Endodontic Practice US Spring 2022 Vol 15 No 1 by MedMark, LLC

4 CE Credits Available in This Issue*

page 8

AAE Special Section

Spring 2022 Vol 15 No 1

endopracticeus.com

Karen Potter, DDS This endodontist improves patients' experience with technology

Risk versus Reward: technology adoption requires thoughtful analysis Dr. Jeffrey L. Linden

The dental operating microscope through the years: past, present, and future Dr. Andrew R. Steidley

Practical considerations for utilizing Prescription Drug Monitoring Programs — a primer Nikki Sowards, PharmD Michael O’Neil, PharmD Tyler Dougherty, PharmD

PROMOTING EXCELLENCE IN ENDODONTICS

“Better patient outcomes.” – Sonia Chopra, DDS

Make a Difference for Your Patients.

Give your patients superior cleaning and disinfection and optimized dentin preservation with an efficient, single-visit GentleWave® Procedure.

Visit sonendo.com/aae22 to register for a GentleWave® System test-drive, lecture and other in-booth events with Sonendo®.

“Doing everything I can for my patients.” – Adam Davis, DDS

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Sigurdsson A et al. (2016) J Endod. 42:1040-48 © 2022 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE and the GENTLEWAVE logo are trademarks of Sonendo, Inc. Patented: sonendo.com/intellectualproperty. MM-1524 Rev 01

“A better patient experience.”

– Kirk A. Coury, DDS, MS

INTRODUCTION

A new idea Spring 2022

Volume 15 Number 1

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

“A

new idea is first condemned as ridiculous and then dismissed as trivial, until finally, it becomes what everyone knows.” — William James (American philosopher 1842-1910) I often think of the quote above as I look back over my professional career and choices when considering the adoption of new technology into my endodontic practice. I first heard of the quote in 1995 during a presentation at Dr. Gary Carr’s Pacific Endodontic Research Foundation (PERF). In the face of intense skepticism, Gary’s deep conviction and resolve inspired him, along with the help of James A. Smith Jr., DMD trusted colleagues, to train hundreds of endodontists in the use of Microscopic Endodontic Techniques — changing our specialty for the better. But consider this: It was more than a decade after 1995 that microscope training became widely incorporated into our endodontic postgraduate programs. As a specialty, we are slow to change and adopt innovative technologies. This is true for multiple reasons; not the least is that change is uncomfortable. Change is uncomfortable in disrupting our routine, the extra time required to learn a new way to “do what we do,” and the necessary financial commitment to purchase innovative technology. These are all valid concerns but should not prevent us from investigating what might help us do a better job for our patients and make our jobs easier and more rewarding after gaining proficiency. I recall three examples that illustrate this in my practice lifetime. The first was the microscope, which was the hardest to adopt. After being in practice for 13 years, the learning curve was steep. Learning technology like the dental operating microscope (DOM) while running a busy practice was difficult, but persistence and perseverance have paid great dividends. The second was cone beam computed tomography (CBCT). I studied and considered the cost/benefit for a couple of years before “pulling the trigger.” Now I cannot fathom practicing without CBCT and its usefulness in diagnosis, treatment planning, and assessing endodontic outcomes (healing). The third is GentleWave® disinfection and cleaning of the root canal system. This technology has proven in my office to better the patient experience (i.e., little to no post-op issues and reduction of actual treatment time), to reduce rotary instrumentation use, and to allow for converting almost every case to a single visit. My point is this: As clinicians, we owe it to ourselves and our patients to investigate innovative technology and consider the benefits and cost (time and money). Only then can we make an informed decision as to whether to adopt it into our practice. Do your due diligence. Talk with trusted colleagues who have successfully adopted whatever modern technology you may consider, and if possible, visit their offices to see how this might benefit you and your patients. You owe it to yourself and your patients to keep an open mind and consider what might make your professional life more rewarding. Dr. James A. Smith Jr.

© MedMark, LLC 2022. 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.

