became Board-certified in 2019, and partnered with Drs. Davis and Uhles in 2020.

Why did you choose endodontics as your focus? Dr. Davis: Since a young age, I have been competitive and always wanted to excel at whatever I did. This has led me to only do a few things, but attempt to do them as well as possible. In addition, I have always enjoyed challenging myself. Endodontics seemed like the most difficult procedure in dentistry, and I believe my competitive nature serves my patients well, as I hate to lose; when a case is particularly challenging, I get great satisfaction out of overcoming that challenge for my patients. Dr. Uhles: As ridiculous as this sounds, I honestly think endodontics chose me. I went to dental school fully expecting to become a general practitioner and move back home and take over the practice of my family dentist. Once I did my first root canal treatment as a dental student, I was hooked! I loved the challenge of that procedure and was always fascinated by the internal anatomy of the teeth. There’s no doubt the “thrill of the fill” left me wanting more.

Dr. Arasu: I’m a creature of habit. I learned in dental school that endodontics afforded me the opportunity to hone a procedural craft. Every case has its own unique challenge — sometimes subtle — that rewards patience and skill. Relieving patients of their dental pain has also helped me find professional purpose.

How has the specialty evolved over the time you have been in practice?

Dr. Davis: In my 20 years of practicing, technology has made things more predictable for our patients. Practitioners can be more efficient to determine cases they should or should not treat, which is important since the addition of technology to our practice typically adds some fixed costs to the procedure. With the addition of CBCT, heat-treated files, and the GentleWave® System, practitioners can provide conservative endodontic access, dentin conservation, minimal shaping, and outstanding treatment with more efficiency than ever before. Dr. Uhles: I was fortunate enough to enter this specialty when technology had really revolutionized the way care was delivered. I was trained with the dental microscope and Volume 14 Number 4

CBCT technology. The biggest change I’ve personally witnessed is the introduction of multisonic cleaning of the root canal system. Without question, it has revolutionized the way we care for our patients and allows us to predictably address the complex anatomy within teeth. Dr. Arasu: I am a relative newcomer to the specialty, but I have come to rely on preoperative CBCT imaging and intraoperative cleaning afforded by the GentleWave Procedure. My patients often marvel at the technological progress that’s enabled comfortable care relative to the procedures they underwent decades ago.

locator. Today, I’d have to add the GentleWave Procedure to that list. Dr. Arasu: I can echo Dr. Uhles on the usefulness of those technologies and will add among them digital record keeping. Patients and providers alike are happy to minimize physical paperwork whenever possible.

Tell us about the recent tornado, and how your supporting partners helped you to rebuild and reopen.

overwhelming, and yet somehow “doing” is what kept us sane. In addition, as March ended, the COVID-19 shutdowns started! Thankfully Dr. Uhles, Dr. Arasu, and I leaned on each other and worked maybe as hard as we ever have to get up and running in a temporary office in about 9 weeks. We could not have done any of it without the best staff out there. As we head into 2022, we are looking forward to seeing the hard work pay off with what will be our crown jewel in our new office and teaching center. Dr. Uhles: March 3, 2020, is certainly a day I will never forget. The tornado that devastated middle Tennessee made a path between our office and the oral surgeon’s office next door. Seeing the devastation was heartbreaking, but we were also thankful for our safety and the fact it occurred during non-business hours. The first week, I don’t think I slept. There wasn’t really a pause to take in the full effect of what happened or to grieve; we just immediately went into recovery mode. Each of us carried some of the burden to ensure that we progressed as quickly as possible to become operational again in a timely manner. Each of us leaned into each other, relying on our individual strengths to

Dr. Davis: Our office has always been out front in regards to adding technologies to improve care for our patients. My must-haves would be microscopes, CBCT, heat-treated files, and the GentleWave System. Dr. Uhles: Up until a few years ago, I used to say there are three pieces of technology I couldn’t work without: the dental microscope, CBCT, and the electronic apex

Dr. Davis: Wow! The tornado was on the ground for nearly 60 miles — a remarkably rare occurrence. There are definitely certain events in your life that you can remember with amazing detail. That day, week, month, year was one of those for me. We had friends who were huddled with their families as the tornado ripped their house apart. We only lost our building. Dr. Uhles and I started communicating a little after midnight, right after the tornado came through. My description of the inside of the building is to imagine a giant from Harry Potter picking the building up, shaking it like a snow globe, and putting it back down. After we assessed, contacted our insurance company, and rallied help, we got to work. There was so much to do it was

Demolition of the office in 2020

Exterior rendering of the reconstructed office and attached clinical education center

Is there any equipment that you wouldn’t want to do without for your practice?

Volume 14 Number 4

Endodontic practice 9

PRACTICE SPOTLIGHT

Severe tornado damage to a Cumberland Endodontics office pictured in the early morning and afternoon of March 3, 2020

PRACTICE SPOTLIGHT

CBCT imaging, operating microscopes, and GentleWave technology in action with Dr. Davis

ensure we kept progressing. Despite the challenges that were ahead, including the COVID-19 pandemic, we were able to open our temporary office 6 weeks later. Dr. Arasu: To set the scene, I was set to be married less than 2 weeks after the tornado struck. I will always be grateful for Drs. Davis and Uhles, who shouldered much of the immediate burden in sifting through the destruction and planning our entry into an interim office. They did so to allow me the opportunity to focus on the wedding preparations. There may not have been much to celebrate in the lead-up, but their attendance at my wedding is a fond memory that I will cherish.

Interior rendering of the patient lobby

Pretreatment patient education with Dr. Uhles

What other great triumphs or challenges have you overcome? Dr. Davis: My personal health is something I like to share. For many years, my health was not a priority. Like many people, a stressful day led to me wanting a reward, and food was my reward. After my middle daughter Olivia was diagnosed with Type 1 diabetes, I began to make changes in my life. In the beginning it was small changes — cutting out fast food, fried foods, and soda. Then I added physical fitness and have transformed my health. This has been a slow and steady process, but it was so difficult to start at 46 years old and so rewarding to see where I am now. My focus is being an example for Olivia. Dr. Uhles: Personally, my favorite triumph since I joined the practice in 2014 is being able to witness our growth — even in the midst of recovering from a tornado and a global pandemic. We’re all very passionate about our profession and root canal therapy, but more importantly, on the patient experience. At the end of the day, patients don’t care about the white lines we see on radiographs. They care about how they are treated, how their needs are addressed, and the overall patient experience. That focus really helps us set Cumberland Endodontics apart. 10 Endodontic practice

Dr. Uhles presenting for Sonendo® at AAE18

Dr. Arasu: The growing impact of the global pandemic on the U.S. followed not long after the loss of our office to the tornado. These existential challenges compelled us to reevaluate our priorities and, above all, appreciate the value of our team. That we were able to navigate those obstacles speaks to the resilience of our staff, doctors, and our broader dental community.

What would your tips be for someone starting an office now? Dr. Uhles: If you’re starting a new office, build the practice the way you want it from day one. Don’t wait for the right time to add this or that piece of technology — you’ll always find an excuse as to why the time isn’t right. Create your ideal working environment from the start, so you can grow your own expertise and experience. Strive every day to be better than the day before, and let your work and brand speak for themselves.

What is your advice for maintaining a successful practice?

With Drs. Davis and Uhles in attendance, Dr. Arasu’s wedding takes place 2 weeks after the tornado

Dr. Uhles: Maintaining a successful practice really comes down to two critical components. The first is to know yourself and your brand and never compromise on what you are trying to achieve. For us, we want to be the best in our field and are dedicated to always putting our patients first. This is our guiding principle, and because of staying true to that vision, we’ve built a positive reputation within our communities, which has allowed us to grow with time. The second critical component to a successful practice is the people who help us achieve our vision. Without a dedicated staff, our vision and brand couldn’t flourish. They are Cumberland Endodontics. EP Volume 14 Number 4

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The integrated HD camera of the EXTARO® 300 from ZEISS records wirelessly to the ZEISS Connect App — empowering patient interaction and informed decisions with images and videos directly transferred to your local network. • Benefit from a digital workflow • Easily educate your patients • Demonstrate the value of your work CAP-en-US_30_030_0185I © Carl Zeiss Meditec USA, Inc., 2021. All rights reserved.

CLINICAL

Dr Iris Slutzky-Goldberg is from the Department of Endodontics, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel.

electrical impulse generator implanted in patients at risk of sudden cardiac death due to ventricular fibrillation or ventricular tachycardia. The device is programmed to detect any cardiac arrhythmias and to correct them by delivering a jolt of electricity.4 Both pacemakers and ICDs may be sensitive to electromagnetic radiation from dental devices. This risk may be increased by proximating the pacemaker and the dental electrical devices.5-7 Furthermore, older pacemakers are more susceptible to electrical interference than modern devices that are hermetically sealed in a metal case with cables that efficiently filter electromagnetic signals.8-10 Therefore, it may be prudent to consult with the patient’s cardiologist to determine whether a dental electrical device can be safely used. Studies have suggested that electronic apex locators (EALs) may cause minor or major interferences with pacemaker function.11-12 In an in vitro study on the effect of different types of EALs on pacemaker function, four of the five EALs tested caused no interference with pacemaker function.13 However, the Bingo-1020 device interfered with the electrical functions of the pacemaker.13 In another study, researchers monitored 27 patients with either an ICD or pacemaker using an ECG during EAL or pulp tester use, and found normal ECGs during use of either of the two devices.14 Similar results were found in a study of 66 patients with different types of pacemakers while using a Root ZX mini; some noise was recorded in the ECG in two of the patients, but pacemaker’s function was not affected.11 The influence of EALs on pacemaker function has been studied in detail in various studies, but the effect of the defibrillator on the accuracy of EAL measurements has not been tested. Since modern defibrillators serve as both a defibrillator and a pacemaker, they constantly regulate the patient’s heart rate throughout the day. We aimed to check the reciprocal effects between two EALs and a defibrillator in an ex vivo model.

Dr. David Keinan is Head, Department of Endodontics, School of Postgraduate Dentistry, Rambam HCC, Haifa, Israel.

Materials and methods

Introduction: The purpose of this ex vivo study was to evaluate the potential electromagnetic interference from an electronic apex locator (EAL) on the function of an implantable cardioverter defibrillator (ICD). In addition, we evaluated the effect of the ICD on EAL reading accuracy. Method: We tested two EALs ex vivo to assess their potential interference with the function of an ICD as determined using a Medtronic Programmer. We also assessed the accuracy of each EAL during the delivery of ICD pacing electrical shocks. Results: None of the EAL devices (BingoPro and MedicNRG XFR) interfered with pacemaker activity. However, the accuracy of the EALs was impaired during ICD pacing; the changes measured were between -1 mm (BingoPro) and -2.5 mm (MedicNRG XFR). We found no effect on EAL function at any of the energy levels tested during the delivery of a series of electric shocks by the defibrillator. Conclusions: In view of the results, the potential risk of overinstrumentation during the use of EALs for length determination in patients with an ICD must be considered.

Introduction Cardiac arrhythmias are relatively common. A cohort of 10,000 dental patients showed that 17.2% had cardiac arrhythmias, and that over 4% of those arrhythmias were life-threatening.1 Pacemakers treat symptomatic cardiac arrhythmias, specifically in patients who do not respond to medication.2 A pacemaker, implanted subcutaneously below the left clavicle, can mechanically replace cardiac cells that are nonfunctioning or poorly functioning.3 An implantable cardioverterdefibrillator (ICD) is a small battery-powered Drs. Roy Gadassi and Ritz Shlomi are from the Medical Corps, Israel Defense Forces (IDF).

12 Endodontic practice

We used 10 randomly chosen single-root

extracted teeth that were kept in tap water and stored at 4°C for this study. The teeth had been extracted for orthodontic or periodontal reasons unrelated to the study. Patients subjected to extraction signed an informed consent to allow use of the teeth for research purposes. We serially marked the teeth to enable comparisons of the results for experiments with both apex locators and the defibrillator. Preparation of teeth for measurement: The crowns were grinded to establish a flat surface to serve as a reproducible reference point for all measurements. Cavity access was achieved using A3 diamond burs (Straus & Co., Ra’anana, Israel). Next, Gates Glidden burs Nos. 1-3 (Dentsply Maillefer, Ballaigues, Switzerland) were used to prepare the coronal third of each canal. During access cavity preparation, the canals were irrigated with a saline solution, and the patency of the apical foramen was verified with a size 10-K file (Dentsply Maillefer Ballaigues, Switzerland). Canal length measurements: Canal length was established by passively introducing a 15 K-File (Dentsply Maillefer) in each canal until its tip was visible at the apical foramen. This procedure was conducted under 2.6× magnification using surgical loupes (Orascoptic, Madison, Wisconsin). After adjusting a silicone stop at the incisal surface, we removed the file from the canal and measured the distance between the tip of the file and the rubber stop with the aid of an endodontic ruler (Dentsply Maillefer). This measurement was repeated three times, and the mean value for each tooth was calculated and recorded as the “actual length” (AL). Electronic length measurements: The next step involved mounting all the roots in alginate (Plastalgin, Septodont, Lancaster, Pennsylvania) in a plastic container. Prior to the experiment, we measured the impedance of the alginate to verify the resemblance between the alginate model and cardiac tissue. We placed each root through a hole in the container and fixed it with acrylic resin to avoid movement during instrumentation. We made a second smaller hole in the top Volume 14 Number 4

Volume 14 Number 4

to 35 J). We recorded EAL readings during shock administration.

Results The impedance of the alginate was measured prior to conducting the experiments. The values accepted were on average 7.30 ± 0.072 Ω. Normal pacing patterns of the defibrillator were observed while testing the effect of apex locators on defibrillator function. None of the EAL devices (BingoPro or MedicNRGXFR) interfered with defibrillator activity. Next, the effect of the defibrillator on the readings of the two types of EALs was examined. Inaccurate readings for BingoPro were demonstrated in as many as seven teeth during pacing especially at high voltages, whereas inaccurate readings for NRGXFR were produced in only three teeth during pacing. BingoPro: In three teeth, the readings were not affected by defibrillator function; in four teeth, the readings were +1 mm longer than the actual length; and in three other teeth, the readings were 1 mm shorter than the actual length Thus, the pacing affected measurements in seven teeth with reading changes

for each tooth at different pacing voltages. The change in readings was ±1 mm. For example, the reading for tooth No. 4 was shorter by 1 mm at 2 V. Medic ApexNRG-XFR: EAL readings remained unchanged in six teeth during defibrillator function. In two teeth, the readings were 2.5 mm longer than the actual length, and in one tooth, the length was 2.5 mm shorter than the actual length. We failed to obtain readings in one tooth (Figure 2). Increasing the pacing voltage caused interference with the EAL readings. This was more prominent for the BingoPro than for the Medic ApexNRG-XFR EAL. When the BingoPro EAL was tested, an increase in voltage to 2.5 V resulted in inaccuracies in as many as five teeth; even more inaccurate readings were obtained with further voltage increases. When defibrillator function was tested with the Medic ApexNRG-XFR, we observed inaccurate results at the lower function voltages, and voltage elevations resulted in overestimated readings in an additional tooth. The number of inaccurate readings increased with pacing voltage increments. While pacing at 1.5 V, we observed inaccurate readings in two teeth with both apex locators. Pacing voltage increments

Figure 1: Experimental settings — The defibrillator leads were placed 10 cm away from the defibrillator, located at a distance of 15 cm from the teeth

Figure 2: Medic ApexNRG-XFR — Reading accuracy vs. pacing voltage. The readings on six teeth were normal during the pacing. However, we observed changes within a range of 2.5 mm. In two teeth, we observed a 2.5 mm increase in EAL readings; and in one tooth, the EAL reading was reduced by 2.5 mm. Tooth No. 2 showed a long reading only at pacings above 4.5 mV Endodontic practice 13

CLINICAL

of the container to stabilize the electrode (lip-clip) and allow it to be in contact with the alginate to simulate the conductivity conditions of the periodontium. Our ex vivo model was adapted with modifications of that by Kaufman, et al.15 For each tooth, an electronic length measurement was carried out using a No. 15 K-file (Dentsply Maillefer) attached to the EAL until the 0.5 marking, in order to ensure that the EAL reading was consistent with the manual length determination. The choice of the 0.5 marking was based on the EAL’s manual, and does not necessarily represent a 0.5 mm distance short of the working length. The Medtronic Virtuoso™ device (Medtronic USA, Inc., Minneapolis Minnesota), is a multi-programmable, implantable cardioverter defibrillator (ICD). This device monitors and regulates a patient’s heart rate by providing ventricular tachyarrhythmia therapies and rate-responsive bradycardia pacing. Defibrillator position: To simulate realistic clinical circumstances of distance between the mouth and the defibrillator, the ICD was placed 15 cm from the first row of teeth, and the defibrillator leads were placed 10 cm away from the pacemaker (Figure 1). Measurements of effects of apex locaters on functions of the defibrillator: Two EALs were used to test reciprocal effects between EALs and the cardiac defibrillator (BingoPro, Forum Technologies, Rishon Lezion, Israel) and Medic ApexNRG-XFR™ (Afik, Afikim, Israel). The EALs are usually operated by a 7–9 V battery releasing low-intensity electric signs that decrease within the square of the distance.16 According to recommendations, the EAL should be placed at least 15–20 cm from the free edges of the defibrillator electrodes.17 Thus, we placed the defibrillator and electrodes separated from the teeth and from the EAL (Figure 1). The measurements were made with the defibrillator set at maximum sensitivity (unipolar AAI mode, 0.1 mV). Pace monitoring was carried out using a Medtronic CareLink Programmer (Medtronic). First, the effect of the defibrillator was measured on the action of the EAL while the defibrillator was set at maximum sensitivity (unipolar AAI mode, 0.1 mV) without pacing. After obtaining a stable EAL (maintained for 30 s), we programmed the defibrillator to pacing from a low to a high amplitude (1.5/0.4 V to 8/1.5 V) and recorded EAL readings during the pacing. During the second stage, the effect of defibrillator shock administration was assessed on the accuracy of EAL measurements. After pacing, the defibrillator was set to deliver a series of electric shocks starting from the lowest to highest energy level (1 J

CLINICAL resulted in more inaccurate readings, especially for the BingoPro EAL (observed at pacing voltages above 4.5 V).