ISSN number 2372-6245

James A. Smith Jr., DMD, graduated from the University of Alabama School of Dentistry in 1980 and received his postgraduate certificate in Endodontics from the same institution in 1982. He is the founder of Advanced Endodontics in Birmingham, Alabama. Dr. Smith has been in private practice for 39 years and recently retired as an Adjunct Assistant Professor from the Department of Endodontics at the University of Alabama at Birmingham School of Dentistry.

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Volume 15 Number 1

TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

Don’t just survive — thrive!

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

CLINICAL

A CONVERSATION WITH ...

Karen Potter, DDS

This tech-savvy endodontist discusses her practice’s focus and the role technology plays in allowing her to provide an improved patient experience Cover image of Dr. Karen Potter courtesy of Sonendo.

Minimally invasive endodontics with a novel shaping file Dr. Reid V. Pullen uses a safe, effective, and efficient shaping system to paint a “beautiful endodontic canvas”......................13

CASE REPORT

COMPANY PROFILE

Risk versus reward: technology adoption requires thoughtful analysis

Dr. Jeffery J. Linden discusses the value of a supporting community when making big decisions Endodontic Practice US

Volume 15 Number 1

AAE SPECIAL SECTION

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TABLE OF CONTENTS

CONTINUING EDUCATION

The dental operating microscope through the years: past, present, and future Dr. Andrew R. Steidley offers insights into the history, uses, and

SERVICE PROFILE

benefits of the dental operating microscope (DOM)

Endo Mastery Endodontic practice coaching to transform your practice and life! .............................................................. 42 PRODUCT PROFILE

Built to Last. Built for You. Built by Boyd!........... 44

SERVICE PROFILE

SMALL TALK

Dr. Christopher Sabourin built Endodontic SuperSystems (ESS) for quality of life...........................46

Drs. Joel C. Small and Edwin McDonald show how leadership styles affect practices’ productivity....................................... 48

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*Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://endopracticeus.com/category/continuing-education/

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Endodontic Practice US

Volume 15 Number 1

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PUBLISHER’S PERSPECTIVE

Don’t just survive — thrive!

Published by

hen preparing my first message of 2022, I was looking for inspiration. I found a quote by author Richelle E. Goodrich, which said, “Revitalized, I find the strength to battle new tomorrows.” She added, “This year, I survived. Next year, I will thrive!” Revitalization is a key to continuing to grow and prosper in the coming years. It means to give new life or vitality. Here at MedMark, revitalization is exactly what we concentrate on every day — for our readers and our authors and, ultimately, for our patients. For our spring issue, our page design has changed. That is part of our revitalization. Our articles and topics will conLisa Moler tinue to motivate. But you will also find: Founder/Publisher, • Easier-to-read bold headlines and a humanist, more MedMark Media legible typeface • More color and a fresh color palette with new accent colors • More reader-friendly text and column width • More bookshelf-friendly size — the publication now is easier to store for long-term reference In this issue, a CE by Dr. Andrew R. Steidley shares details on the history and features of the dental operating microscope that make it an asset to endodontics. A CE by Nikki Sowards, PharmD; Michael O’Neil, PharmD; and Tyler Dougherty, PharmD; shows how dentists can utilize state prescription drug monitoring programs (PDMPs) to inform clinicians and identify “red flags” when prescribing controlled substances. Pass the quizzes for these CEs and obtain 2 CE credits each! In a conversation with Karen Potter, DDS, she reflects on the amazing assistance that technology — especially CBCT and GentleWave® — gave her in diagnostics, treatment planning, and practice. In his article on minimally invasive endodontics, Dr. Reid V. Pullen shows how certain tools in his practice help paint “a beautiful endodontic canvas.” While we all are laser-focused on succeeding and expanding our options this year, we also should remember the importance of practicing empathy and kindness. Stories of these past 2 years of the COVID-19 pandemic taught us that we all have a personal and professional story that has deeply impacted our lives. Some share these challenges with the world, and some prefer to keep them personal; but in the light of what we have all gone through, part of the revitalization of 2022 will be to recognize that we need each other’s support to move forward. There are many ways to practice kindness in the dental world. Be a mentor to another dentist who has questions on technique or materials that work for you. Motivate a colleague who is just starting out or is restarting. Use your social media to be an inspiration. Call peers, and suggest they read an interesting article that will help move their practice forward. Tell a few people in your personal life that you are proud of them. Revitalization means so much, especially this year, and MedMark is proud to be a catalyst for positive change. For our readers, our articles and webinars can help you gain or change perspective and move in new directions. For manufacturers and innovators, our marketing services can bring you the attention you deserve and the recognition you seek. Our motto this year is “Renew in 2022!” With our combined experience and insights, we can stride into the future together. For this issue, we put a new spin on the quote at the beginning of this perspective. “Last year, I survived. This year, I will thrive!” To your best success, Lisa Moler Founder/Publisher, MedMark Media Endodontic Practice US

Volume 15 Number 1

Publisher Lisa Moler lmoler@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 Sales Assistant & Client Services Melissa Minnick melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury amzi@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Webmaster Mike Campbell webmaster@medmarkmedia.com eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager April Gutierrez socialmedia@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 Rate 1 year (4 issues) $149 https://endopracticeus.com/subscribe/

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A CONVERSATION WITH ...

Karen Potter, DDS This tech-savvy endodontist discusses her practice’s focus and the role technology plays in allowing her to provide an improved patient experience What made you decide to concentrate on endodontics? I was born and raised in the beautiful seaside community of San Clemente, California. I came from a “dental family,” as my father was a generalist and my mother was a dental hygienist. I worked in my dad’s dental office during summers and learned about providing the highest quality dental care there. In our small community, I learned that I had to always do my best by people and stand behind my work. After graduating, I moved to Los Angeles to pursue degrees in Spanish and Natural Sciences at the University of Southern California (USC). I graduated magna cum laude and moved to University of California, Los Angeles (UCLA) for dental school where I developed my interest in endodontics. I loved the idea of saving natural dentition, alleviating patients’ pain, and having a small practice where I could spend one-on-one time with all my patients and give them compassionate care at a painful and daunting time. After graduating summa cum laude from UCLA, I earned my Certificate of Endodontics at the University of Iowa where I realized my passion for endodontics and vowed to be a lifelong teacher and student. I learned that endodontists have an important role because people highly value maintaining their natural dentition. I pursued Board Certification in 2011 and returned to San Clemente to practice. After starting my practice, I established a Vision Statement that guides my decision-making every day. This Vision encompasses providing the most compassionate, thorough, and skillful endodontic treatment possible using the most advanced technology and best customer service.

Are you tech-savvy? What types of technology are beneficial in your practice?

Dr. Karen Potter with a patient

position was in Leawood, Kansas, with Dr. Paul Jones, who was one of the first endodontists to utilize CBCT. I was astounded by the amazing assistance that technology gave me in my diagnosis, treatment planning, and practice of endodontics and vowed to thoroughly investigate upcoming technologies throughout my career to make sure I was providing the best quality of care. When Sonendo®, the manufacturers of the GentleWave® System, began promoting their technology around 2015, my interest immediately peaked. Sonendo’s headquarters is 10 miles from my office, so I was introduced to the company early on. Like other practitioners, Sonendo’s claims of canal-cleaning capability and efficacy made me skeptical. As more research came out, I got more intrigued. Finally, several of my endodontic colleagues had adopted the technology and were raving fans. That’s when I transitioned my practice to a GentleWave practice, and I’ve never looked back. The combination of CBCT and the GentleWave System has made my practice a primarily single-visit practice

While I do not consider myself “cutting edge,” I think that I am tech-savvy. My interest in technology began when I first graduated from my residency in 2009. My first associateship

Karen Potter, DDS, was born and raised in San Clemente, California. She attended the University of Southern California, where she graduated magna cum laude. She then attended the UCLA School of Dentistry and graduated summa cum laude. At UCLA, she spent time in leadership and endodontic research, which allowed her to publish multiple articles. After UCLA, she attended her Endodontic residency program at the University of Iowa. She practices in San Clemente and has been a Diplomate with the American Board of Endodontists for over 10 years. Dr. Potter is a busy working mother of three who loves to share her passion for Endodontics through teaching and social media. You can follow her @karenpotterdds. Disclosure: Dr. Potter is a consultant for Sonendo®

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A CONVERSATION WITH ...

for me to share my passion for endodontics and try to educate the general population that it is important to save natural teeth when possible.

with a high emphasis on dentin preservation. My goal is to save as many teeth as possible by saving as much dentin as possible. By knowing my anatomy preoperatively with CBCT and then by conservatively cleaning those spaces with GentleWave, I have been able to provide more efficient and thorough care.