Discussion This study evaluated interferences during EAL use in patients with ICDs, including the effect of the defibrillator on the accuracy of EAL readings. Data regarding the effect of EALs on the function of pacemakers or defibrillators is abundant in the literature. Some studies have shown absence of interference of EALs with ICD function, in accordance with our study,18-20 while other studies have reported minor11,12 and severe effects.12 An in vivo study examining the effect of electronic dental devices on pacemaker function21 found that pacemaker function was not affected by any of the electronic dental devices tested, including an air scaler, ultrasonic curettes, electric pulp tester, and an electrotome. However, the researchers recommended increased caution in patients with old pacemakers or with standardized dental devices.21 In the present study, the accuracy of both apex locators was interrupted during pacing. Inaccurate readings were obtained for both EALs, although the BingoPro readings were more often interrupted than those of the Medic ApexNRG-XFR. This difference may be attributed to the mode of action of both devices. The function of BingoPro is based on two alternating currents of -500 Hz and 8 kHz. On the other hand, Medic ApexNRGXFR uses square multifrequency currents, which undergo digital processing. According to its manufacturers, the device takes the basic analog signals emanating from the file, before it is exposed to any distortion, and converts it into a digital signal configuration, which is then analyzed. The available reading is an average of the majority of the signals. The multiple currents might compensate for the distortion caused by the ICD by canceling the effects of eccentric results. Most pacemaker power sources deliver approximately 2.5 to 3 V, while ICDs deliver higher energies at 700 to 800 V within 10 to 15 ms.22 Modern ICD designs have been improved with better shapes, more reliability, and more efficient capacitors to produce high voltages than older designs. The higher voltages produced by ICDs as compared to those by EALs may explain the interference of the ICD with adjacent electronic devices (similar to the interferences found with the EALs assessed in this study). The results of this study demonstrate that the EALs tested did not affect ICD function, whereas the ICD had an effect on the accuracy of EAL readings. One explanation for this difference can be related to the difference in the impedance of the tissues involved. The 14 Endodontic practice

average impedance value of normal sheep myocardium was found to be 158 ± 26 Ω,23 whereas the impedance of the oral mucosa was found to be 6.5 Ω.24 Therefore, lower currents are required to provoke a change in a device connected to the oral mucosa (e.g., EAL) compared with a device implanted in the myocardium (e.g., ICD). The importance of a precise working length during root canal treatment is well recognized in the endodontic literature.25 The apical extent of canal filling was found to be a significant prognostic factor for the root canal treatment outcome.25-27 Furthermore, apical extrusion of debris may lead to a higher risk of flare-ups28 and even persistent periapical radiolucency.29,30 Although a tolerance of ± 0.5 to 1 mm seems to exist for accuracy of the EAL as reported in the endodontic literature,31 longer readings in excess of 1 mm to 2.5 mm (BingoPro and Medic ApexNRGXFR, respectively) may lead to substantial clinical implications, especially when treating patients with ICDs. These patients are at higher risk for bacterial endocarditis.32 Therefore, overinstrumentation in patients with ICDs should be avoided to prevent invasion of bacteria into the bloodstream.33

Conclusions The potential impact of electronic dental devices on the function of pacemakers and ICDs has been widely studied.34-36 Although this influence has been reduced with the development of modern pacemakers and ICDs, the prudent dentist should consult with the patient’s cardiologist. Clinical precautions include keeping a distance of at least 10 to 20 cm from the pacemaker or ICD.17 To our knowledge, this is the first study to assess the impact of ICDs on the accuracy of EAL readings. We have shown that some of the length measurements for both EAL devices were longer than the actual lengths, especially under high ICD voltages. Therefore, the potential risk of overinstrumentation during the use of EALs for length determination in patients with an ICD must be considered. EP REFERENCES: 1. Little JW, Simmons MS, Kunik RL, Rhodus NL, Merry JW. Evaluation of an EKG system for the dental office. Gen Dent. 1990;38:278-281. 2. Miller MA, Neuzil P, Dukkipati SR, Reddy VY. Leadless Cardiac Pacemakers: Back to the Future. J Am Coll Cardiol 2015;66:1179-1189. 3. Kotsakou M, Kioumis I, Lazaridis G, et al. Pacemaker insertion. Ann Transl Med. 2015;3:42. 4. Stevenson WG, Chaitman BR, Ellenbogen KA, et al. Clinical assessment and management of patients with implanted cardioverter-defibrillators presenting to nonelectrophysiologists. Circulation 2004;110:3866-3869. 5. Pisano P Jr, Mazzola JG, Tassiopoulos A, Romanos GE. Electrosurgery and ultrasonics on patients with implantable cardiac devices: Evidence of side effects in the dental practice. Quintessence Int. 2016;47:151-160. 6. Tom J. Management of Patients with Cardiovascular Implantable Electronic Devices in Dental, Oral, and Maxillofacial Surgery. Anesth Prog. 2016; 63:95-104. 7. Trenter SC, Walmsley AD. Ultrasonic dental scaler: associated hazards. J Clin Periodontol. 2003;30:95-101. 8. Simon AB, Linde B, Bonnette GH, Schlentz RJ. The individual

with a pacemaker in the dental environment. J Am Dent Assoc. 1975;91:1224-1229. 9.

Dadalti MT, da Cunha AJ, de Araújo MC, de Moraes LG, Risso Pde A. Electromagnetic interference of endodontic equipments with cardiovascular implantable electronic device. J Dent. 2016;46:68-72.

10. Misiri J, Kusumoto F, Goldschlager N. Electromagnetic interference and implanted cardiac devices: the medical environment (part II). Clin Cardiol. 2012;35:321-328. 11. Conde-Mir I, Miranda-Rius J, Trucco E, et al. In-vivo compatibility between pacemakers and dental equipment. Eur J Oral Sci. 2018;126:307-315. 12. Moraes AP, Silva EJ, Lamas CC, Portugal PH, Neves AA. Influence of electronic apex locators and a gutta-percha heating device on implanted cardiac devices: an in vivo study. Int Endod J. 2016;49:526-32. 13. Gomez G, Duran-Sindreu F, Jara Clemente F, et al. The effects of six electronic apex locators on pacemaker function: an in vitro study. Int Endod J. 2013; 46:399–405. 14. Wilson BL, Broberg C, Baumgartner JC, Harris C, Kron J. Safety of electronic apex locators and pulp testers in patients with implanted cardiac pacemakers or cardioverter/defibrillators. J Endod. 2006;32:847-852. 15. Kaufman AY, Keila S, Yoshpe M. Accuracy of a new apex locator: an in vitro study. Int Endod J. 2002;35:186-192. 16. Pinski SL, Trohman RG. Interference in implanted cardiac devices, Part I. Pacing Clin Electrophysiol. 2002;25:1367-1381. 17. AlRahabi MK, Ghabbani HM. Influence and safety of electronic apex locators in patients with cardiovascular implantable electronic devices: a systematic review. Libyan J Med. 2019;14:1547071. 18. Sriman N, Prabhakar V, Bhuvaneswaran JS, Subha N. Interference of apex locator, pulp tester and diathermy on pacemaker function. J Conserv Dent. 2015;18:15-9. 19. Idzahi K, de Cock CC, Shemesh H, Brand HS. Interference of electronic apex locators with implantable cardioverter defibrillators. J Endod. 2014; 40:277-280. 20. Maheshwari KR, Nikdel K, Guillaume G, et al. Evaluating the Effects of Different Dental Devices on Implantable Cardioverter Defibrillators. J Endod. 2015;41:692-695. 21. U Zappa, M Studer, A Merkle, H Graf, C Simona. Effect of electrically powered dental devices on cardiac parameter function in humans. J Endod. 1991; 85:33-36. 22. Mond HG, Freitag G. The cardiac implantable electronic device power source: evolution and revolution. Pacing Clin Electrophysiol. 2014; 37:1728-1745. 23. Fallert MA, Mirotznik MS, Downing SW, et al. Myocardial electrical impedance mapping of ischemic sheep hearts and healing aneurysms. Circulation. 1993;87:199-207. 24. Sunada I. New method for measuring the length of the root canal. J Dent Res. 1962;41:375-87. 25. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long term results of endodontic treatment. J Endod. 1990;16:498-504. 26. Ng L-Y, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of nonsurgical root canal treatment: part 1: periapical health. Int Endod J. 2011;44:583-609. 27. Bergenholtz G, Lekholm U, Milthon R, Engstrom B. Influence of apical overinstrumentation and overfilling on re-treated root canals. J Endod. 1979; 5:310-314. 28. Siqueira JF Jr. Microbial causes of endodontic flare-ups. Int Endod J. 2003; 36:453-463. 29. Nair PN, Sjögren U, Krey G, Sundqvist G. Therapy-resistant foreign body giant cell granuloma at the periapex of a rootfilled human tooth. J Endod. 1990;16:589-595. 30. Yusuf H. The significance of the presence of foreign material periapically as a cause of failure of root treatment. Oral Surg Oral Med Oral Pathol. 1982; 54:566-574. 31. Pagavino G, Pace R, Baccetti T. A SEM study of in vivo accuracy of the Root ZX electronic apex locator. J Endod. 1998;24:438-441. 32. Edelstein S, Yahalom M. Cardiac device-related endocarditis: Epidemiology, pathogenesis, diagnosis and treatment — a review. Int J Angiol. 2009;18:167-172. 33. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group [published correction appears in Circulation. 2007 Oct 9;116(15):e376-7]. Circulation. 2007;116:1736-1754. 34. Lahor-Soler E, Miranda-Rius J, Brunet-Llobet L, Sabate de la Cruz X. Capacity of dental equipment to interfere with cardiac implantable electrical devices. Eur J Oral Sci. 2015;123:194-201. 35. Roedig JJ, Shah J, Elayi CS, Miller CS. Interference of cardiac pacemaker and implantable cardioverter-defibrillator activity during electronic dental device use. J Am Dent Assoc. 2010;141:521-526. 36. Stoopler ET, Sia YW, Kuperstein AS. Does ultrasonic dental equipment affect cardiovascular implantable electronic devices? J Can Dent Assoc. 2011;77:b113.

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CASE REPORT

Introduction

Introduction: The GentleWave® device is claimed to provide more complete irrigation of the root canal system than traditional irrigation methods, potentially resulting in better treatment outcomes. One way to measure the efficacy of a clinical technique or device is to use it to retreat teeth that did not respond to conventional retreatment protocols. Materials and methods: Retreatment was performed on five patients. In each case, the patients remained symptomatic after initial instrumentation, placement of calcium hydroxide paste in the canals for a month, followed by replacement of Ledermix® paste for approximately 2 months. At that point, the teeth were re-accessed, a GentleWave® (Sonendo®) cycle was run, and the teeth were obturated and restored. The patients were contacted by phone 1 day and 1 week later, and four of the patients attended recall appointments at 6-8 months. The fifth patient was contacted and questioned by phone at 6 months, but declined to attend a recall appointment. Results: At the 6-month recall, one patient was unchanged, two were improved but not 100%, and two were symptom-free. The results suggest that the GentleWave system may improve the outcome for some patients who remain symptomatic after traditional retreatment methods.

Irrigation is considered an important contributor to successful root canal treatment. Traditional endodontic treatment utilizes needle irrigation by hand as the primary method. Many products and devices have been developed in an effort to make the irrigation more effective. One such device is the GentleWave (GW) system (Sonendo). Many claims have been made by users about the benefits of GW, some of which are supported by published studies. The claims include more thorough cleaning of the root canal system than other methods, high success rates, less postoperative pain than other methods, obturation of more “accessory anatomy” than other methods, and that single-visit treatment is possible for most teeth. Several in vitro studies reported more thorough cleaning of the root canal system in initial treatment.1-6 One study showed no difference.7 Minimal canal preparation is recommended by Sonendo to maintain as much of the tooth’s structural integrity as possible, and GW was shown to effectively clean canals prepared to size 15.04.8 Several case reports demonstrated an abundance of accessory anatomy obturated after irrigation with GW.9,10 GW was shown to be comparable to other methods (although not very effective) at removing remnants of gutta percha and sealer during retreatment.11,12 One in vitro study reported no apical extrusion of irrigant, as opposed to the findings with hand irrigation.13 Studies reported GW sometimes removes obstructions in the canals14,15 including separated instrument segments.16 Several case series report high short-term success rates;17-19 however, there were no control teeth treated for comparison. Two of the case series articles reported minimal18 or no19 postoperative pain, but a prospective, randomized study reported no difference between GW and hand irrigation.20 A

Rick Schwartz, DDS, graduated from the University of Minnesota School of Dentistry in 1977 and completed a 2-year general dentistry residency. He did a combination of private practice, teaching, and dental materials research before entering endodontic training in 1996. He has authored over 100 publications and was a cover author on three editions of Fundamentals of Operative Dentistry by Quintessence Publishing Co. He is first author of the book Best Practices in Endodontics, also from Quintessence, and is a cover author of Advanced CBCT for Endodontics. For the past 24 years, he has been in full-time private practice limited to endodontics in San Antonio, Texas. He has lectured extensively in the United States and in 17 other countries.

16 Endodontic practice

common criticism of the GW literature is that the majority of the published studies to date were supported by Sonendo. There are many obstacles to performing outcome studies in endodontics that are prospective, randomized, and with adequate power to determine the efficacy of treatments, including studies on new irrigation technologies. One method to evaluate potential benefit is to retreat teeth with previous root canal treatment, which has been refractory to traditional methods. The purpose of this case series is to report the findings of five patients who remained symptomatic after initial treatment followed by conventional multi-visit retreatment of at least three appointments. A GW cycle was added at the last appointment, and the teeth were obturated and restored. Follow-ups of at least 6 months were obtained, and the results are reported.

Materials and methods The five patients in this case series have several things in common. They had received initial treatment within the previous 2 years, and were referred for evaluation because the teeth remained at least mildly symptomatic. Clinical testing was performed on the teeth in the quadrant and opposing quadrant, included biting pressure, percussion, cold, and periodontal probing as well as periapical and bitewing radiographs. Each patient had preoperative CBCT imaging performed as part of the evaluation. Retreatment was initiated, the obturating material was removed with a combination of rotary instruments and chloroform, patency was obtained, and when the canals were considered to be adequately prepared, calcium hydroxide paste was placed with a Lentulo spiral. The process was essentially the same for each patient. An effort was made to minimize the enlargement of the canals during retreatment. Irrigants included 6% sodium hypochlorite (Clorox®), Volume 14 Number 4

Case series Patient 1 This patient was a 65-year-old white female (Figure 1). She reported allergy to penicillin and had been taking Fosomax® for 2 years, but recently discontinued. She was also taking Premarin®, estradiol, and progesterone for postmenopausal symptoms. She originally presented to the author’s practice for evaluation with spontaneous pain, tenderness, and temperature sensitivity in the right mandible. Testing localized the tenderness to tooth No. 30. It was tender to pressure and percussion, and was hyper-responsive to cold compared to the adjacent teeth, but with minimal lingering. There were no cracks evident with transillumination and no significant periodontal probing. The provisional diagnosis was symptomatic irreversible pulpitis with acute apical periodontitis of unknown etiology. A crack was suspected, even though not visualized externally, based on the shallow restoration. Root canal treatment of four canals was completed by the author over two appointments with calcium hydroxide dressing for 30 days. The pulp was hyperemic on entry. No cracks were evident internally with the microscope. She was asymptomatic at the second appointment when the tooth was obturated Volume 14 Number 4

CASE REPORT

which was used throughout instrumentation plus 17% EDTA (Pulpdent®) for the last minute. Both irrigants were activated. At the second appointment, about a month later, all five patients remained symptomatic to some degree. The canals received additional instrumentation and irrigation and Ledermix paste (Reimser Pharma Gmbh) was placed. At the third appointment, about 2 months later, they remained at least mildly symptomatic. At this point, they were considered to be “refractory” to traditional treatment. The teeth were re-accessed, and an 8-minute GentleWave cycle was run. The canals were obturated with gutta percha and a bioceramic cement (Brasseler USA®), and the access was restored immediately with a bonded composite restoration. The patients were called the next day and at 1 week to ask about their symptoms. They were asked if their tooth was completely better (100%), better but not 100%, worse, or the same as before treatment. With one exception, in which the patient declined to return for recall, they were seen again at least 6 months after completion of treatment for evaluation and radiographs. That patient was contacted by telephone.

Figures 1A-1D: 1A. Preoperative. 1B. Postoperative (asymptomatic at this point) initial treatment by the author. 1C. Retreatment was performed at 6-month recall (due to tenderness and periodic spontaneous pain). 1D. 8-month recall after retreatment with GW. Patient 1 was improved but minor symptoms remained. The patient decided she could “live with it”

and restored with a bonded composite resin. The tooth was taken out of occlusion at the first appointment in anticipation of a cuspal coverage restoration. She returned 2 days later with spontaneous pain and tenderness from tooth No. 30. The occlusion was adjusted further, and she was prescribed a Medrol® Dose Pack (Pfizer), which relieved her symptoms. She was back again 5 months later with spontaneous pain and tenderness. Because of periodic symptoms, she had not had any further restorative treatment on tooth No. 30. Testing confirmed tooth No. 30 was the source of her tenderness. A second CBCT scan indicated there were no untreated canals. The following options were discussed: retreatment, surgery, extraction, or no treatment and live with the symptoms. She opted for no further treatment at that point. Six months later, she decided she was tired of “living with it.” Four canals were retreated. Calcium hydroxide was placed initially for a month, followed by 2 months of Ledermix. At each appointment, her symptoms had not improved. At the third appointment, a GentleWave cycle was run, the canals were obturated with gutta percha and a bioceramic cement, and the tooth was restored with a bonded composite resin. Once again, no cracks were visible internally. The author spoke to her several times over the succeeding months. She reported she

improved after the last appointment, but “not 100%.” She said she chews on the tooth comfortably, but is still “aware of it” when she brushes or pushes on it with her tongue. She had a cuspal coverage restoration placed, and no further treatment is planned. Patient 2 This 37-year-old white female (Figure 2) had no significant medical issues. She reported her only prescription drug was for birth control and penicillin-caused hives. She presented with spontaneous pain, tenderness, and temperature sensitivity in the left mandible. Testing localized the tenderness to tooth No. 19. The cold sensitivity was localized to tooth No. 18, which was otherwise normal. The crown and RCT No. 19 were completed 2 months earlier by her general dentist. The diagnosis was previous root canal treatment and acute apical periodontitis. CBCT imaging suggested there were no untreated canals. We discussed the options: no treatment, extraction, or retreatment with the possibility of a cracked root. Surgery was not considered. She was younger than usual for a cracked tooth, but had excessive tooth wear for her age. She opted for retreatment. As an initial step, the heavy occlusion on the zirconia crown was adjusted, but after 3 weeks, there was no improvement in her symptoms. It was noted that the mesial and distal contacts were less than ideal.