What are some challenges that you have faced as an endodontist?

How do you encourage the patient to prioritize saving natural teeth?

One of the challenges I’ve faced as an endodontist is insurance reimbursement. As endodontists, we give the patients an invaluable gift — saving their natural dentition. Many of my patients recall their parents being edentulous at a young age. They don’t want to be in the same boat! As our field has advanced technologically, insurance reimbursements have not matched the increasing cost of practicing. Because of this, I am mostly a fee-for-service practice. I feel that my patients need to be treated with quality time and care, and I do not want to feel pressure to shorten my treatment times just to keep afloat. My Vision is to provide VIP service with the greatest technology to every patient, and I want autonomy from insurance companies to allow me to do so. Another challenge I’ve faced is seeing a decrease in referrals as older dentists retire and new dentists buy generalist practices. It is only natural that a newer doctor would want to keep procedures in-house to help build rapport with patients and also avoid sending out possible production income. While this is expected, I have learned to be a resource for new generalists to help them provide the best-quality endodontic care possible. My goal is to be there when they need me and help build them

An endodontists’ job is to try to save natural teeth or to identify when it is not in the patients’ best interests to save their tooth. Encouraging patients to save their natural teeth starts at the referring doctor’s office. It is important for endodontists to have relationships and communication with dentists about the value of saving natural dentition. Some doctors just want to pull the tooth if it seems that the endodontic treatment failed, or if the tooth seems questionable. My role is to educate the generalist about which teeth truly have a hopeless prognosis as well as which teeth we can save with advanced technology and skill. I do this through giving CE courses to my referring doctors and through sharing my knowledge of endodontics on social media. Instagram has been a great way to share cases and knowledge with dentists and non-dentists alike! I started sharing cases on Instagram about 3 years ago, and I will never forget how many of my non-dental friends said, “I never knew in all these years what exactly you did for a living, or what an endodontist is!” I knew then that social media would be an important platform

Figures 1A-1E: 1A. Tooth No. 19 had pulp necrosis and acute apical abscess with buccal swelling of the attached gingiva and a 12 mm pocket on the buccal at the site of the swelling. 1B. Treatment was completed using the GentleWave protocol: Neither hand files nor rotary files were able to negotiate past the distal canal apical bifurcation. ProTaper Gold S2 file was used 1mm short of length on the mesial root and to the level of the bifurcation on the distal root. Canals were obturated with gutta percha and BC Sealer HiFlow. 1C. At the 4-month recall, the patient was asymptomatic, all swelling was resolved, and apical bone was healing. 1D. Preoperative CBCT showing apical and lateral root pathosis. 1E. CBCT at 4-month recall showing substantial apical and lateral bone healing endopracticeus.com

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A CONVERSATION WITH ...

up so that when they are tired of doing endo, they send it over to me! I act as a resource by giving CE courses, taking calls when they’re on vacation, helping them answer questions about tough cases, and even stepping in on a difficult case. Generalists know they can trust me to do the work with the best quality, expertise, and technology available when they’re ready to pass on those procedures.

There are no “easy roots.” Even a tooth that at first glance looks like it may be straightforward can have a surprising complexity.