Figures 2A-2D: 2A. Preoperative. 2B. Calcium hydroxide in the canals. 2C. Obturation after 3 months of intracanal medication. 2D. 6-month recall after retreatment with GW. Improved but minor symptoms remained Endodontic practice 17

CASE REPORT Retreatment was initiated. No cracks were evident internally. The canals were fully prepared, and calcium hydroxide paste was placed. At 1 month, there was only slight improvement of her symptoms. The tooth was taken completely out of occlusion, the canals received additional instrumentation and irrigation, and were refilled with calcium hydroxide paste. A Medrol Dose Pack was prescribed. The next day the patient reported her tooth felt better, but the steroids made her feel “hot and mean.” After 2 additional months, she was improved, but some chewing tenderness remained. The canals were further instrumented and irrigated, and Ledermix paste was placed in the canals. After 2 additional months, she noted no additional improvement. The tooth was accessed, a GentleWave cycle was run, the canals were obturated with gutta percha and bioceramic cement, and the access opening was restored with bonded composite. The next day she reported she was pain-free, but at 1 week she reported minor symptoms had returned. At 6-month recall she reported she could chew comfortably on that side, but tooth No. 19 “felt different” than her other teeth. She said she was having no problem living with the minor symptoms. The zirconia crown was not replaced. Patient 3 This 53-year-old white female (Figure 3) reported a history of hypertension and hyperlipidemia. She was currently taking metoprolol and enalapril. She presented with asymptomatic chronic apical periodontitis on tooth No. 30. She reported the original RCTs were done about 20 years earlier and had been retreated about 2 years ago. She reported a history of spontaneous pain and tenderness associated with tooth No. 30, but was asymptomatic on the day of her evaluation appointment. The diagnosis was previous root canal treatment and chronic apical periodontitis. CBCT imaging showed the distolingual canal appeared to be untreated. Options presented to the patient were no treatment, extraction, and retreatment. After some discussion, we decided to attempt retreatment. Retreatment was initiated, and no cracks were observed internally. Three plastic carriers were removed, four canals were instrumented to full length, and calcium hydroxide paste was placed. 18 Endodontic practice

Figures 3A-3D: 3A. Preoperative. 3B. Calcium hydroxide in the canals. 3C. Obturation after 3 months of intracanal medication in the canals. 3D. At 6-month recall, she was asymptomatic, and there was radiographic evidence the bone was healing

Figures 4A-4D: 4A. Preoperative. 4B. Axial CBCT slice showing bone loss around the mesial root. 4C. Postoperative. 4D. At 6-month recall, there was no change in her symptoms.

At 1 month, she reported periodic mild spontaneous pain, and tooth No. 30 was mildly tender to pressure and percussion. The canals were further instrumented and irrigated, and Ledermix paste was placed. Two months later, she reported similar symptoms as the previous appointment, although it appeared some regeneration of the bone had occurred based on the periapical radiographs. Access was made, a GentleWave cycle was run, the canals were obturated with gutta percha and bioceramic sealer, and the access was restored with bonded composite. She reported no symptoms after a follow-up 1 day later and 1 week later. At 6-month recall, she reported no further symptoms, and there appeared to be additional evidence of healing on the periapical radiographs. Patient 4 This 73-year-old white female (Figure 4) had knee replacement surgery a year before and was premedicated with amoxicillin per her physician’s instructions. She was taking Prozac® for depression and a “baby aspirin” each day. She presented with biting tenderness in the right mandible. Testing localized the pain to tooth No. 30. The diagnosis was previous root canal treatment and chronic apical periodontitis. The existing RCT was about 2 years old, and she reported periodic pain since it was completed. A scan

suggested no untreated canals, but a radiolucency in the apical area of the mesial root was evident. We discussed the options: no treatment, retreatment, extraction, or apical surgery. She opted for retreatment, which was performed over three appointments as described with the previous patients. Her symptoms never improved. Her pain was largely unchanged the day after retreatment was completed, at 1 week and 6 months. She said she was able to chew soft foods on that side, but crunchy foods were a problem. She declined CBCT imaging at the recall appointment, and subsequently had the tooth extracted. Patient 5 This 71-year-old male (Figure 5) presented with controlled hypertension and hyperlipidemia, and was diagnosed as prediabetic, controlled with diet. The original RCT was performed 6 months earlier by a local endodontist. The canal preparations appeared to be somewhat underprepared and “short,” and the patient had persistent biting pain. Testing indicated tooth No. 30 was the source. The diagnosis was previous root canal treatment and acute apical periodontitis. CBCT imaging indicated no untreated canals. Three options were discussed: no treatment, retreatment, and extraction. He opted for retreatment, which was performed as described with the previous patients over Volume 14 Number 4

REFERENCES 1. 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 2. Ma, Y Shen, Y Yang, Y Gao, et al. In Vitro Study of Calcium Hydroxide Removal from Mandibular Molar Root Canals. J Endod. 2015; 41:553-558. 3. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of Root Canal Debridement of Human Molars Using the GentleWave System. J Endod. 2015;41(10):1701-1705. 4. Wang Z, Shen Y, Haapasalo M. Root Canal Wall Dentin Structure in Uninstrumented but Cleaned Human Premolars: A Scanning Electron Microscopic Study. J Endod. 2018; 44(5):842-848. 5. Choi HW, Park SY, Kang MK, Shon WJ. Comparative Analysis of Biofilm Removal Efficacy by Multisonic Ultracleaning System and Passive Ultrasonic Activation. Materials (Basel). 2019;12(21):3492.

Figure 5A-5B: 5A. Preoperative. 5B. Postoperative. The patient declined to come back for a 6-month recall, but reported no pain or other issues

a 3-month period. He remained symptomatic when he presented at the third appointment. As with the others, A GW cycle was run, the canals were obturated, and the tooth was immediately restored. He was painfree the day after obturation and at 1 week and 6 months. He declined to come in for a 6-month recall, so there is not a recall radiograph available, but he said over the phone he was having no issues, and tooth No. 30 felt the same as his other teeth.

Discussion This case series provides a low level of evidence because of the small sample size and lack of controls, among other things. Like most case series, it is a starting point that suggests there might be value in performing larger, controlled, randomized studies. Historically, the author has primarily performed multi-visit root canal treatment, with calcium hydroxide paste placed in the canals for about a month between the first and second appointment. In most cases, teeth were not obturated until all the signs and symptoms were resolved. About twice a month, patients would return for the second appointment with an ongoing problem. They received additional instrumentation and irrigation, and in most cases, Ledermix was placed. Ledermix is a paste containing the antibiotic demeclocycline hydrochloride and a steroid, triamcinolone acetonide. It is currently not sold in the U.S. Most of the time the patients’ symptoms would resolve within a day or two after the Ledermix was placed. The five cases in this series were exceptions, Volume 14 Number 4

seen over about a 6-month period in 2020. The author prescribes a Medrol Dose Pack on occasion for patients with severe or persistent pain. It consists of 4 mg methyl prednisolone tablets, which the patient takes in a decreasing dose over 6 days. It generally relieves spontaneous pain and tenderness within a few hours of the first dose. In most cases, in a well-treated tooth, the symptoms don’t return. The GentleWave system utilizes 3% sodium hypochlorite for the majority of the irrigation cycle followed by a shorter cycle with 8% EDTA. Wang21 showed less erosion of the canal walls when the irrigants were used in this order compared to the reverse order. According to the company, it works best in small canals with minimal preparation (personal communication). It is interesting to note that all five teeth were mandibular first molars, the most common failures in the author’s practice. Four of the five patients were females. Of the five teeth in this case series, one patient had no improvement of symptoms after the GW cycle, two patients reported improvement; but their symptoms were not completely resolved at recall, and two resolved completely, to the point that the treated teeth were indistinguishable from their surrounding teeth. It is not certain the improvement was due to the GW cycle, of course. Factors such as time, additional instrumentation, and irrigation may have contributed. Nonetheless, the results suggest that some “refractory” teeth, which don’t respond to conventional retreatment

6. Zhang D, Shen Y, de la Fuente-Nunez C, Haapasalo M. In Vitro Evaluation by Quantitative Real-Time PCR and Culturing of the Effectiveness of Disinfection of Multispecies Biofilms in Root Canals by Two Irrigation Systems. Clinical Oral Investigation. 2019;23(2):913-920. 7. Park SY, Kang MK, Choi HW, Shon WJ. Comparative Analysis of Root Canal Filling Debris and Smear Layer Removal Efficacy Using Various Root Canal Activation Systems during Endodontic Retreatment. Medicina (Kaunas). 20201;56(11):615. 8. Zhong X, Shen Y, Jingzhi M, Chen W, Haapasalo M. Quality of Root Filling After Obturation with Gutta-Percha and Three Different Sealers of Minimally Instrumented Root Canals of the Maxillary First Molar. J Endod. 2019;45(8):1030-1035. 9. Ford MW. Complex Apical Anatomy Revealed Following Endodontic Treatment of a Maxillary Molar Using the GentleWave System: A Case Report. Dentistry. 2017;7(8):446. 10. Pullen RV. Root Canal Treatment of a Maxillary First Molar with an Uninstrumented Fifth Canal: A Clinical Case Report. Int J Dent Hyg. 2017;5(1):219. 11. Wright C, Glickman G, Jalali P, Umorin M. Effectiveness of Gutta-Percha/Sealer Removal During Retreatment of Extracted Human Molars Using the GentleWave System. J Endod. 2019;45(6):808-812. 12. Crozeta BM, Chaves de Souza L, Silva-Sousa YTC, et al. Evaluation of Passive Ultrasonic Irrigation and GentleWave system as adjuvants in endodontic retreatment. J Endod. 2020;46(9):1279-1285. 13. Charara K, Friedman S, Sherman A, et al. Assessment of Apical Extrusion During Root Canal Irrigation with the Novel GentleWave System in a Simulated Apical Environment. J. Endod. 2016;42(1):135-139. 14. Chan R, Versiani M, Friedman S, Malkhassian G, SousaNeto M, Leoni G, Silva-Sousa Y Basrani B. Efficacy of Three Supplementary Irrigation Protocols in the Removal of Hard Tissue Debris from the Mesial Root Canal System of Mandibular Molars. J Endod. 2019;45(7):923-929. 15. Chen B, Szabo D, Shen Y, et al. Removal of Calcifications From Distal Canals of Mandibular Molars by a Non-Instrumentation Cleaning System: A Micro-CT Study. Endod J. 2020; 46(1):11-16. 16. Wohlgemuth P, Cuocolo D, Vandrangi P, Sigurdsson A. Effectiveness of the GentleWave System in Removing Separated Instruments. J Endod. 2015;41(11):1895-1898. 17. Sigurdsson A, Le KT, Woo SM, et al. Six-Month Healing Success Rates After Endodontic Treatment Using the Novel GentleWave System: The PURE Prospective Multicenter Clinical Study. J Clin Exp Dent. 2016;8(3):290-298. 18. Sigurdsson A, Garland RW, Le KT, Woo SM. 12-Month Healing Rates After Endodontic Therapy Using the Novel GentleWave System: A Prospective Multicenter Clinical Study. J Endod. 2016;42(7):1040-1048. 19. Sigurdsson A, Garland RW, Le KT, Rassoulian SA. Healing of Periapical Lesions After Endodontic Treatment with the GentleWave Procedure: A Prospective Multicenter Clinical Study. J Endod. 2018;44(3):510-517. 20. Grigsby D Jr, Ordinola-Zapata R, McClanahan SB, Fok A. Postoperative Pain after Treatment Using the GentleWave System: A Randomized Controlled Trial. J Endod. 2020;46(8):1017-1022. 21. Wang Z, Maezono H, Shen Y, Haapasalo M. Evaluation of Root Canal Dentin Erosion After Different Irrigation Methods Using Energy-Dispersive X-ray Spectroscopy. J Endod. 2016;42(12):1834-1839.

Endodontic practice 19

CASE REPORT

protocols and 3 months of an intracanal dressing, may benefit from the addition of GW irrigation. EP

TECHNIQUE

The GEMS method Drs. Hamid R. Abedi and Farzad Foroughi explain a novel approach for flapless endodontic surgery Introduction It has been shown that endodontic microsurgery is the most cost-effective treatment modality for failing endodontically treated molar teeth.1 The success rate of endodontic surgery in a large study of 424 molars over 10 years shows an average of 84% to 88.5%.2 Another study shows survival as even higher at 94%.3 This is similar to the success rate of implants, which often uses less strict criteria for success relying on survivability and retention instead of success.4 There are very few studies looking at tooth retention comparing endodontic surgery and singletooth implants. What should a clinician do with a tooth that has not healed after conventional root canal therapy? The choices range from retreatment and/or new coronal restoration to endodontic microsurgery and extraction and replacement with a fixed dental partial or single-tooth implant. Over the past few decades, considerable advances have been made in both dental implants and endodontic microsurgery (EMS). Traditional endodontic surgery (TES) has been performed for over 100 years and consisted of anesthesia, raising a full-thickness flap, root-end resection, retrograde preparation of the apical part of the canal using a handpiece and bur, and placement of a root-end filling often in the form of amalgam.5 Current endodontic microsurgery (EMS) uses newer technologies in the form of enhanced lighting and magnification, often

entailing the use of an operating microscope to better identify canals, fractures, and isthmuses; dyes to delineate lamina dura, piezo, or ultrasonic root-end preparation instruments facilitating accurate root-end preparation along the long axis of the root canal in a conservative manner without blocking visibility; and new root-end filling materials, such as mineral trioxide aggregate (MTA), and nano bioceramic materials that have improved leakage resistance, biocompatibility, antimicrobial properties, and moisture tolerance.6,7 In addition, better bone grafting and membranes can help in certain periodontal defects that can occur during surgery. Recent meta-analyses indicate that EMS is more successful than TES.8 Surprisingly, healing tends to occur more rapidly after endodontic surgery than conventional nonsurgical root canal therapy.9 With the increased usage of CBCT, there is undoubtedly an increase in the diagnosis of periradicular lesions and pathologies. Many studies have shown much improvement in diagnosis of periradicular lesions with CBCT compared to conventional periapical radiographs by a factor of 3 times to 4 times.10 Endodontic microsurgery is inherently a difficult procedure, and in the last decade, there have been efforts to simplify the procedure by using guides. CAD/CAM guides were used in 2007 to help with the osteotomy and root-end resection.11 Guided endodontic microsurgery (GEMS) is a proven technique for treating

failing nonsurgically retreated teeth. By using cone beam computed tomographic imaging (CBCT), design by CAD software, and 3D-printing technology, it is possible to address some of these challenging cases, while a small number of research articles and presentations in this area explain the use of a single surgical hard tissue guide adapted from implant surgery.12 There are limited comprehensive techniques that address both the hard and soft tissues in a flapless technique. The authors have developed a soft tissue guide that integrates with the hard tissue guide to allow minimally traumatic surgery for both the hard and soft tissues. The authors have performed more than 30 surgeries using the GEMS procedure and are currently working with the University of California, San Francisco, on clinical trials. In addition, there is exciting work being done to allow guided root-end filling placement. The GEMS protocol was written by the Cornerstone Specialty Products’ (CSPs’) R&D team (Protocol number CSP20210115-V2) and the surgical stent filed for patent in June 2018 (Patents number: US2020/0000549A1, US2020/0306008A1 and US2021/0022831A1). First, the doctor should take a full CBCT and intraoral scan of the patient. The intraoral scan must sufficiently cover enough buccal soft tissue up to the mesiobuccal fold. Many IO scanners allow operators to disable the artificial scan to extend beyond the limits of the attached gingiva. After completion, the DICOM and

Hamid R. Abedi, DDS, MS, MBA, has been practicing dentistry and is a former Assistant Professor at Loma Linda University, Department of Endodontics. He enjoys teaching endodontics and has lectured extensively in his specialty field both in the United States and abroad. Farzad Foroughi, MBA, PhD in Biomedical engineering (Dental Materials), is a biomaterials and tissue engineering scientist with substantial hands-on experience in 3D biomaterials. His interests are in dental materials and dentistry devices design. Disclosure: Dr. Hamid R. Abedi is founder/CEO of Cornerstone Dental Specialties.

20 Endodontic practice

Figures 1A and 1B: After anesthesia. 1A. A properly designed and carefully reflected flap will result in proper access and post-op healing. The basic principles of full thickness semilunar flap design should be followed. Place the surgical stent as indicated in the following picture. Regarding the patient’s tissue, flap design is flexible (vertical or horizontal). 1B. The surgical stent should be placed gently on the teeth so that the tissue is directed toward the back of the tissue separator Volume 14 Number 4

TECHNIQUE A.

Figures 2A-2F: GEMS method requires two files to complete the stent. 2A. CBCT (DICOM format) from the patient. 2B. 3D oral scan (STL format). 2C. Imported both format files on 3Shape software and designed a custom stent. 2D. After design, the stent is 3D-printed. 2E. The stent and stopper are ready to use. The stopper will control the depth of the trephine bur. 2F. All tools will be shipped to doctor for surgery (stent, stopper, trephine bur, surgical blade, and absorbable suture) A.

STL files are sent to CSPdental.com to design and create the GEMS guide. Insert the trephine bur with the stopper attached into the surgical stent. Practice caution, and move slowly while drilling through bone until the stopper touches the stent body. In some cases, there is debris from the root tip or bone left in the surgical site. You can remove it with bone curette. The surgical site is flushed with copious amounts of sterile saline to remove soft and hard tissue debris, hemorrhage, blood clots, and excess root-end filling material. Before injecting the bone graft, take a radiograph to verify that the canal is properly prepared with the rotary instruments. By developing a robust methodology, the authors can help clinicians perform the GEMS approach and maintain a natural dentition. The GEMS method is wholly owned by Cornerstone Specialty Products (CSP), LLC. For information, visit www.cspdental.com. Courses will be available, including live patient demonstrations. To register, go to www.ctidental.org. EP

REFERENCES 1. Kim SG, Solomon C. Cost-effectiveness of endodontic molar retreatment compared with fixed partial dentures and single-tooth implant alternatives. J Endod. 2011;37(3):321-325.

2. Bliggenstorfer S, Chappuis V, von Arx T. Outcome of Periapical Surgery in Molars: A Retrospective Analysis of 424 Teeth. J Endod. 2021;47(11):1703-1714. 3. Taschieri S. Fabbro M. Testori T. Weinstein R. Microscope versus endoscope in root-end management: a randomized controlled study. Int J Oral Maxillofac Implants. 2008;37(11):1022-1026. 4. Norton MR, Wilson J. Dental implants placed in extraction sites implanted with bioactive glass: human histology and clinical outcome. Int J Oral Maxillofac Implants. 2002;17(2):249-257. 5. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique. J Endod. 2006;32(5):412-416. 6. Wuchenich G. Meadows D. Torabinejad M. A comparison between two root end preparation techniques in human cadavers. J Endod. 1994;20(6):279-282. 7. Torabinejad M, Pitt Ford TR, McKendry DJ, et al. Histologic assessment of mineral trioxide aggregate as a root-end filling in monkeys, J Endod. 1997;2:223(4)5-228.

8. Setzer FC, Shah SB, Kohli MR, et al. Outcome of endodontic surgery: a meta-analysis of the literature–part 1: Comparison of traditional root-end surgery and endodontic microsurgery. J Endod. 2010;36(11):1757-1765. 9. Iqbal MK, Kratchman SI, Guess GM, et al. Microscopic periradicular surgery: perioperative predictors for postoperative clinical outcomes and quality of life assessment. J Endod. 2007;33:239-244. 10. Patel S, Dawood A, Mannocci F, et al. Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J. 2009;42(6):507-515. 11. Pinsky HM, Champleboux G, Sarment DP. Periapical surgery using CAD/CAM guidance: preclinical results. J Endod. 2007;33(29:148-151.

Figures 3A-3C: 3A. CBCT pattern from a patient and sent to CSP lab studio shows tooth No. 13 has a large lesion. 3B. The process of the design is shown. The location of the stent was designed on the lesion. 3C. The case followed 10 months’ post-surgery demonstrating full tissue healing 22 Endodontic practice

12. Strbac GD, Schnappauf A, Giannis K, Moritz A, Ulm C. Guided Modern Endodontic Surgery: A Novel Approach for Guided Osteotomy and Root Resection, J Endod. 2017;43(3):496-501.

Volume 14 Number 4

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

Submitting articles Endodontic Practice US requires original, unpublished article submissions on endodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 2,400 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Endodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to endodontics. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 14 Number 4

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text. Number tables consecutively and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

Manuscript review All clinical and continuing education manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkmedia.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

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

Endodontic practice 23

CONTINUING EDUCATION

Maintenance and retention of dental records Dr. Bruce H. Seidberg discusses legal obligations of dentists for record keeping Introduction Dentists have both a professional and a legal obligation to maintain clinically relevant, accurate dental records of their patients. These records not only are essential for the continuity of treatment and evidence in the case of a dispute or litigation, but also obviate the need for assumptions regarding a dentist’s usual practice and for the transfer of records at the time of a sale of the practice or retirement of the provider. They chronologically document the care of a patient and enhance communication between the provider and other healthcare professionals.1 One of the primary sources of information for litigation is the patients’ record, which can substantiate or diminish a claim.

Major considerations Two major considerations determining the length of time records must be retained: 1. The legal requirements set forth by federal and state laws and individual state dental acts. 2. The allegations of civil actions alleging malpractice or breach of contract.2 Beyond patient care, the dental record is important because it may be used as evidence in court or in a regulatory action to establish the diagnostic analysis that was performed and what treatment was rendered to the patient. A quality dental record can be used to respond to a patient complaint, in defense of allegations of malpractice, or to justify treatment in case of an audit by a third-party payor. An allegation of professional negligence can arise long after treatment has been

Bruce H. Seidberg, DDS, MScD, JD, is a consultant for dental malpractice cases and recently retired Board-certified endodontist. He is a Past President of the American College of Legal Medicine and of the Onondaga and Cayuga County Dental Societies and a Past Chairman of the NYS Board for Dentistry. Dr. Seidberg is a graduate of the SUNY Buffalo School of Dentistry, Boston University School of Graduate Dentistry, and Kensington University College of Law. He has been awarded the AAE Presidential Award for his dedication to endodontics and the ACLM Gold Medal for his work on behalf of law and dentistry. Dr. Seidberg has lectured about risk management issues in the dental office and can be reached at bseidberg@me.com.

24 Endodontic practice

Educational aims and objectives

This self-instructional course for dentists aims to identify proper maintenance and retention of dental records.

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 reasons for maintaining dental records for certain periods of time.

•

Realize the need for certain considerations determining the length of time that records must be retained.

•

Identify the Doctrine of Continuous Treatment and the Foreign Object Doctrine and how those affect the Statute of Limitations.

•

Recognize what patients are legally entitled to regarding their records.

•

Identify who is responsible for maintaining records in certain circumstances.

•

Identify options for a records storage services.

completed, so ideally patient records should be maintained indefinitely. The actual length of time records must be kept is usually determined by a Statute of Limitation (SOL) law3 — a period of time established by statute, measured in years, within which a party may bring a lawsuit.4 The SOLs differ based on the cause of action and from state to state. For example, in New York State, professional negligence is 2½ years from the date an act occurred or failed to occur. The SOL for minors is extended to 2½ years past the age of 18 for all malpractice causes of action and for a maximum limit of 10 years from the last treatment date. These dates may vary for minors. It is important to understand the SOLs of the state in which a provider practices because they clearly define the length of time required to retain records of adults and minors.

2½ years from 12/1/15 to 6/1/18. This doctrine applies to adults and is adjusted accordingly for minors. The Foreign Object Doctrine extends the SOL 1 year from the date of discovery of the object or 1 year from the date a reasonably prudent person should have discovered the object. Foreign objects are unintentionally implanted in a body; i.e., a file used in an endodontic procedure or separated instrument, or a sponge used in a surgical procedure — not objects that are intentionally implanted such as prosthetic devices or dental implants. The Foreign Object Doctrine can be neutralized if the practitioner informs the patient about the event and documents the foreign object and conversation with the patient; i.e., an endodontic-separated instrument or excessive overextended endodontic filling/sealer material.

Legal doctrines

Clinical components

Two doctrines can extend the Statute of Limitation (SOL): the Doctrine of Continuous Treatment and the Foreign Object Doctrine. The Continuous Treatment extends the SOL calculated from the last date of treatment of the specific matter about which the complaint is made. For example, if there is a procedure completed on tooth No. 3 on 6/1/15, then 2½ years for action would be 12/1/17. However if that procedure on tooth No. 3 is adjusted or altered on 12/1/15, the tolling of time for action would be extended

Dental records can be your best friend or your worst enemy. Dental records consist of many clinical components: • patient demographics • medical history • dental history • SOAP diagnostics • radiographs • photographs • study models • copies of all correspondence • copies of prescriptions Volume 14 Number 4

informed consent documentation referrals for specialty treatment treatment progress notes all financial records including, but not limited to, insurance communications.5,6,7,8,9 The patient record is the actual means of communication between the treating practitioner and other clinicians who may treat that patient in the future or with third parties. Patients are mobile and change providers for many reasons. The dental records must be accurate and contain enough information to allow another provider to understand the patient’s history of treatment in a prior office.10 The patient record may also be used as evidence in court or in a regulatory action to establish the diagnostic analysis that was performed, and what treatment was rendered to the patient. If documented properly, the record can successfully be used to respond to a patient complaint in defense of allegations of malpractice, or to justify treatment in case of an audit by a third-party payor. If the record is not accurately maintained, it will be your worst enemy. Accurate contemporaneous records are essential evidence in the case of a dispute or litigation. Patients are legally entitled to access their complete dental records, and upon request, the dental office must provide the patient with a copy of all requested records in a timely fashion, usually within 10 working days. Providers are advised to provide only copies of requested documents and to retain all original ones. Now that more records are in electronic format, the new Open Notes Rule (aka the Federal Information Blocking Rule) requires those reports to also be accessible.11 The electronic technology challenges existing systems for ensuring confidentiality. The benefit of rapid accessibility to information must be balanced against the potential impact on confidentiality. Therefore, procedures must provide security against unauthorized access to stored and retained files.12 In the event there is a claim of lost records, or they are not made available either to the patient or third party in a litigation proceeding, the provider can be subject to an allegation claim of spoliation. A provider cannot single out one particular document or record and destroy it without looking guilty.13 Spoliation is a charge of purposely destroying or failure to preserve evidence that is necessary for understanding previous treatment or to aid in the defense of pending litigation.14 If the court determines that the records were destroyed purposely or prematurely, Volume 14 Number 4

the court would more likely than not instruct the jury that had the records actually existed and had been produced in court, they would have proved facts favorable to the plaintiff. However, had the records been produced, the defense could have a more favorable opportunity to succeed.15

Practice structure In a multipractitioner practice of any nature, the party responsible for maintaining the original patient record of all patients treated at that practice facility will be determined by the type of professional corporation (PC) or structure of the practice and the sales agreement. Unless the agreement specifies differently, the professional corporation (the buyer) would more likely than not be considered the owner of the dental records of the seller, whether paper or electronic and whether or not the new owner was involved in the patient’s treatment. If the structure of practice is an officesharing arrangement, and the dentist is an independent contractor rather than practice employee, each dentist would likely be considered as practicing under a separate legal entity, whether it be a PC, limited liability company, partnership, or solo proprietorship. Associate agreements, either for employee associates or independent contractors, should include language that specifies the associate’s access to patient charts and ownership issues.16 State laws may also specify the obligations of buyer and/or seller regarding record ownership, maintenance and/or retention in the event of a practice sale. If the practice has been sold, the sales agreement itself should spell out the terms for record retention and access, but it must be compliant with state laws. When a dental practice is purchased, the existing dental records become proprietary to the new owner. According to most state regulations, the new dentist must maintain these records for a minimum of 5 years from the last dated entry, even if the new dentist did not provide the most recent services.

Record storage Paper records can take up enormous amounts of space and require dry secure storage. They should not be left in public areas where nonauthorized personnel can gain access to them. To save space, records can be converted to microfilm (or microfiche), which takes up a lot less space than paper records. Another option is to opt for a records storage service. This method can be expensive over several years. In those

dental offices that are considered covered entities, a HIPAA business associate agreement may be required if outsourcing records storage. Diagnostic and/or treatment casts may be photographed and stored in some cases. However, prior to completely converting records to one of these methods, a dentist should consult with his/her own attorney and professional liability insurance company. Electronic storage is another option. Although time-consuming, paper records can be scanned to a hard drive, which should then have a backup made to another drive. One of the hard drives should be stored in a safe deposit box and the other available to stay with the originator. The benefit of this method is that a retired originator may choose to live in different parts of the country for periods of time but will always have accessibility to records if and when necessary. The keeper of records is always responsible for record confidentiality and integrity and provide protection from vulnerability to a hacker’s attack. State laws must be followed. State law can be quite specific on regulations related to healthcare record keeping.17 All dentists and healthcare providers should have record retention policies that are consistent with federal and state statutory and regulatory requirements and statutes of limitation. The policy should include, but not be limited to, protection of records against loss or destruction and laws of confidentiality. All employees should have knowledge of the policy to avoid the unintentional destruction of any patient record. The policy should include provisions for the maintenance and destruction, as appropriate, of patients’ records in the event of the dentist’s death. Patient records may be important documents in the event of a malpractice suit against the dentist’s estate after his/her death. The office’s professional liability insurance company will likely have recommendations about retention. Many liability insurance carriers recommend that patient records be kept for a minimum of 7 years from the date an adult patient was last seen, and 7 years after a minor patient’s last treatment or when the minor patient turns 21, whichever is longer. They also generally recommend a minimum of 7 years retention after retirement or practice closure. In some states, proper maintenance and retention is a requirement of having a dental license.18 Accurate legible records are always required from a legal/risk management perspective. Endodontic practice 25

CONTINUING EDUCATION

• • • •

CONTINUING EDUCATION The length of time for the retention of records for active clinical practices is the same, or similar, in each governing state as it is for the sale of a practice or retirement. There is a difference in retention time for adults’ records and those of minors. The best advice would be to keep original patient records forever,19 but that may not be feasible in some cases. Requirements vary from state to state for adults from a 2-year period to 7 years or longer. If they are not kept permanently, then a 10-year retention period for adults is highly recommended.20 Minors are generally defined as age 18 and under, and their records must be kept until the age of 21 or as calculated by the Statute of Limitations of each state. In no event should records of a minor be destroyed in less than 7 years.21

Check current state statutes and regulations Although most state statutes are in place, legislative bodies are known to have changed them from time to time. Therefore, always check the current status of your states’ regulations before making final decisions about retention or destruction of records. The following list includes examples of current state statutes and regulations that govern record retention Illinois: 2.6 Dental records must be stored securely and safeguarded against loss or damage including a secure backup of electronic records. 2.7 Dental practitioners should be aware of local privacy laws that govern the retention of records, which require retention from 7-10 years. Dental records must be stored securely and safeguarded against loss or damage including a secure backup of electronic records.22 California: The minimum retention time of patient records is 7 years only if the dentist ceases operation. Beyond that, California law does not specify the period of time that patient records must be maintained after the patient discontinues treatment.23 Pennsylvania: A patient’s dental record must be maintained by a dentist for a minimum of 5 years from the date of the last dental entry.24 New York: Professionals are required to maintain records for each patient that accurately reflect the evaluation and treatment of the patient according to section 29.2(a) (3) of the Rules of the Board of Regents. All patient records must be retained for at least 6 years, with the exception of records for minor patients, which must be maintained for at least 6 years and for 1 year after the minor patient reaches the age of 26 Endodontic practice

21. Dentists who retire or sell their practices must make provisions for records to be maintained and accessed, if requested. The obligation to maintain records is not changed by the retirement or sale of a practice by a dentist.25 Texas: Dental licensee shall make, maintain, and keep adequate dental records for and upon each dental patient for reference, identification, and protection of the patient and the dentist. Records shall be kept for a period of not less than 5 years from the last date of treatment by the dentist. If a patient was younger than 18 years of age when last treated by the dentist, the records shall be maintained by the dentist until the patient reaches age 21 or for 5 years from the date of last treatment, whichever is longer.26 Florida: A dentist shall maintain the written dental record for a period of at least 4 years from the date the patient was last examined or treated by the dentist. Malpractice or HIPPA laws may require a longer retention.27 Ohio: Records should be retained “in line with NHS recommended Retention Schedule.” This states that general Dental Services records should be retained for a minimum period of 10 years from the date of discharge of the patient from the practice or when the patient was last seen.28 Colorado: All patient records must be kept for 7 years after the patient’s last dental visit, or 7 years after the patient turns 18 for all pediatric patients.29 Washington: A licensed dentist shall keep readily accessible patient records for at least 6 years from the date of the last treatment.30 Tennessee: Dental records shall be retained for a period of not less than 7 years from the dentist’s or his supervisees’ last professional contact with the patient except for the following: Dental records for incompetent patients shall be retained indefinitely. Dental records of minors shall be retained for a period of not less than 1 year after the minor reaches the age of majority or 7 years from the date of the dentist’s last professional contact with the patient, whichever is longer. Notwithstanding the foregoing, no dental record involving services which are currently under dispute shall be destroyed until the dispute is resolved.31

Records retention The American Medical Association (AMA) and American Medical Records Association (AMRA) recommend a 10-year retention period and the Joint Commission

for Accreditation of Healthcare Organizations (JCAHO) states that retention time should depend upon the need for using the records in continuing patient care and for legal, research, or educational purposes, and on law and regulations.32 The ADA states that retention of records following a patient’s last visit varies with state laws and provisions of contracted dental benefit plans. The ADA recommends checking with your attorney, state dental board, or state dental association for specific requirements of your state.33 In the sale of a practice or retirement, all patients of record must be notified of the provider’s intent to either transfer the records to a subsequent provider or how to access them after a certain date if necessary. Notification should be done by certified mail with signed returned receipt. A copy of notification should be kept in the patient’s record. Records cannot be transferred to another provider without the permission of the patient and without violating the laws of confidentiality. Unless the patient objects at the time of the notification, or within a reasonable time, confidentiality may be waived.34 Patients must be given the opportunity to request copies of their records or to have them sent to a new provider; requests should be in writing. Some states, like Colorado, specify within their codes a specific format to follow for the notification: “When a dental office plans to dispose of records, affected patients must be notified by email, mail, or publication at least 60 days prior to destruction. Affected patients must have at least 30 days to claim their records, and these records must be provided at no charge. Notice by publication must be placed in both a major and community newspaper (one day per week for four consecutive weeks). The posting can be done either in print or online. HIPAA compliant destruction methods must be followed for both paper and electronic records.”35 Patients can request a copy of their records for whatever purpose; i.e., personal use or transferring to another provider. The original provider must comply within a reasonable time, such as 10 working days; the request should be in writing and documented in the record. The provider should always keep the original records and only provide copies. It is legal to charge for the copying of records as most states have a set amount for copying pages. A reasonable charge can made for duplicating radiographs and models.36,37 Unlike the scenario of the mobile patients requesting copies of Volume 14 Number 4

7. Seidberg, BH. Risk Management Concepts for Dentists. Endodontic Practice US. 2015;8(1). 8. Seidberg BH. Principles of Informed Consent. Orthodontic Practice US. 2019;10(1). 9. Seidberg BH. Record Keeping in Dentistry. Nevada Dental Journal. 2010. 10. Seidberg BH. Record Keeping in Dentistry. Nevada Dental Journal. 2010. 11. Clark C. Open Notes Shines Light on Errors in Patient Medical Records. MedPage®. https://www.medpagetoday.com/special-reports/exclusives/94504. Published September 15, 2021. Accessed November 8, 2021. 12. Appleby K, Tarver J. “Understanding Medical Records.” Medical Records Review. 3rd ed. Gaithersburg, MD: Aspen Law & Business, Division of Aspen Publishers; 1999.

1. Roach WH Jr, Younger P, Conner C, Cartwright KK. Medical Records and the Law. 2nd edition. Aspen Publication; 1994. 2. Pollack BR: Handbook of Dental Jurisprudence and Risk Management. Littleton, MA: PSG Publishing Co; 1987. 3. Appleby K, Tarver J. “Understanding Medical Records.” Medical Records Review. 3rd ed. Gaithersburg, MD: Aspen Law & Business, Division of Aspen Publishers; 1999.

22. Illinois General Assembly 225 ILCS 25/50 23. California Health and Safety Code: Section 123145. 24. Pennsylvania Regulations: Title 49 Pa Code § 33.209(b). 25. NYS Dentistry: Practice Guidelines; Office of the Professions wwwop.nysed.gov. 26. Texas Code: 22 Tex. Admin. Code § 108.8, 27. Florida Rule 64B5-17.002(2), FAC 28. Ohio Rule 3701-83-11, General medical records, Ohio Revised Code: July 30, 2019.

13. Foreman D. Dental Law: The Complete Guide to the Business of Dentistry. Directed Media, Inc.; 1990.

29. New State Recordkeeping Rules. Journal of the Colorado Dental Association. Winter 2017;96(1).

14. Gaffney N. “How Long is a Dentist Required to Keep Patient Records” (blog). https://hallboothsmith.com/how-long-isa-dentist-required-to-keep-patient-records/. Published Nov 19, 2020. Accessed November 8, 2021.