How have you traditionally attained your goals in cleaning and debridement of the root canal system, and how has new technology changed that? Many of our teachers have said, “You could fill the canals with anything, and if you’ve disinfected them properly, they’ll heal.” Basically, it’s what you take out of the canals, not what you put in, that will lead to healing. Endodontists strive to come as close to complete disinfection as possible (reduce bacterial load below a clinically relevant level) so that the apical tissues around the tooth can heal. Traditionally, we have done this using bleach, chlorhexidine, EDTA, calcium hydroxide, and activation techniques. These traditional techniques relied on files to open the canals to a certain size to allow for the fluids to penetrate the deeper areas of the teeth. Certain canals could not easily be reached, which is why we would leave medication in canals for weeks or months to hopefully diffuse to these areas. With these techniques, we have a high success rate. However, it can be cumbersome for the patient to return to the office multiple times, and we often remove unnecessary amounts of dentin. Nowadays, more practitioners use technology such as laser and GentleWave to achieve these goals more efficiently and without removing unnecessary tooth structure. I have adopted a GentleWave protocol that allows me to treat 99% of cases in a single visit without using intracanal medicaments and without enlarging canal sizes. The mechanism of action of the GentleWave delivers degassed irrigation fluids to all reaches of the root with instrumentation as small as a 15 file. This allows me to provide quality endodontic care in a single visit with minimal instrumentation.

How has your practice promoted patient convenience? One of my goals is to provide prompt treatment. I try to leave space for emergencies when I’m in the office, and I routinely come in on my days off, if needed, for patients in pain or patients who need IV sedation. I am also able to be more efficient since implementing the GentleWave protocol. I am currently treating most cases, even retreatments, in a single visit. To have a complete procedure done where the patient can leave and get the tooth restored right away is a huge service. Another goal is to provide pain-free treatment: It’s inconvenient for patients to return because they can’t get numb or they’re having postoperative complications. I get the patient profoundly numb by using infiltration and nerve block as a primary technique with supplemental techniques as needed. While I’m doing Endodontic Practice US

initial anesthesia, I use a facial massager on the patient’s cheek to help relax them and distract them from the injection. Leaving the facial massager on the bolus of anesthetic after injection also helps distribute the fluid to the desired tissues and can even push the fluid into the mental foramen if anesthetizing a mandibular premolar tooth. Patients have responded well to this technique. Pain-free treatment also includes not sending the patient away with severe postoperative pain. I always administer ibuprofen or acetaminophen to my patients before they leave the office, so it’s in their system before the anesthetic wears off. Also, using the GentleWave System provides a lower incidence of postoperative pain and flare-up. Instead of maintaining mechanical patency throughout the procedure by pushing the tip of a file (and any debris in its way) through the apical foramen, I’m staying short of the apical foramen and trusting the GentleWave to maintain patency. I call every patient the night of the treatment to check in, and since I’ve been using the GentleWave, I rarely have any problems with postoperative pain.

How does your GentleWave® System promote minimally invasive endodontics? When I first started using GentleWave, I thought of it as supplemental irrigation and not its own protocol. Thus, I instrumented to normal sizes and ran the GentleWave at the end of the procedure to maximize my disinfection. However, as I learned to trust the technology, I started to shape my canals smaller to preserve natural dentin and lead to better fracture resistance. Now I am able to confidently shape most canals to a 15/04 file size, and some larger canals maintain their natural shape altogether. GentleWave also helps me promote minimally invasive endodontics because many times I can see on a preoperative CBCT that the canal anatomy joins with another canal. In these instances, I no longer shape that branch of the canal to a complete size, just make enough space for my fluids to penetrate and let GentleWave do the rest. This will save me time by not troughing a tight MB2 canal, for example, that I know joins in with the main canal. I trust the technology to debride the canal space, and I preserve all of that additional dentin that I would have traditionally removed to get a file down.

What are the main drawbacks to manual instrumentation during RCT? For my first 12 years as an endodontist, I would pick my way through canals, pre-bending files and hoping I could find the right pathway. I would also trough down pericervical dentin to try and locate and treat canals. This technique was timeconsuming and fatiguing for my hands and wrists. Once I could Volume 15 Number 1

A CONVERSATION WITH ...

get a small file to length, I had to hope that my bend in the file would find a pathway down one of the many apical foramina at the root apex. Even then, I could not feel confident that my rotary instruments would scrape more than 50% of the canal surfaces or that my irrigation fluids would disinfect these spaces due to the dreaded vapor lock. With particularly tortuous canal morphology, my file could snap and be left behind in the canal. By utilizing GentleWave, I minimize my use of hand and rotary instruments and rely mainly on chemical debridement for treatment so I don’t have to worry anymore.

would likely never reach that second ML branch. Now I remove the bulk of tissue that I can from the main canal and trust GentleWave to do the rest of the cleaning. GentleWave removes the risk of me, in my imperfect humanity, taking a file into spaces that I may destroy and lets me maintain what’s natural by barely (or not even) touching those spaces.