30. Washington State: WAC 246-817-310 patient record retention and accessibility requirements.

15. Seidberg BH. Author’s Risk Management Lecture Series; 2015-2019

32. Appleby K, Tarver J. “Understanding Medical Records.” Medical Records Review. 3rd ed. Gaithersburg, MD: Aspen Law & Business, Division of Aspen Publishers; 1999.

16. American Dental Association, 2010, ada.org

31. Tennessee: Tenn. Comp. R. & Regs. 0460-02-.12, Practice of Dentistry TCA 63-5-108.

33. ADA Center for Professional Success, ada.org

17. American Dental Association, 2010, ada.org 18. Gaffney N. “How Long is a Dentist Required to Keep Patient Records” (blog). https://hallboothsmith.com/how-long-isa-dentist-required-to-keep-patient-records/. Published Nov 19, 2020. Accessed November 8, 2021. 19. Pollack BR: Handbook of Dental Jurisprudence and Risk Management. Littleton, MA: PSG Publishing Co; 1987. 20. Seidberg, BH: Authors Risk Management Lecture Series,

34. Pollack BR: Handbook of Dental Jurisprudence and Risk Management. Littleton, MA: PSG Publishing Co; 1987. 35. New State Recordkeeping Rules. Journal of the Colorado Dental Association. Winter 2017;96(1). 36. Ohio Revised Code § 3701.741. 37. New York Sections 17 and 18 of Public Health Law (PHL), Laws of 1991, Chapter 165, sections 48 and 49.

A PERSONALIZED COACHING PROGRAM FOR ENDODONTISTS

Disclaimer: The material presented in this manuscript is for general information intended to provide helpful information for the reasons why records must be maintained, retained, and when and how to dispose of them. This is not intended to substitute for, or be interpreted, as actual legal advice. It is intended solely for the purpose to be used as suggestions to reduce and manage various risks in the practice of dentistry and medicine. Readers should communicate with their personal attorney and professional liability carrier for the actual legal advice pertaining to any legal dispute they may be involved in. Readers are encouraged to be familiar with the dental practice act, the statutes of limitation, and regulations of the state they practice within for the maintenance and retention of patient records policies prior to disposing of them.

REFERENCES

2015-2019. 21. Appleby K, Tarver J. “Understanding Medical Records.” Medical Records Review. 3rd ed. Gaithersburg, MD: Aspen Law & Business, Division of Aspen Publishers; 1999.

PRODUCTIVE SCHEDULING

30-MIN FREE PRACTICE ASSESSMENT CALL EMAIL TO SCHEDULE

INFO@ENDO2ENO.COM

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4. Roach WH, Younger P, Conner C, Cartwright KK. Medical Records and the Law, Aspen Publication. 1994. 5. Seidberg BH. Understanding the legal concepts of informed consent; The Bulletin, New York State Fifth District Dental Society, V56#2, 2011. 6. Seidberg, BH: Principles of Informed Consent; NYSAGD Journal; Winter 2015.

Volume 14 Number 4

CLINICAL EFFICIENCY

endo2endo.com Endodontic practice 27

CONTINUING EDUCATION

their records for personal use or to have them sent elsewhere because of changing providers and who can be charged a fee determined by state law,36,37 the patients cannot be charged when it is the provider initiating the request. Records should not be destroyed any time prior to the federal or state law timeline, and it is highly recommended that they be kept for a period of time longer than any recommendation. When the decision is made to dispose of records, they should not be destroyed in a casual manner or by just delivering them to a local transfer station (dump). The most common way to ensure that records are completely destroyed safely is to shred them. Some practices choose to do this themselves, while others outsource the work to a professional shredding company. Keep in mind that just as with a storage company, you will need a business associate privacy agreement or a certificate of the dated shredding. Because an allegation of professional negligence can arise long after treatment has been completed, the sale of an office, retirement, and even death, patient records should ideally be maintained indefinitely. That may be realistic but not practical in all cases. Providers are encouraged to be familiar with the dental practice act and the statutes of limitation and regulations of the state they practice within for the maintenance and retention of patient records policy prior to disposing of them. EP

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: 550 Date Published: December 7, 2021 Expiration Date: December 7, 2024

Maintenance and retention of dental records SEIDBERG

1. A. quality dental record can be used to respond ________. a. to a patient complaint b. in defense of allegations of malpractice c. to justify treatment in case of an audit by a third-party payor d. all of the above 2. The _______ extends the Statute of Limitations (SOL) calculated from the last date of treatment of the specific matter about which the complaint is made. a. Doctrine of Continuous Treatment b. Doctrine of Clinical Components c. Open Notes Rule d. Doctrine of Destroyed Records 3. _______ must be accurate and contain enough information to allow another provider to understand the patient’s history of treatment in a prior office. a. The phone call to the new dentist to summarize previous treatments b. Dental records c. The dentist’s recollection of treatment d. The patient’s recollection of treatment 4. Patients are legally entitled to access their complete dental records, and upon request, the dental office must provide the patient with a copy of all requested

28 Endodontic practice

records in a timely fashion, usually within ____ working days. a. 3 b. 7 c. 10 d. 14 5. Now that more records are in electronic format, the new _______ require(s) dental records to be accessible. a. Open Notes Rule b. Federal Information Blocking Rule c. Foreign Objects Rule d. both a and b 6. (Regarding electronic technology) The benefit of rapid accessibility to information must be balanced against the _______. a. potential loss of financial remuneration b. potential loss of referrals c. potential impact on confidentiality d. potential for an audit 7. _________ is a charge of purposely destroying or failure to preserve evidence that is necessary for understanding previous treatment or to aid in the defense of pending litigation. a. Spoliation b. Misclassification

c. Document exemption d. The Stark Law 8. If the structure of practice is an office sharing arrangement, and the dentist is an independent contractor rather than practice employee, each dentist would likely be considered as practicing under a separate legal entity, whether it be a _______ or solo proprietorship. a. PC b. limited liability company c. partnership d. all of the above 9. In no event should records of a minor be destroyed in less than ______. a. 1 year b. 3 years c. 7 years d. 10 years 10. When using a shredding company, you will need _______. a. a business associate privacy agreement or a certificate of the dated shredding b. a photograph of the shredding truck on your premises c. to keep a small bag of the shreds as evidence of the shredding d. an assistant to witness the shredding

Volume 14 Number 4

CE CREDITS

ENDODONTIC PRACTICE CE

Ali Oromchian, JD, LLM, offers suggestions to find out about your potential new hires without legal concerns

hen you’re in the position of leading a company or charged with hiring a team to run a practice, you want to make sure you’re hiring the best possible candidates. However, when your business is a dental practice, it’s not only your financial success that’s a concern, but also people’s dental health and overall well-being. That’s why the job interview is essential to master — it‘s the key to bringing in candidates who can make your practice thrive. It can also be the roadblock that results in the construction of a lackluster team. To build a practice that consistently brings in loyal patients and provides quality care, start by focusing on the dental job interview. If you can master this first step in the teambuilding process, you’ll continue to build a solid foundation as your team grows. It’s essential to ensure the interview process is fair, nondiscriminatory, and most of all, legally compliant to avoid getting yourself and your practice in legal hot water. Keep reading to learn about the essential questions you should focus on during a job interview and which questions you should legally avoid.

Why the dental job interview matters The hiring process has always mattered for a dental practice. Choosing the right people to staff your team can make for a group of employees who work well together and help keep patients happy. Choosing the wrong people can make for an unpleasant and stressful environment both for colleagues and the patients they serve.1 However, the hiring process, including the job interview, is more important than ever because there is currently a shortage of dental job applicants post-COVID-19. In fact, according to ADA News from the American Dental Association, more than 80% of practices attempting to hire staff are currently finding the process either very challenging or extremely challenging.2 More than half of dental professionals even consider recruiting their most challenging HR issue.3 This means that dental practice owners or hiring managers Volume 14 Number 4

Educational aims and objectives

This self-instructional course for dentists aims to demonstrate the importance of the interview process in the dental industry to find quality hires.

Expected outcomes

Realize the importance of the hiring process and the regulations associated with it.

•

Recognize which questions dental professionals should avoid in the interview process.

•

Identify key questions to ask to find quality hires for dental practices.

are focusing on making their practice a desirable place to work. While a cohesive, kind, and qualified team may convince a candidate to join a practice, a disjointed, improperly trained, or unhappy team may turn someone away. Make clear in the interview process that you care about your team members and the overall culture at the practice. Allow team members to engage in open communication with candidates to ensure they receive an accurate picture of what to expect regarding the work environment and the role itself. Approaching interviews in this manner will yield more success and help you find the right, motivated, and qualified candidates you need to serve your patients.

The best dental job interview questions to ask candidates Now that you understand the importance of acing interviews in the dental industry, let’s see which interview questions are the right ones to ask. To begin, start by making a checklist of the technical skills and soft skills (i.e., personal attributes needed for success such as time management and teamwork) desired as well as the level of experience and competencies you need. This makes it quick and easy to hone in on which candidates are options to consider, and which are not. You’ll also want to leverage the expertise of an HR specialist to manage the process of hiring a new team member for your practice. HR specialists are experts in interviewing and

CONTINUING EDUCATION

The five best dental job interview questions to ask — and two to avoid — to build an outstanding team

hiring, and they can ensure your process is legally compliant and effective. They can also identify both promising signs and red flags in a candidate that you may have overlooked due to a lack of interviewing or hiring experience. It’s also important to keep in mind that you can take time during the interview process to express interest in a job candidate and to make a potential new employee feel welcomed. The dental job interview is both a screening and recruiting process: You want to assess whether or not the candidates meet the requirements of the job description and if they are a good fit (i.e., they display those soft skills you desire). Once you have established that, you can determine if it is appropriate to engage them in further discussions that help attract the candidate to the role and your practice. The best job interview questions to ask a candidate for your dental practice follow. Ali Oromchian, JD, LLM, is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clients’ businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States. To contact the author, please email ao@dmcounsel or visit www.hrforhealth.com. Disclosure: Mr. Oromchian is cofounder and Chief Executive Officer of HR for Health in the San Francisco Bay Area.

Endodontic practice 29

CONTINUING EDUCATION Why did you decide to work in the field of dentistry? Your field is a particular one: It has its perks and its drawbacks, and it offers very specific hours, benefits, and challenges. When you’re interviewing candidates, ask why they’re drawn to this particular field. This will give you insight into what they’re passionate about doing, how they want to spend their time, and how deep their knowledge of the field is. It is with these questions that you can get the candidates to talk about their education and previous dental work experience. All of the candidates’ experience should demonstrate purposeful steps toward making a decision to have a career in dentistry. When your candidates answer, listen for the qualities you are seeking. Do they align with the values expected of all employees at the practice? Do they like helping people? Do they have empathy for those in pain? Are they fascinated by the human body and innovative technologies being developed to help it? Alternatively, are they mostly focused on the paycheck? This is a question that reveals candidates’ true values and motivations and gives you insight into whether they’re in it for the same reason as the rest of your team. This can give you a clue into whether everyone’s values will align for a cohesive culture and shared interests. How do you envision dentistry as we move into the future? This is an open-ended question. However, it can show you whether candidates see potential growth in the field, and if they’ve considered ways their position might change down the road. In a dental job interview, you don’t just want to know if someone has the right skills to perform day-to-day tasks. You want to see if candidates are thinking about a long-term career with your practice — or at least in the field. The answer candidates give to this question also gives you insight into the candidates’ ability to think creatively, to genuinely understand issues in the dental field and, more importantly, understand new ways dental professionals might be able to help solve those problems. Static thinkers can keep a practice static. Dynamic thinkers can help ensure that a practice continuously evolves, staying on the cutting edge of what dentistry has to offer. Finally, in a job interview, you want to see if the candidates are planning to be in the field for a long time, or whether the job you’re offering is just a stepping-stone. You want to boost retention as much as possible and minimize turnover, so candidates who 30 Endodontic practice

haven’t considered the future of dentistry might be giving a sign that you’re not in their long-term plans. How do you stay on top of the latest trends and news in the dental field? Similar to the previous question, this inquiry shows whether candidates are invested in the field and show the concrete ways they are doing so. To provide the best dental care possible, you need employees who are interested in how the industry is changing and improving. Again, dental job candidates who are thinking about the future of dentistry are likely to want to have a job in the field in the future. Those who are not may be thinking of this job as a temporary position on the way to doing something else. It’s important to keep an eye on this because it may be a sign that hiring them will lead to turnover, which is very disruptive and expensive for a dental team. According to a recent survey, 27% of employees in the dental industry will leave within 2 years of being hired.3 Have you previously worked in a stressful work environment? If so, can you describe a time when you performed well despite the stress you experienced? It’s no secret that working in a dental office can be stressful. This question can help identify if candidates are prepared for the stress that comes from working in a practice and how they might handle that stress. You want your candidates to demonstrate their competence and ability to remain calm when things get difficult. This is especially important because patients look to dental staff to calm them down when they’re scared or stressed. The professionals around them should be able to stay calm and avoid compounding stress in the office environment. Asking about stress management is also a window into your candidates’ emotional intelligence — a generally important quality to have when you’re working with patients and other team members. Have you experienced any failures in your career, and if so, how did they help you grow? This is another question that asks about the candidates’ weaknesses in a dental job interview — and it also allows you to see what mistakes they’ve made and, more importantly, how they have reacted when faced with a failure. You want new team members who can overcome any challenge, and who won’t get defeated if things become difficult.

This particular question gives some insight into creative thinking because candidates may reveal that they were able to come up with a clever solution to help improve their professional “failure.” Creative staff members are always exciting and motivating to have around, coming up with innovative solutions and forward-thinking ideas, which can help keep a practice growing and evolving as time passes.

Dental job interview questions to avoid asking any candidate The preceding questions are essential to ask in any dental job interview, as they allow you to examine candidates beyond their qualifications and achievements. The candidates can give you an idea of their quickthinking and problem-solving abilities as well as how they will interact with patients and colleagues. However, there are also some questions that you should never ask in an interview because they could get you or your practice in trouble. Many questions may seem harmless enough on the surface, but in reality they could be discriminatory or even illegal. Certain questions can also make your practice seem unappealing, which could drive away potentially great candidates in an already tough hiring market. So how do you avoid certain questions, while still finding out what you need to know about candidates? When interviewing dental practice candidates, make sure all questions are fair, nondiscriminatory, and solely based on experience or other job-related factors. Several questions that you should never ask in job interviews with dental candidates follow. What’s your current salary? While you can discuss salary in an interview if a candidate brings it up, it’s important to be aware of the state you’re located in, as many states have laws/restrictions around salary inquiries. Never, under any circumstances, should you ask the candidates what they make at their current job. Not only does it put the candidate in a weird position (allowing their potential employer to manipulate their offer based on what they currently make), but it’s a risky question legally, since many states prohibit it. If your candidates directly share their salary with you, that’s fine — but you’ll want to take note of the fact that they actively shared that info without being asked. Take this opportunity to redirect the conversation toward the topic of salary range for the particular role the candidates are interviewing for. You want to proceed Volume 14 Number 4

Table 1: Interview questions to avoid and legal alternatives

Tell me more about yourself [insert personal protected information here]. A lot of personal information is legally protected in the professional realm. Candidates and employees are not allowed to be asked about certain topics, since they might be discriminated against based on these answers. These topics include things such as disabilities (including pregnancy), age, previous medical history, marriage status, and more. Essentially, job interviews should be strictly professional and should be solely focused on the job duties/competencies required for the role and candidates’ professional experience — both in the past and their goals for the future. Avoid all personal topics if possible unless a candidate brings something up — then you can simply listen and attempt to redirect the conversation. Following these guidelines ensures you won’t risk discriminating against candidates based on personal or protected information they shared with you. How much longer do you plan to work before you retire? While on the surface it makes sense to ask this question — after all you don’t want to hire someone and get them trained just so they can leave you a few years later — this could get you into serious trouble. Instead try asking “What are your long-term career goals?” This will help you understand where candidates see themselves in the future and hopefully give you an idea of if they plan to retire soon.

How to hone your dental job interview questions for interviews that work again and again Now that you understand what questions you should and shouldn’t ask during a dental job interview, you can get to work creating a standard list of questions for each position at your practice. After all, the questions shouldn’t vary based on the person — the answers will be what makes a candidate stand out and seem hirable. Once you’ve created a set list of questions for each position, you should return to that list every time you have to interview new candidates for that job to ensure consistency with your hiring process and to avoid claims of discrimination. The questions should be a good tool for revealing who you will hire, and who is not the best fit for your practice.4 If you Volume 14 Number 4

What not to ask

What to ask instead

Are you a U.S. citizen? What is your birthplace or national origin?

Are you authorized to work in the U.S.?

How long have you lived here?

What is your current address and phone number?

What religion do you practice?

What days are you available to work?

Which religious holidays do you observe?

Are you able to work with our required schedule?

How much longer do you plan to work before you

What are your long-term career goals?

retire? Do you have or plan to have children, or are you pregnant?

Are you available to work overtime on occasion? Can you travel?

If you get pregnant, will you continue to work, and will you come back after maternity leave?

What are your long-term career goals?

Do you have kids?

What is your experience with “x” age group?

We’ve always had a man/woman do this job. How do you think you will stack up?

What do you have to offer our company?

How do you feel about supervising men/women?

Tell me about your previous experience managing

Do you have any disabilities, handicaps, or mental conditions? What is the nature or severity of your disability?

Are you able to perform the specific duties of this position?

Have you had any recent or past illnesses or

Are you able to perform the essential functions of this job with or without reasonable accommodations?

operations?

teams.

already have a set list of questions, but realize you need to change up some of them, you can tweak the questions you already have. You don’t need to toss out the entire interview and start over! Here are some examples of questions that might seem discriminatory, but are actually useful — and fine to ask once tweaked. • “Do you have children?” might turn into “Are you able to meet the attendance requirements of this position?” After all, managers or bosses aren’t interested in whether a person has kids or not; they are wondering if there are life situations that will interfere with a candidate’s work regularly. • “How old are you?” can be shifted to “Are you over the age of 18?” You don’t need to know how old someone is for them to do the job; you only need to know that it’s legal for them to work for you. • “Are you religious?” can be shifted to “Are you available on weekends?” No boss needs to know potential team members’ religion. Bosses may only worry about religion because people who practice religion may be unavailable at certain times. So, ask about

the issue directly as it pertains to the requirements of the position — “Are you going to be available on weekends?” If they say yes or no, it doesn’t matter why. It just informs you about whether they have the availability to be at the practice on the days and at the times you need them to be there. Avoiding an expensive lawsuit and gaining peace of mind is easy when you follow the guidelines already discussed. EP This article is intended to provide general information and is not intended as legal advice. REFERENCES 1. Wojcik S. Destress in the office with these 4 Tips for dental practices. HR for Health. https://www.hrforhealth.com/ blog/destress-in-the-office-with-these-4-tips. Published April 20, 2021. Accessed October 21, 2021. 2. Versaci MB. Understaffed and ready to hire, dentists face applicant shortages as they emerge from COVID-19 pandemic. ADA News. https://www.ada.org/en/publications/ada-news/2021-archive/june/dentists-face-applicantshortages-as-they-emerge-from-covid-19-pandemic. Published June 9, 2021. Accessed October 21, 2021. 3. HR for Health. Unnecessary Risk: The State of Human Resources Compliance in Dentistry. A Special Report on Private Practices, Dental Groups, & DSOs [white paper]. HR for Health: 2021. https://f.hubspotusercontent40. net/hubfs/5014795/DSO%20Whitepaper%202021.pdf Accessed October 21, 2021 4. Wojcik S. Provide Your New Dental Hire with 4 Essential Documents to Prevent Getting Sued [blog]. https://www. hrforhealth.com/blog/four-essential-new-dental-hire-documents. Published September 2, 2021. Accessed October 21, 2021.

Endodontic practice 31

CONTINUING EDUCATION

cautiously and ensure your knowledge is up-to-date regarding salary questions. You don’t want to violate a law before you’ve ever even decided whether you want to make a candidate an offer.

n To receive credit: Go online to https://endopracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 550 Date Published: December 7, 2021 Expiration Date: December 7, 2024

The five best dental job interview questions to ask — and two to avoid — to build an outstanding team OROMCHIAN

1. According to ADA News from the American Dental Association, more than _____ of practices attempting to hire staff are currently finding the process either very challenging or extremely challenging. a. 40% b. 66% c. 80% d. 92% 2. More than ______ of dental professionals even consider recruiting their most challenging HR issue. a. one-quarter b. half c one-third d. three-quarters 3. To begin, start by making a checklist of the _______ desired as well as the level of experience and competencies you need. a. technical skills and soft skills b. religion c. lowest salary d. attractiveness 4. With the question “How do you envision dentistry as we move into the future?” The answer candidates give to this question gives you insight into the candidate’s ability to _______. a. think creatively b. genuinely understand issues in the

32 Endodontic practice

dental field c. understand new ways dental professionals might be able to help solve those problems d. all of the above 5. According to a recent survey, 27% of employees in the dental industry will leave within ______ of being hired. a. 6 months b. 1 year c. 2 years d. 5 years 6. Many questions may seem harmless enough on the surface, but in reality they could be _______. a. discriminatory b. illegal c. too difficult to answer d. both a and b 7. When interviewing dental practice candidates, make sure all questions are ______. a. fair b. nondiscriminatory c. solely based on experience or other job-related factors d. all of the above 8. Avoid all personal topics if possible unless a candidate brings something up

— then you can simply _______. a. tell the applicant a similarly personal bit of information about yourself b. listen and attempt to redirect the conversation c. realize that since the applicant started the topic, you can ask more personal questions d. stop the interview, and do not offer the candidate the job even if he/she is qualified 9. Now that you understand what questions you should and shouldn’t ask during a dental job interview, you can get to work creating a _______ for each position at your practice. a. list of questions depending on the applicant’s gender b. standard list of questions c. list of questions depending on the applicant’s age d. list of questions depending on where the applicant lives 10. Instead of “How old are you?” which may be construed as discriminatory, a more useful question would be __________. a. “Are you over the age of 18?” b. “How old are your children?” c. “What is your religion?” d. “Are you planning to have more children?”

Volume 14 Number 4

CE CREDITS

ENDODONTIC PRACTICE CE

Dr. Albert (Ace) Goerig discusses an effective method of providing essential care

he great advantage that endodontics has is that almost everything we do is classified as essential care. Regardless of the economy, insurance, or demographics, conditions requiring endodontic treatment occur with predictable frequency in any population. It’s an enduring clinical need, with associated pain often motivating patients to seek timely care. The great disadvantage we have is that a significant portion of our patient flow is therefore driven by the need for prompt emergency care. By the time patients with escalating pain see their GP, it may be so severe that treatment is needed as quickly as possible … ideally the same day. That is the source of our Catch-22 lifestyle gap. We can be a hero to patients and referrers alike for quickly providing essential care, but to do so requires that we are almost always available on short notice when the emergency referral call comes in. As a result, many endodontists end up working more days per week, more days per year, and fewer vacation weeks than any other dental specialty. In fact, Endo Mastery had a new client last year whose biggest problem was its top referrer. The referrer insisted as an explicitly voiced condition for continued referrals that the endodontist be available every day (including weekends) without exception. While most referrers are not so exploitive, it is true that we implicitly worry about what our referrers will do if we’re not available. Will time off drive them to refer to someone else?

The solution to improved lifestyle Schedule coverage is the fundamental issue that must be solved for endodontists to truly have time freedom. Therefore, a solo practitioner will always need to make tradeoffs that balance time off with the needs of referrers and patients. However, two endodontists working together do not require compromises at all. It’s a lifestyle model for endodontics that creates flexibility for the lifestyle doctors want. With two doctors, a practice can be open every week of the year (provided you plan your vacation weeks at separate times). That means you could take as many vacation weeks every year as you want, and in turn you cover the schedule for the weeks your partner takes off. At Endo Mastery, we think Volume 14 Number 4

10 weeks off per year is a good goal — great lifestyle with your family and lots of time to recharge and avoid burnout. The lifestyle benefit also extends to the weeks you are working in the practice because you don’t have to be there (or on call) 5 days a week. You can work 4 or 3 days per week to your preference, with your partner providing schedule coverage on the other days. For example, you work Monday, Tuesday, Wednesday; and your partner works Wednesday, Thursday, Friday. It might sound like reduced days means reduced revenues, but that is not true. The average endodontist completes three to four cases per day. With a properly designed schedule template and a highly trained team, you can complete six or seven cases per day easily and effortlessly without feeling rushed. In 3 days, you can complete as many cases as you previously did in 5 days. Plus, with more schedule coverage from two doctors, referrers learn they can rely on your practice even more, and your reputation and referrals actually increase. An even smarter lifestyle coverage strategy for two doctors is to alternate weeks in which they start or end the week. For example, this week you work Monday, Tuesday, Wednesday; and next week you work Wednesday, Thursday, Friday. That results in working 3 days (at the same or higher revenues than 5 days), then a 2-day weekend, then 3 more workdays, then a 6-day weekend. Six days! It’s like another whole week off every two weeks!

Implementing the vision In this scenario with perfect coverage, the total workdays for the year per doctor is 146 days (10 weeks x 5 days + 16 2-week

cycles x 6 days) with no decrease in revenues. That’s a far cry from the 240 days (5 days per week x 48 weeks per year) that a solo doctor feels pressured to work. Of course, forming that partnership can be a challenge. It might be difficult to bring two doctors with existing teams and practices together under one roof. When both doctors are closely aligned on the vision and goals, then it becomes possible. However, in my view, the best way to achieve great lifestyle is by growing your practice to the point where you can add an associate. You can maintain control of your practice while developing a working relationship (and expanded profitability) with another doctor who meets your goals for lifestyle. Plus, the young endodontist benefits by joining a successful practice focused on long-term quality of life for doctors. It’s win-win for both doctors. One of the most exciting things that I get to do as a practice coach is work with doctors to create a vision like this. Endo Mastery helps doctors grow their practices, become associate-ready, integrate a new associate, and transform the owner-doctor’s life with incredible financial success and time freedom. EP Albert Goerig, DDS, MS, is a Diplomate of the American Board of Endodontics and a soughtafter 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’s private endodontic practice in Olympia, Washington, is 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. To learn more, visit www.endomastery.com or call 800-482-7563.

Endodontic practice 33

PRACTICE MANAGEMENT

Solving endo’s Catch-22 lifestyle gap

GROUP PRACTICE SPECIAL SECTION

Cornerstone Dental Specialties Tell us about your unique endodontic practice model. We are the largest Mobile Endodontic Practice in North America. Instead of patients accessing their endodontic treatment in the traditional brick-and-mortar system, we provide services at the referring dentist’s office. We furnish everything, including the dental assistant in a turn-key system. All we require is a little help from the front desk to schedule and take a deposit, and the use of one to two chairs on the days we perform root canals. Patients love this method of accessing care. Nobody likes to drive across town to a new environment, especially in pain and under stress. The referring dentists love it as they never lose the patient, and they can start and bill their final restoration often the same day. We are clinician owned and privately held.

What size is your group, and what are your growth plans? Currently, we have approximately 45 providers who service over 250 locations in 13 states. Since 2004, we have completed over 1 million RCTs as a group. Cornerstone Dental Specialties is our largest division, which is focused on supporting DSOs and larger groups. Our division that supports individual private practices is called enroot™ — it is our fastest-growing platform. Our plan is to add 22 to 25 providers over the next 3 years.

What type of provider thrives in this unique system? We look for providers who are comfortable with working in 10 to 13 different locations on a rotating basis, usually 30 to 60 minutes away from their home base. Some offices have a demand for 2 days a month, others 1 day. Most of our providers perform

six to eight RCTs in a typical 8-hour day, but the providers always control their schedules and their treatment protocols. We do not get involved in that. We are a support organization; they control their practice. We are PACE certified, and we have a massive “state-of-theart” training facility in Irvine, California. All our providers have seasoned mentors to help, and we offer training in every aspect of endodontics, including a Fellowship for general dentists who want to focus on endodontic therapy as their main area of practice. Some of those Fellows go on to work in our environment, and some go back to private practice.

Why do providers choose to join one of these platforms? In both cases, most of our providers are looking to get their clinical skills enhanced without worrying about all the hassles of starting a private practice or entering as

For more information Visit www.cdsdental.com/portal/social-media for information on the DSO/Group model or scan the QR code.. For enroot™, our ownership model for private practices, visit www.enrootusa.com.

an associate having to work hard to build their own referral network. Being able to get ramped up and generate an above average income in year one is very appealing. They like the support, and we manage every aspect of their nonclinical duties — all on a mobile app so everything is at their fingertips. They can just focus on delivering great care. We have providers who are recent residency grads, providers who have sold their practice, and providers who did this on their own and like being mobile but not managing the business aspects.

Why would a provider choose Cornerstone Dental versus enroot™ as a model? Providers who tend to lean toward Cornerstone are usually ones that just want to work as Independent Contractors or Employees. They may have a large debt load or are going to sunset in 5 to 7 years and want the security of an established base of business day one. Also, available markets often are limited. The enroot model tends to attract more entrepreneurial personalities that want to be involved in building their businesses. It’s a hybrid approach of ownership with support and risk mitigation but not zero risk. However, it has no geographical constraints, but markets with limited specialists increase the odds of success.

How do providers learn more? For more information on the DSO/ Group model, visit www.cdsdental.com. For enroot™, our ownership model for private practices, visit www.enrootusa.com. Also, feel free to email tvonsydow@corsgroup.com. 34 Endodontic practice

Volume 14 Number 4

SPECIAL SECTION

GROUP PRACTICE Endo1 Partners

What inspired you to establish your group practice? After finding that existing partnership organizations did not truly understand the unique needs of dental surgical specialists, Drs. Matthew Haddad, Daryl Dudum, Mark Haddad, and Darron Rishwain came together to establish Endo1 Partners. Their vision was to build a first-of-its-kind endodontic partnership organization that provides business and operational support services to reduce administrative burden, increase efficiency, and fuel growth for a nationwide network of like-minded specialists.

What is the most rewarding part of growing a successful group practice and team? Endo1 Partners has experienced rapid growth since making their vision a reality. As a result, the leadership team has had the opportunity to connect with more specialists than they ever could have imagined and support them as they take their practices to the next level. More than 175 specialists from over 100 locations across 15 states have formed new professional and personal relationships within a growing network of specialists. While they operated independently of one another before, they now have the chance to work together to streamline practice management and maximize the patient experience because of the Endo1 Partners platform.

What differentiates your group practice from others? Endo1 Partners is the only group practice that was founded and is led by practicing endodontists. Endo-owned and endorun means the Endo1 Partners model is distinctive. For example, partners tell the organization what they need—not the other way around. While all partners are required to use accounting, human resources and IT services, other services are offered a la carte. The Endo1 Partners team will work with partners every step of the way to identify other services their practice needs to drive success. In addition to centralized services, partners enjoy group benefits and discounts, and professional development opportunities. Endo1 Partners also provides the latest Volume 14 Number 4

industry information, including current best practices, tools, and techniques from bestin-class specialists and practices.

What is the best part of being a part of a group practice? Partnering with Endo1 Partners enables specialists to receive all the benefits of joining a group practice, while maintaining control of their businesses. Partners retain equity and control of their practice, so they can continue to treat patients under their brand and with their existing team.

How do you keep all members of the group feeling important and heard? Endo1 Partners operates more like a tight-knit family than a business. The leadership team visits with potential partners to ensure a good fit and stays in touch even after partners have been integrated. Additionally,

Endo1 Partners hosts annual partner meetings where partners can socialize with one another, network with vendors, and earn continuing education credits. This culture of support and open communication enables partners to achieve a high level of trust, comfort, and transparency with the Endo1 Partners network. This culture will not change even as Endo1 Partners continues to grow.

What does the future look like for Endo1 Partners? In just two years, Endo1 Partners has become the largest and fastest-growing group dedicated specifically to supporting specialists. Endo1 Partners expects to continue this impressive growth trajectory, as it evolves from a single group practice into a family of brands. This continued interest and sustained growth really demonstrates the strength and potential of Endo1 Partners.

It’s Time to Thrive Together You deserve to have control over your business, as well as the peace of mind that comes from the support of a nationwide network. With Endo1 Partners, you can have both! Get in touch with Endo1 Partners today to learn how we can help you thrive on your terms. With the support of Endo1 Partners, there is nothing you can’t do!

Endodontic practice 35

GROUP PRACTICE SPECIAL SECTION

U.S. Endo Partners What is U.S. Endo Partners? Established in 2018, U.S. Endo Partners is an endodontist-led, patient-driven specialty services partnership. We give endodontists the community and resources they need to help more patients, provide outstanding care, and save more teeth — all while living vibrant, balanced lives. Our collaborative and supportive environment thrives on helping doctors achieve their loftiest goals, while growing together as a team.

How are you more collaborative? Our mission is to provide growth and opportunity for our doctors; our keys to success are our collaborative culture and steadfast commitment to our core values. We are dedicated to pursuing excellence and learning through humility. Along with our expert business partners, we work collectively to carve a forward path that elevates our individual and group performance and advances our specialty. We cultivate a culture of trust, respect, and gratitude — mentoring one another and teaching best practices in clinical care, practice management, and leadership. These efforts not only improve us as clinicians, but also make us better people. We meet regularly in-person and online to stay connected to one another and collaborate with some of the most-respected names in endodontics. Our vast network allows us to stay abreast of key trends, issues, and innovations that are important to, and affect, our specialty. We devote time to sharing information and experiences on a deeper level and charting our course. U.S. Endo Partners is led by an unsurpassed Clinical Advisory Board (CAB) with decades of experience under its collective belt. Our

CAB guides our endodontists through clinical practice questions and concerns.

How does U.S. Endo Partners support its endodontists? Simply put, we meet our doctors and their teams where they are. All our practices join with a desire to grow and improve, but

Talk success with us Visit https://usendopartners.com/success/ or scan the QR code.

each journey is unique — recognizing that allows us to offer every practice a customized approach, while leaving doctors fully empowered and in control of their success. From finance and marketing to compliance and insurance, U.S. Endo’s growing team of professional experts provides information that enables our doctors to better understand their business, so they can make the right decisions for themselves, their teams, and their futures. When the need for improvement is recognized, we support our partners by providing customized solutions and resources to help them navigate and implement changes — lessening the pains of growth and speeding up the rewards of success.

How would you describe your culture? We are a true partnership — accessible, dedicated, and invested in each other’s success, and committed to constant learning and improvement. Together we strive to help more patients, expand access to care, and spread the life-changing power of saving teeth. 36 Endodontic practice

Volume 14 Number 4

Dr. John West shares colleagues’ perceptions on improving performance and increasing endodontic predictability Introduction “Change is the only constant.” The Greek philosopher Heraclitus is credited for speaking one of nature’s absolute rules about time and change. However, perhaps because events and things like inventions were slow to change 2,500 years ago, Heraclitus did not mention the rate of change. In April 2021, the rate of change is becoming exponential. In fact, we are at the knee of the exponential technological curve, and the rate of change is continuously increasing. In this article, I have chosen to link the phenomenon of endodontic change from the past, present, and future, inviting the reader to ponder this question: Is the Endodontic Triad “dead or alive?” My goal is to see the Triad (Clean, Shape, Pack) through the eyes of change, which will hopefully invigorate each reader to embrace new possibilities for becoming a better endodontic clinician.

Context This is an article by a clinician, for clinicians, about clinicians. Endodontics is about clinician decisions. My aspiration in this writing is that we all make the best decisions toward improving our performance and increasing our

patients’ endodontic predictability. My assertion is The Endodontic Triad is alive!

Endodontic capacity for success: the rationale for endodontics Endodontics is an extension of restorative dentistry into the radicular space. It is nature that sets the rules about our success. Nature promises that if a disease, such as endodontic disease, is eliminated, then the symptoms of the disease simultaneously cease. Therefore, endodontics has a 100% capacity for healing if the root canal system is rendered innocuous, and the tooth is periodontally sound and restorable.1 But every dentist knows we experience our own individual success rates, and they are 100% − X. What is X? It is the clinician and the host: 1. our knowledge of what to do 2. our ability to do it 3. our willingness to do it matched against the host response Can endodontic technology bring the big “X” in 100% − X to become a much smaller “x”; i.e., 100% − x? It can, and it will. However, there are biologic and percentage success comparison challenges in producing the new, smaller “x.”

Professor Shimon Friedman, an authority on endodontic success/failure studies, suggested three biologic culprits currently preventing 100% predictability: 1. inaccessible niches with infected tissue 2. the very resilience of bacterial biofilms 3. bacterial films outside the radicular space2 Dr. Friedman further reports that it is difficult to measure and to compare success from study to study and from clinician to clinician. He notes that reported success rates have ranged from 29% to 100% because of variations in research methodologies (study cohort, follow-up, outcome assessment, data analysis). This includes the very definition of “success,” noted as follows: • no radiographic or clinical signs of disease • no symptoms, even in the presence of disease • tooth retention, even in the presence of disease and symptoms2 Despite these challenges, the goal of closing the gap between the big X and the small x is endodontics’ “clear and present” opportunity. Endodontics does not shrink from this responsibility. It welcomes it. Bring on the “aliveness” part of The Endodontic Triad: “Dead or Alive?”