What would you tell a colleague who is reluctant to try new techniques/procedures? Skepticism is what makes us discerning and critical endodontists. We need to question everything, consult with colleagues, and demand independent evidence-based research. However, every decade or so a new technology arrives that really is a game changer — rotary, microscopes, EAL, CBCT, and now GentleWave. Even if you don’t want to be the first to adopt a new technology, at least don’t be the last! Talk to colleagues. I constantly share my experiences with colleagues and routinely have people from the industry watch me work. I post cases (the good, the bad, and the ugly) on social media in hopes that even one other practitioner can learn from my experiences. It’s ok to be reluctant to try new things; we’re really good at embracing routine. I challenge you this year to step out of your comfort zone. You won’t regret it, and your patients will reap the benefits! EP

How does the GentleWave® Procedure help patients who have complex apical anatomy? There are no “easy roots.” Even a tooth that at first glance looks like it may be straightforward can have a surprising complexity. This is why I take a CBCT on every case that I treat. I want to make sure I know what I am dealing with before I even touch a handpiece. Most teeth are quite complex, particularly in the apical third. GentleWave helps me treat complex apical anatomy by cleaning the spaces that I could never reach with a file. So often do I see a 2-1-2 canal configuration on a maxillary first molar MB root, which in the past, I would stress out about and medicate the canals, even though my calcium hydroxide

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COMPANY PROFILE

Risk versus reward: technology adoption requires thoughtful analysis Dr. Jeffery J. Linden discusses the value of a supporting community when making big decisions

fter 25 years of solo practice, Jeffery J. Linden, DDS, of Advanced Endodontic Specialists in South Barrington, Illinois, knows the importance of technology and understands how cutting-edge innovations can improve patient outcomes. He also knows, however, that embracing technology without thorough analysis can be detrimental to a practice. Dr. Linden said his recent partnership with US Endo Partners has proven helpful in making big technology decisions a little easier. “Risk/Reward” analysis is undoubtably omnipresent for many clinicians. The return on investment — of both money and time — must be weighed heavily against patients’ experiences. Practitioners often choose not to upgrade their technology because of the time needed to learn and implement it, as well as the costs that might have to be passed on to patients. Until an endodontist feels comfortable with new technology, applying it without sacrificing care can be challenging; at first, patients can perceive that the procedure takes longer than it took using tried-and-true techniques. “Is this going to make my life easier as a clinician?” Dr. Linden asked. “I have to incorporate this machine and amend my workflow, as well as take into account how the assistants do their jobs. Change can be hard after 25 years; I have to be convinced that it is going to make a significant difference.” Additionally, no matter how good the technology is, some practitioners find the cost too burdensome. US Endo Partners allayed Dr. Linden’s fears and increased his confidence in implementing new technology — a 3D-imaging unit. The endodontist-led, patient-driven collaborative model of US Endo Partners benefited Dr. Linden and his patients by backing the significant investment of a new dental cone beam computed tomography (CBCT) unit. Dr. Linden, a longtime user of CBCT in his office, had been reluctant to purchase the latest