The past A.

Figures 1A-1D: The Past. 1A. Image from Gary Grey’s 1973 Boston University thesis demonstrating a thoroughly debrided horizontal section of an extracted tooth. Only hand files, Gates Gliddens, and NaOCl were available in those days. 1B. Two endodontically treated teeth in a row by Professor Herbert Schilder in the 1960s. Note the radicular shapes were appropriate for their roots (minimally invasive endodontics by today’s standards) and the solid obturation with multiple portals of exit visibly filled. 1C. Standing on the shoulders of giants. I taught my mentor, Schilder, the use and value of the microscope (circa 1993). 1D. In the 1970s, Schilder used to refer to the then-endodontic attempts at clean, shape, pack “gadgets” as “complicated solutions to nonexistent problems.” He meant that if the endodontic anatomy is eliminated using a compulsive attitude to do so, a capacity for 100% success is available to all dentists. My contracted “Rube Goldberg” cartoon from 1985 reflects this same insight Volume 14 Number 4

Endodontics became a dental specialty in 1964. At its very beginning, endodontics’ idea of the Triad was revelatory, as was the deep commitment to it. Even in the age before NiTi, microscopes, apex locators, and digital imaging, careful and vigilant attention to technical detail produced verifiable success.3,4 It has been said many John West, DDS, MSD, received his DDS degree from the University of Washington, where he is an affiliate professor, and his MSD degree in endodontics from Boston University, where he was honored with the Distinguished Alumni Award. Dr. West is founder and director of the Center for Endodontics in Tacoma, Washington, where he is in private endodontic practice. He can be reached at 253-377-2007 or via email at johnwest@ centerforendodontics.com. Disclosure: Dr. West is co-inventor of ProTaper, ProGlider, WaveOne, Gold Glider, and Calamus products.

Endodontic practice 37

ENDODONTIC PERSPECTIVE

The Endodontic Triad: dead or alive?

ENDODONTIC PERSPECTIVE

times before that we stand on the shoulders of giants, and now future giants stand on our shoulders today (Figure 1).

The present I first chose to write this article for personal, curious, and selfish reasons. I wondered if I am using the best tools, techniques, and technologies that endodontics has to offer. Am I stuck in my ways? Am I missing a transformational endodontic moment, or maybe I am missing a better way to find orifi or something simple like that? A better way to see if I’m missing anything — and, if so, what I am missing — is to seek out a few of my respected endodontist peers whom 1) I know perform the Endodontic Triad, or parts of it, differently than I; 2) have extremely successful practices and probably are at chairside as of this writing; 3) are continually striving to learn to be their best and understand that this adventure into optimum endodontic predictability is both a journey and a destination; 4) walk the talk; and 5) are not only lifetime students but also lifetime teachers. Next, I must define my first three survey questions about Clean, Shape, and Pack (CSP).5,6 I realize different clinicians use different terms to describe nonsurgical endodontic treatment. CSP is the term that I have used to describe the Triad for over 4 decades. For example, in our office, we say, “Schedule Mary for CSP No. 14.” It is easy to say and easy to note on the daily schedule. It has always described my exact and purposeful process for intended patient outcomes — namely, eliminating the root canal system in order to cure or prevent a lesion of endodontic origin.7-11 Please substitute any words you want to describe the Triad: Clean, Shape, Pack. Feel free to even reverse the order. Possible Triad words you are more than welcome to substitute are: 38 Endodontic practice

Clean: Debride organic and nonorganic root canal system contents, disinfect. (There are over 100 trillion microbes in the human body. It is no surprise a few may stray into the pulp space where they are not welcome.) Shape: Preparation to facilitate cleaning and conefit for obturation control, instrument, verify, or ensure patent tunnel for fluid flow Pack: Fill, obturate, thermoplastic seal, 3D seal, endodontic seal, cork

The Respected Clinician Clean, Shape, Pack, and Sealer Survey Agreeing to my definitions, I chose to survey 10 respected endodontists who have proofread my condensing of their answers and have selected pre- and post-treatment images that they believe radiographically represent their trenchant visual expression of the Endodontic Triad (Figure 2). Below, in alphabetical order, are their answers to my survey. Their techniques or armamentaria were copied and pasted from the survey, and where a quotable opinion was offered, it appears in quotes. 1. Dr. George Bruder (gbruder@idifl.com) • Clean: “SyAct has moved toward a novel methodology and implemented ‘The SyAct System’ that combines a state-ofthe-art handpiece with cutting-edge fluid engineering and nanoparticle technologies, which will be released later in 2021.” • Shape: “TruShape® and TruNatomy™ rotary files (Dentsply Sirona) improve three-dimensional canal wall contact and canal debridement. These narrower files provide clinicians with proper cleaning and shaping principles while preserving the endo/resto complex.” • Pack: “I prefer heat-softened, 3D guttapercha techniques, but I am examining core-obturation systems, single conebased techniques, and others.”

H. Figures 2A-2I: The Present. Pretreatment and posttreatment radiographic expressions of the Endodontic Triad submitted by 10 respected endodontists: 2A. Dr. George Bruder. 2B. Dr. L. Stephen Buchanan. 2C. Dr. Gary Glassman. 2D. Dr. Manor Haas. 2E. Dr. John Khademi. 2F. Dr. Charles Maupin. 2G. Dr. Tom McClammy. 2H. Dr. Blake McCray. 2I. Dr. Terry Pannkuk. 2J. Dr. Reid Pullen

• Sealer: ThermaSeal Plus (Dentsply Sirona) 2. Dr. L. Stephen Buchanan (lstephenbuchanan@gmail.com) • Clean: PulpSucker (PS) Multi-canalar Negative Pressure Irrigation System 17% EDTA irrigant during instrumentation. 8% Chlor-XTRA™ (Vista Apex) 2.0 NaOCl run through PS System catheters for 15 minutes after instrumentation is completed. • Shape: Traverse™ Rotary Negotiation Files (Kerr) — single-file negotiation in 85% of canals. ProLube™ lubricant until initial negotiation and apex location are completed. Tri-Auto ZX2 (Morita) endo handpiece with embedded apex locator. NT K-files (Dentsply Maillefer) for gauging. ZenFlex™ Rotary Shaping Files (Kerr) — single-file shaping. • Pack: Continuous wave of condensation with elements™ IC/System-B (Kerr). In development — vacuum-drawn Bio-Ceramic Sealer as the final step in PS procedures. (This is 3D obturation without downpacking or backfilling.) • Sealer: Bioceramic Sealer 3. Dr. Gary Glassman (gary@rootcanals.ca) • Clean: “EndoVac™ (Kerr), through a series of 3 NaOCl microcycles and apical negative pressure, delivers irrigant continuously to the apical terminus without extrusion past the apex using apical negative pressure.” “The EndoActivator® (EA) (Dentsply Sirona), by sonically activating the irrigant solutions, enhances the disinfection process and aids in the removal of tissue and debris within the root canal system.” Volume 14 Number 4

compatibility, minimal shrinkage, and low solubility. Small particle size allows for obturation of narrow anatomy, including accessory and lateral canals.” 4. Dr. Manor Haas (manor@drhaas.ca) • Clean: “During instrumentation, I use 2.5% NaOCl as a lubricant and for irrigation. As for final flush, I use NaOCl, then dry canals, and finish with QMix. I agitate both NaOCl and QMix with the EndoActivator for 30-plus seconds per canal. I use a 30-g side-venting endo irrigating needle to deliver these agents.” • Shape: “I start with C-files (Nos. 6, 8, 10) as needed, depending on the size of the canals, followed by PathFiles for exceptionally calcified or curved canals, or WaveOne® Gold Glider (Dentsply Sirona) for less calcified canals, to obtain a glidepath. I finish with ProTaper Gold® files (Dentsply Sirona). I determine the master file size with apical gauging versus a one-size-fits-all technique. For instance, I would tend to instrument larger at the apex in a palatal root of a maxillary molar versus the buccal roots.”

• Pack: “Gutta-Smart™ with Conform Fit™ cones (Dentsply Sirona). I absolutely love the ease of use and freedom that these cordless units provide me. And I love the feel and fit of the Conform Fit cones, which I have found to provide much better apical tug-back than other cones I have used.” • Sealer: “Ribbon. Not bioceramic sealer as it might create problems if the case ever has to be retreated or if post space needs to be prepared after sealer is set.” 5. Dr. John Khademi (jakhademi@gmail.com) • Clean: GentleWave® (Sonendo) • Shape: “Files. V Taper files 17/V.04 (SS White Dental) to ensure sufficient space for GentleWave® fluid flow and that canals are obturatable. EAL used to identify that the foramen is reached. In smaller canals, such as an MB2, there is not adequate natural shape for predictable fluid flow, so an adequate fluid path is ensured by taking a small (17/V.04) or very small 14/V.03 to within 0.5 mm of the apex or full EAL length.” • Pack: Single-cone Buchanan red-label.

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(262) 501-0075 Endodontic practice 39

ENDODONTIC PERSPECTIVE

“Full-strength NaOCl and QMix® (Dentsply Sirona) remove the organic component of the smear layer and disinfect the root canal system while Q-Mix (EDTA plus chlorhexidine analogue) removes the organic component of the smear layer.” • Shape: “ProTaper Gold™ (PTG) (Dentsply Sirona), with special affinity for SX and ProGlider™. PTG produces minimally invasive endodontic preparations when DFUs are followed. PTG is predictable, efficient, safe, and simple for the automatic creation of the appropriate shape for the root that the root canal resides in. The bottom line: PTG maintains root canal systems’ original anatomy. The SX/ProGlider sequence makes shaping with the PTG series a breeze. The SX rapidly and efficiently removes coronal dentinal interferences, and the ProGlider enhances glidepath preparation.” • Pack: “Vertical compaction of warm gutta percha using the continuous wave of condensation utilizing the Gutta-Smart Pack and Flow device (Dentsply Sirona).” • Sealer: “ThermaSeal Plus Sealer (Dentsply Sirona) offers excellent bio-

ENDODONTIC PERSPECTIVE • Sealer: “EndoSequence® BC Sealer (Brasseler® USA). These small and extremely small shapes need a very thin sealer/film thickness.” 6. Dr. Charles Maupin (drmaupin@maupinendo.com) • Clean: “Laser-activated irrigation of sodium hypochlorite, EDTA, and distilled water using the Waterlase® (BIOLASE) to generate shockwaves, forcing the irrigants throughout the root canal system.” • Shape: “Size 15/04 to 20/06 EndoSequence Scout files (Brasseler USA). The shape is created only to allow a pathway for the pressure waves created from the Waterlase laser to travel throughout the root canal system.” • Pack: “Modified warm vertical technique. A narrow anterior Touch ’n Heat tip (Kerr) is used for a deep-down pack, followed by a backfill using the Hot Shot.” • Sealer: “My preferred sealer is Pulp Canal Sealer EWT (Kerr), which has a long track record of success. The powder allows the operator to control the consistency of the sealer. Coming in a close second would be EndoSequence BC sealer due to its ease of use.” 7. Dr. Tom McClammy (drmcclammy@nsendodontics.com) • Clean: “Since 2017, I have been utilizing GentleWave technology. While I do not think it is the perfect system, I do believe that it is the closest thing we have to debride, disinfect, and therefore ‘clean’ the RCS. There will undoubtedly be innovations in the future that compete with GentleWave, but I think it is the best we have right now.” • Shape: “When addressing specifically NiTi instruments, today I am able to use fewer (2 to 3) and smaller instruments: for

E. 40 Endodontic practice

example, 14/.03, 17/.03, and 20/.06 VT from SSW. Of special focus is preserving peri-cervical dentin and producing a sufficient-size tunnel from orifice to foramen.” • Pack: A single, nonstandardized cone-fit validated with EAL and a digital image. • Sealer: “EndoSequence BC sealer, which is now being marketed by numerous dental companies.”

Sequence BC Sealer monobloc for resorbed large portals of exit when gutta percha cannot be controlled.” 10. Dr. Reid Pullen (reidpullen3@hotmail.com) • Clean: “I predominantly use EndoActivator but also GentleWave on certain cases. Once shaping and conefit are finished, I run EndoActivator for 30 to 60 seconds in each canal, followed by EndoVac, followed by EndoActivator again with QMix to remove the smear layer.” • Shape: “I predominantly use ProTaper Gold S1 to F3. With smaller, tighter canals, I will finish with F1. I also use the WaveOne Gold reciprocating system.” • Pack: “Vertical compaction of warm gutta percha. I use the cordless GuttaSmart heat tip (black tip) for downpack and the Gutta-Smart 25-gauge tip for backfill.” • Sealer: Thermaseal Ribbon (Dentsply Sirona) or Kerr pulp canal sealer

8. Dr. Blake McCray (bwm.dds@gmail.com) • Clean: “GentleWave disinfection 90% of the time and EndoActivator irrigation 10% of the time.” • Shape: “ProTaper Gold on every case. Always finish with F1 unless a canal dictates a larger size.” • Pack: “Single cone on every case with matching ProTaper Gold gutta-percha.” • Sealer: EndoSeal MTA 9. Dr. Terry Pannkuk (terry@pannkuk.com) • Clean: “Clorox® Ultra (8.25% NaOCl) is the mainstay irrigant; alcohol is used to clear between irrigants; 17% EDTA is used at the end to clear and then dry with alcohol. An ultrasonic file (ACTEON North America) is used on low power to activate the irrigant. Most recently, I am using a patented intracanal form of trichloroacetic acid (TCA) as a pulp dehydrant. The observable benefits are (1) it more efficiently establishes patency; (2) it allows easier file entry for tight, small, calcified canals; (3) it decreases postoperative pain; (4) enhanced cleaning; and (5) more. Launching in 2021.” • Shape: “Precurved K-files and ProTaper Gold S1 to F3, depending on the anatomy. Passive Gates Glidden burs for initial flaring.” • Pack: Vertical compaction of warm gutta-percha technique. • Sealer: “Kerr regular set (ZOE). Endo-

Survey observations and trends from the 10 respected endodontists 1. None of these endodontists do the same thing! There is more than one way to bake a cake. This should say something profound to the reader. The greatest variable may not be the tools of the Triad; it is you and me — our skills and our willingness to show them off. 2. All those surveyed enjoy enormous clinical success. All have robust recall systems. They all have a penchant for seeking proof of positive outcomes. 3. All of the above aspire to be their best. 4. All are lifetime students and resist just trying to be right. Their “rightness” comes from maximizing predictability and shrinking their “X” to 100% − x. 5. Endodontics is still extremely

D. Figures 3A-3F: The Future. 3A. A virtual headset to see an endodontic tooth in 3D. 3B. Targeting all foramina (courtesy of Tooth Atlas). 3C. Smartphone pack app activated. 3D. Shooting seal bullets. 3E. Foramina sealed. 3F. The anterior teeth would discolor due to untreated necrotic pulp. In this esthetic situation, it is time to access, vacuum root canal system contents (this is good anyway, as latent bacteria could creep out from the foraminal seals), and then fill the root canal system. Then correct the discolored tooth with either “walking bleach” or veneer or maybe some futuristic paint!

Volume 14 Number 4

The future The Endodontic Triad is alive and well. Many endodontic companies and inventive endodontists are investigating more predictable ways to treat endodontic disease. For example, I can report as a Dentsply Sirona KOL leader/designer that much energy and innovation is being given to the 2021 launches of products addressing all three parts of the Endodontic Triad as well as sealers. Peering into the future, sometimes innovations can become fantasies, and sometimes these mysterious and abstract fantasies become reality (Figure 3). But the “X” in 100% − X is about to become a smaller “x.”

My invitation to a 10-step operatory mindset This article is full of endodontic strategies, recipes, and prescriptions for tools, techniques, and technology. Most require some learning curve, purchase, and change. But I invite you, the reader, to improve your Volume 14 Number 4

endodontic predictability without lifting a finger. Are you all ears? It is a mental shift.14 For the next 2 weeks, when you enter the operatory to treat an endodontic patient, I encourage you to savagely focus on this 10-Step Mindset of where you want to go: 1. I am slowing down. In the words of Simon and Garfunkel (1960s), “Slow down, you move too fast/ You got to make the morning last.” Remember, slow and steady wins the race. 2. I am designing my access so that I am finding all the canals but with respect to a “maximally” appropriate access size and shape — not too big and not too small, just right. 3. I am taking the time to identify all orifi. 4. I am removing restrictive orifi dentin triangles before sliding down the canal. 5. I look at pretreatment periapical radiographs and vividly imagine the desired final radiographic result. 6. I am proceeding with a lighter touch than ever before, knowing root canal systems are delicate and require restraint versus pushing.15 7. If I am behind schedule, I choose to close the access and reschedule. The clock is the kiss of death in endodontics. 8. I irrigate after every endodontic instrument is removed from the canal and before re-entry. I recurve the manual file on each re-entry. 9. I stop myself if I am thinking negative thoughts about how I am doing and experiencing my endodontic treatment. As soon as I notice that I am following my mind to a place I do not want to go, I just understand where this thought is taking me. I hear the nonstop voice in my head. 10. That’s it! There is nothing for me to do. Just observe! I sit back and watch myself do something different, something that moves me toward experiencing the real outcome I wanted in the first place. By seeing, feeling, and thinking this 10-Step Mindset, you will measurably improve your endodontic outcomes. Your brain will literally rewire, and new neural networks will form. Because of the brain’s neuroplasticity, we can train the brain by what we focus on. You will have a new normal! Call me if it does not work! There is magic and freedom in what I am suggesting to you. In summary, stay tuned. Things are changing in endodontics, maybe even in pulp regeneration, but remember that fundamentals are still the salient ingredient of predictability.

Closing comments The Endodontic Triad is changing, and at an increasing rate, CSP will change, and the vocabulary of CSP will probably change with new tools, techniques, and technology. During these changes, what is our responsibility to the public? Do these changes close the 100% − X to essentially 0%? What will the changes cost? How long is the proving time? What if cleaning better is not better or really does not matter? What if the need for clinician shaping is eliminated or performed by robotics? What if packing material is a miracle future filler that easily bonds with the entire root canal system’s walls by the push of a button? However, technology can fail. Do you remember the promise of N2, Hydron, and Resilon? All were removed from the marketplace. Do you remember Canal Finder? It is our responsibility to our patients to be the gatekeepers of new technology benefits. Early adopters of new technology always take a risk, but it should not be our patients’ risk. The race for the ultimate Endodontic Triad is on. The Endodontic Triad is alive and well! And it will be different. In closing, here’s one more lasting thought: Let endodontics be whatever it becomes. And now your next endodontic patient has a question: Are you ready for the moment? EP REFERENCES 1. West JD. Rules of engagement: Mastering the endodontic game, part 1. Dent Today. 2006;25(6):94-101. 2. Friedman S. Prognosis of healing in treated teeth with endodontic infections. In: Fouad FA, ed. Endodontic Microbiology. 2nd ed. Wiley-Blackwell; 2017. 3. Schilder H. Filling root canals in three dimensions. Dent Clin North Am. 1967:723-744. 4. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18:269-296. 5. Ruddle CJ. Endodontic triad for success: The role of minimally invasive technology. Dent Today. 2015; 34:76-80. 6. The Ruddle Show. Ruddle Projects & Diagnostic Imaging. S03:E07. www.theruddleshow.com. Released November 25, 2020. 7. West JD. The endodontic glidepath: Secret to rotary safety. Dent Today. 2010;29(9):86-93. 8. West JD. The three Fs of predictable endodontics: Finding, following, and finishing. Dent Today. 2016;90-96. 9. West JD. Endodontic predictability: What matters? Dent Today. 2013;108-113. 10. West JD. Root canal system anatomy only matters when it matters. Endodontic Practice US. 2015;56-58. 11. West JD. The evolving look of “the look.” Dent Today. 2019;62-66. 12. Khademi J. Restoratively driven, minimally invasive endodontics. Dent Today. 2019;66-69. 13. West JD. The pendulum swings. Dent Today. 2019;8-10. 14. West JD. The set up: Endodontic predictability. Dent Today. 2020;66-71. 15. West JD. Restraint: The lost art of endodontics. Dent Today. 2018;100-103.

This article was reprinted with permission from Dentistry Today.

Endodontic practice 41

ENDODONTIC PERSPECTIVE

meticulous and, regardless of advancing technology, resolving to honor the fundamental basics of root canal system treatment remains indispensable for predictable success. 6. Cleaning the root canal system is the new frontier in endodontics. In the past, this Triad member was the one most ignored. 7. Canal shapes are becoming narrower due to innovations in cleaning and filling, which preserve the natural anatomy of the root canal system. 8. The concept of minimally invasive endodontics (MIE) is becoming mainstream.12 However, remember the pendulum always swings back and forth, and in the case of endodontics, the pendulum is swinging between disruptive technology and timetested fundamentals.13 In addition, adhesive dentistry is not so focused on minimal access size or ferrule preservation. 9. Obturation techniques are becoming easier and more simplified. 10. Some of the endodontists were antithetical toward the three-word Triad and want to instead call it a “Biad.” Others might see the Triad as a “Uniad.” To me, all the parts of the Triad are perfectly intact and required. It is only the emphasis and delivery of the Triad’s parts that are being challenged and are changing. The answers to my survey were edited in the interest of article word count. However, all the doctors surveyed invite you to contact them if you want to learn more from them.

SERVICE PROFILE

U.S. Endo Partners Dr. Eric Young discusses operating his practice with the help of fully informed, data-based decisions

s endodontists, stress is something we all sign up for. We know going in we will be providing medical care to someone in urgent need of treatment. Our rigorous training prepares us for an incalculable number of treatments and situations. We spend years learning the skills in order to practice our profession in the effort to be able to treat patients in need. Ultimately, many of us hope to own our own endodontic practice. The reality is that owning a practice is getting harder. Not only are we giving our patients the best endodontic care possible, but the demands of practice management and everything that comes along with it requires more of our time.

There are few, if any, classes offered to endodontists on practice management. There is a glaring absence of resources offered in team education or compliance issues regarding regulatory, legal, or patients. When starting our endodontic practice, Creekside Endodontics, my brother and I faced a steep learning curve that we would still be climbing without U.S. Endo Partners. Eric Young, DDS, graduated from the University of the Pacific School of Dentistry in 2007. He continued his education while serving our country in the United States Army. In 2008, he completed an Advanced General Dentistry residency and went on to serve tours in Egypt and Afghanistan with the 3rd Special Forces Group. Dr. Young finished his dental education at Harvard University School of Dental Medicine, where he received a postgraduate certificate in Endodontics.

42 Endodontic practice

On the first day we joined U.S. Endo Partners, what they did was so simple but so crucial. It was rudimentary but exactly what we needed to take our practice to the next level. They simply asked us, “How can we help?” Ultimately, U.S. Endo Partners support their doctors to allow them to focus on their patients. U.S. Endo Partners do not tell you what to do or how to run your business. They share their own best practices based on years of clinical experience throughout our partnership of 130-plus endodontists (and growing)! One of the ways in which we benefited from this partnership was through their software and patient management systems. Doctors appreciate having an efficient tool to keep track of their practices. It allows them to make fully informed, data-based decisions. It gives endodontists more confidence in how they operate. If you own your own practice, you know how integral that is to operational success. When doctors experience a better, more efficient way, they frequently experience a

sense of rejuvenation in their practice. This carries over to their teams and their patients. Endodontists feel like they are doing things on a more efficient level that helps them to achieve more each day. Success is contagious. When you minimize practice inefficiencies, not only do practices benefit as a whole, but ultimately and most importantly, our patients do too. We found that U.S. Endo Partners is comprised of specialists who understand the power of putting people in their sweet spot. That synergy of everyone working together is the magic formula. This is driving the feeling of confidence for the doctor to keep moving forward to free up the doctor. I’ve spoken to many of my partners at U.S. Endo Partners about their experiences. The feedback has been nothing short of amazing. Some have called it an “aha moment.” Their lightbulb goes on. Their previous process was not wrong. The collaborative process of U.S. Endo Partners and their patient management system was just a better, more efficient way. If you are interested in having your own “aha moment,” contact the professionals at U.S. Endo Partners. The feeling of rejuvenating your practice is worth it. EP Volume 14 Number 4

‘‘

U.S. Endo Partners amplifies our individual and financial value more than we can alone.

– Dr. Eric Young, DDS, MMSc Creekside Endodontics

The first and foremost.

Started in

2018

Endo led

Patient focused

U.S. Endo Partners creates value for endodontists through our collective strength. We get better pricing for our partners, increasing their net worth. Our Clinical Advisory Board increases our collective knowledge. We increase the time our partner endodontists get to spend with what is most important to them. U.S. Endo Partners amplifies the value of our partners every minute of the day. www.USEndoPartners.com/Success

PRODUCT PROFILE

Triton® — All-in-one irrigation solution

nlike traditional irrigants or other advanced 2:1 solutions, Triton® works differently by avoiding the use of EDTA and CHX altogether. The non-NaOCl components in Triton proactively dissolve the dentinal debris, allowing for a lower concentration of NaOCl to be exposed to organic debris without as much buffering. Synergistic and simultaneous dissolution of organic and inorganic debris permits the clinician to use lower volumes of irrigation solution and ensure maximum clinical efficiency.

Efficient and effective By using a lower concentration of NaOCl and a patent-pending proprietary blend of surfactants and gentle chelating agents, Triton is the first irrigant to deliver all of the benefits of NaOCl, EDTA, and CHX in a single-step all-in-one irrigation solution. NaOCl is rapidly neutralized upon contact with EDTA (and inorganic dentinal debris). Triton maintains an effective NaOCl concentration for organic tissue dissolution while simultaneously allowing for inorganic debris removal in just one step.

The efficacy of various irrigants against E faecalis biofilm was investigated both with and without dentin chips present. In the presence of dentin chips, only Triton was able eliminate all E faecalis. And Triton kills bacteria more quickly. In an ex vivo evaluation of live versus dead bacteria comparing three different irrigation protocols, Triton was more effective than 6% NaOCl + 17% EDTA in half the time.

Features and benefits at a glance • Multifunctional single irrigation solution reduces chair time, procedural steps, and overall irrigation costs • Simultaneous organic and inorganic debris removal • Less cytotoxic than 6% NaOCl with EDTA • More effective at smear layer removal versus NaOCl with EDTA • Dissolves organic tissue up to 1.7x faster than traditional NaOCl Tested and proven effective by worldrenowned endodontists, Triton has quickly become a preferred irrigation protocol

Ex vivo evaluation — live (green) versus dead (red) bacteri

Procedural Step and Irrigation Cost Comparison* NaOCl+EDTA+CHX

NaOCl+EDTA

2:1 Solutions

Triton

Solutions Used

Syringes Used

Tips Used

Water Rinse Required

Yes

Recommended

Yes

Avg Tip+Syringe Cost per Procedure

$3.84

$2.97

$3.84

$1.28

Irrigation Solution Cost per Procedure

$1.19

$0.85

$2.38

$1.87

Total Irrigation Cost per Procedure

$5.03

$3.82

$6.22

$3.15

*Data on file. The average general practioner does 115 root canal therapies a year, making the total annual irrigation cost with Triton only $362.25 in 2021. Clinical consideration: A sterile water rinse is recommended before placing CHX or a CHX-containing “2-in-1” solution to avoid a para-chloroaniline (PCA) reaction.

44 Endodontic practice

Triton all-in-one irrigation solution

because of its convenience and ease of use. It replaces all irrigants with a single, lower concentration NaOCl-based solution and provides consistent cleaning with predictable outcomes. Besides reducing chair time by eliminating the need for multiple irrigation solutions and sterile water rinses, Triton is also cost-effective. It reduces the number of single-use disposable syringes and tips you will require. In some cases, Triton can cut your total irrigation cost per procedure in half. Dr. Allen Ali Nasseh of Real World Endo notes the benefits of Triton to his Boston, Massachusetts-based practice: “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.”

About Brasseler USA® Since 1976, Brasseler USA has focused on developing products and providing services that support the practice of core operatory procedures. Today Brasseler USA® is the premier dental instrumentation company in North America offering the most extensive selection of dental and surgical instrumentation under one brand. To order, call 800-841-4522 or fax 888-610-1937. In Canada, call 800-3633838. Visit the website at BrasselerUSA. com. EP This information was provided by Brasseler USA®.

Volume 14 Number 4

BY YOUR SIDE

NEW!

ENDOSEQUENCE ® VT SCOUT EndoSequence VT Scout Files feature a proprietary variable tapered design that allows for deep apical shaping while preserving coronal tooth structure. This design is comparable to the V Taper™ 2 file, previously sold by SS White®. Minor design upgrades include a short 16mm compression-fit nickel handle and a more robust stopper. These heat-treated NiTi files are extremely resistant to cyclic fatigue and are preferred by clinicians that embrace a minimally invasive shaping philosophy.

Variable tapered design Extremely conservative maximum flute diameter Provides an optimal “deep apical shape” Variable taper design provides a deep apical shape with reduced coronal taper

Taper ID

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Proprietary heattreated NiTi for improved resistance to cyclic fatigue

V-Taper™ is a trademark of Edge Endo®. SS White® is a trademark of SS White Dental, Inc.

B-5579-EP-12.21

SERVICE PROFILE

Endo1 Partners A partnership organization focused on patient and partner satisfaction

magine being able to solely focus on the “practice” part of your practice. Endo1 Partners empowers dental surgical specialists like you to do just that — and helps you to achieve all your business goals. This was the idea that inspired practicing endodontists Matthew Haddad, DMD; Daryl Dudum, DDS; Mark Haddad, DDS; and Darron Rishwain, DDS; to establish Endo1 Partners. These industry-leading professionals came together to form the first-ofits-kind endodontic partnership organization after finding that existing groups did not truly understand the specific needs and challenges of specialists. “We were seeing a growing number of specialists weighed down by the burden of running a business; and as practicing endodontists, we understood this burden since we were also in it every single day,” said Dr. Matthew Haddad, Founding Partner and Co-CEO. “Our vision was to help likeminded specialists run their practices in the most productive, advantageous way, so we created the partnership organization we always wanted to join.” Endo1 Partners now provides support for those complex, nonclinical services to a network of more than 175 specialists and over 100 locations across 15 states. In addition to centralized services and shared back-office support, partner endodontists also have access to group benefits and discounts, specialized training, credentialing, cutting-edge equipment, and the latest industry information. Endo1 Partners takes the stress of practice management off your plate, so you can spend more time doing what you love. All these resources will help reduce your administrative burden, increase efficiency, and fuel growth, so you can focus on what matters most — providing high-quality patient care and growing your business. This focus on patient and partner satisfaction isn’t a gimmick. It is one of the core principles that drives everything Endo1 Partners does. Even as Endo1 Partners 46 Endodontic practice

Endo1 Partners founders Daryl Dudum, DDS; Matthew Haddad, DMD; Mark Haddad, DDS; and Darron Rishwain, DDS

“Our primary focus has always been patient and partner satisfaction, and we have found that this approach truly resonates with the specialists we bring on board.” – Dr. Daryl Dudum, Founding Partner and Co-CEO

continues to grow its network, expand its suite of business and operational support services, and enhance its infrastructure, the founding partners are committed to making sure that company values stay in place long-term — values such as honesty, clinical autonomy, maturity, excellence, growth, and caring. Do you share these same values? Do you put patients and staff first? Are you interested in partnering with a nationwide network of like-minded specialists you can trust? If you answered yes to any or all these questions, Endo1 Partners may be the right fit for you.

It’s Time to Thrive Together Endo1 Partners boasts a unique model that allows you to prosper on your terms. You will receive all the benefits of joining a group practice, while maintaining control of your business. Partners retain equity and control of their practice, so they can continue to treat patients under their brand and with their existing team. Contact info@endo1partners.com or 305-206-7388 today to learn how Endo1 Partners can help you and your practice thrive. With the support of Endo1 Partners, there is nothing you can’t do! EP Volume 14 Number 4

100+ PRACTICES

175+ SPECIALISTS

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

I Endo1partners.com

SMALL TALK

How to create your best year ever Drs. Joel C. Small and Edwin McDonald discuss how to develop a team of peak performers

t almost seems counterintuitive that dental practices could be experiencing their best year ever. Considering the numerous demands being placed on dental practices through governmental mandates, lockdowns, new COVID-19 safety protocols, inflation, etc., one would naturally assume that having a successful year would be difficult if not impossible. Yet many of our clients are experiencing their most productive year ever. We have observed this phenomenon and have identified several key factors leading to their success. A current industry-wide challenge for clinical healthcare practices is staffing. Acquiring and maintaining quality staff have become arduous tasks for most doctors. Consequently, we have to do more with less staff, and being shorthanded can have a profound effect on our current staff as they are having to work harder to maintain productivity. As a result, many of us share a very real concern that our current staff may ultimately burn out and seek employment elsewhere. It is our belief that the longer the staffing shortage issue continues, the more likely this concern will become reality. Doctors now have to ask more of their teams. Tapping into the teams’ discretionary energy and receiving 110% effort from them requires exceptional leadership skill. Those leaders who know how to access this vital source of energy and scale their teams’ capabilities and capacity to handle an increased workload are finding success despite these current difficulties. Developing our practices’ human capital by creating peak performing teams

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.

48 Endodontic practice

is an absolute imperative for success in today’s challenging environment. Understanding how to develop peak performers will simplify and expedite the process. The following suggestions will prove helpful in achieving this goal.

intelligent understand the importance of how we show up for our team. Emotionally intelligent leaders are powerful influencers. Through their words and deeds, they create strong practice cultures that are conducive to peak performance.

1. Become a people developer

3. Become a collaborator

This concept is not new. Many leadership opinion leaders believe that developing an organization’s human capital is a leader’s primary responsibility. However, developing people goes beyond just developing technical skills. Of equal importance is the development of their mental capabilities and capacity to handle increased workloads. We are currently working with our clients to help them acquire basic coaching skills, so they can develop their teams’ capabilities much more rapidly and predictably. Coaching as a leadership style is becoming the gold standard for team development and is currently being utilized by many Fortune 500 companies. Many of us unknowingly serve as a barrier to team development by requiring all decisions to pass through us. Granting teams a degree of autonomy and the authority to make decisions within predetermined boundaries is important, and allowing this to occur within a psychological safe environment is essential. Our staff, just like us, are human, and they will make mistakes even while having the best intentions. With the right attitude and coaching skills, doctors can turn mistakes into valuable teachable moments for our teams, and in doing so, we will see our teams develop into peak performers at an accelerated pace. Furthermore, we will begin to see greater levels of commitment to our cause and begin tapping into our team’s discretionary energy.

Stephen R. Covey — author of The 7 Habits of Highly Effective People (a New York Times best seller) — stated, “We believe we see the world as it is, when in fact we see the world as we are.” Each of us has a lens, created by past experiences, through which we see the world. Too often we mistakenly believe that our worldview is the most accurate and our decisions the most correct. Jennifer Garvey Berger in her book, Unlocking Leadership Mindtraps, stated, “When leaders believe they are right in a complex world, they become dangerous because they ignore data that would show them they are wrong.” This powerful statement holds true for many of us in the healthcare profession. We are accustomed to making daily unilateral decisions regarding our patients’ care. Unfortunately, this same mindset does not serve us well as leaders. By collaborating with our teams and advisors, we are inviting a diversity of opinions and experiences that will prove valuable in making the best possible decisions. Furthermore, by including our teams in the decision-making process, they will feel empowered and appreciated for their contribution and will feel less inhibited when offering valuable unfiltered feedback in the future.

2. Become emotionally intelligent How we see ourselves as leaders doesn’t matter — what matters most is how those we lead view us. Authority can be a doubleedged sword. We can use authority to gain compliance from our teams, but authority by itself will never create the necessary commitment that allows us to receive our teams’ discretionary energy. Those of us who are emotionally

4. Be trustworthy Trust is foundational to everything we have mentioned. Without trust, peak performance will be unreachable. Trust develops over time and requires an adherence to commonly shared values and our consistency between words and deeds. If you have not already noticed, this entire process is all about us, the leaders. Taking teams to peak performance will happen if we allow it and make it happen. Our teams will never exceed our ability to lead them. We must define what peak performance looks like for our team and coach them toward reaching this worthy goal. EP Volume 14 Number 4

ProTaper Ultimate™

Navigating tough challenges requires performance without limits

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It is all about passion. Endodontics expertise requires performance. Introducing a new solution combining the latest generation of ProTaper files, enhanced disinfection and dedicated obturation that works seamlessly together. Shaping: 1 Slider-Shaper-Finishers sequence to cover a full range of anatomical situations. Cleaning: More than 25% better cleaning efficacy vs. sodium hypochlorite soak without activation.* Obturation: Obturation with ideal fit 100% of the time. dentsplysirona.com/protaperultimate *Only applicable for EndoActivator®

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