Dr. Linden knows the importance of technology and understands how cuttingedge innovations can improve patient outcomes. Pictured here is his solo practice — Advanced Endodontic Specialists in South Barrington, Illinois

model due to the cost; with US Endo’s support, it became an easier decision. “There is a huge advantage in the power of numbers with purchasing an expensive piece of equipment. If six or seven endodontists need a CBCT at the same time, you can negotiate better prices. It benefits all of us — patients, doctors, everyone,” Dr. Linden said. US Endo also provides Dr. Linden the clinical support and training to optimize the use of CBCT. Recently, US Endo formed an exclusive partnership with cone-beam expert, Dr. Bruno Azevedo, to work with practices to perfect their use of the technology. Dr. Azevedo trains teams to safely and confidently use the machine, reduce liability, improve the quality of images, and better interpret findings for more accurate diagnoses. Dr. Azevedo encourages endodontists to view CBCT as an essential tool to support the clinical decision, as it offers valuable information about when to treat, how to treat, and — just as important — when not to treat. Being part of a supportive culture and peer network is a paramount benefit of US Endo for Dr. Linden; the collaboration is made even better because he surrounds himself with high-caliber professionals. “If everyone is sharing what they are doing, and we take the best parts to move forward as a specialty, that is a hugely important advantage for my practice,” Dr. Linden said. “I am on my own and have to figure a lot of things out for myself. But as part of US Endo, it facilitates the learning process. We share ideas, techniques, and technologies. They are all like-minded individuals interested in doing the best.” EP

Jeffery J. Linden, DDS, was born and raised in Dubuque, Iowa, where he attended Loras College and earned a BS degree in Chemistry in 1988. In 1992, he received his dental degree from the University of Iowa College of Dentistry. After graduating from dental school, Dr. Linden served a General Practice Residency at Barnes and Jewish Hospitals in St. Louis, Missouri, and then practiced general dentistry in St. Louis. In 1994, he started his Endodontic Residency at the University of Southern California in Los Angeles. From 1997 to 2003, he practiced with Park Dental Specialists, a multispecialty group practice in Chicago. There, he founded the endodontic department of this practice. In 2003, Dr. Linden created and developed his own private practice — Advanced Endodontic Specialists. Disclosure: Dr. Linden is a clinician-partner member of US Endo Partners.

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Minimally invasive endodontics with a novel shaping file Dr. Reid V. Pullen uses a safe, effective, and efficient shaping system to paint a “beautiful endodontic canvas”

ndodontic treatment often starts with two questions: (1) Can we shape the canal system safely, effectively, and efficiently? (2) Can we do this in a minimally invasive manner, preserving precious tooth structure while eliminating necrotic tissue and microbes to produce a healing environment? Figure 1: Pre-op tooth No. 19 With the advent of enhanced disinfection — GentleWave® (Sonendo®), SWEEPS® (Shock Wave-Enhanced Emission Photoacoustic Streaming, Fotona), the SmartLite® Pro EndoActivator® (sonic activation, Dentsply Sirona), EndoUltra® (ultrasonic activation, Vista), EndoVac™ (apical negative pressure system, Kerr Dental), and the Gentlefile® Smart System (Tornado Disinfection Kit, Medic NRG) — the hope is that endodontic therapy can be performed in a minimally invasive manner, while maximally disinfecting the canal system (Figures 1, 2, and 3). Two of these devices, GentleWave (Figure 4) and SWEEPS (Figure 5) have generated interest in the field of endodontics and show potential at effectively debriding a minimally shaped canal system verses standard needle irrigation (SNI). GentleWave, with the new CleanFlow® procedure instrument, emits multisonic sound waves in the presence of degassed sodium hypochlorite and EDTA. This device is able to remove the majority of pulp tissue and microbes from the root canal system in minimally shaped canals.1 SWEEPS emits a photon laser pulse pair into sodium hypochlorite and EDTA, which creates a hypersonic shockwave in the canal.2 Both systems have shown to be effective at removing canal debris and microbes.1,3 Chemical debridement is only one piece of the endodontic minimally invasive puzzle. At this point in time, we must shape the canals in order to provide space for obturation materials. There are many file systems on the market that are able to safely shape canals in a minimally invasive protocol. TruNatomy™ (Dentsply Sirona) (Figure 6) is one file system that preserves peri-

Figure 2: Post-op

Figure 3: Recall 18 months

Figures 4 and 5: 4. GentleWave 5. LightWalker Laser (SWEEPS)

Reid V. Pullen, DDS, graduated from USC Dental School in 1999. He completed an advanced education in general dentistry in 2000 while serving in the Army Dental Corps in Landstuhl, Germany. He graduated from the Long Beach VA Endodontic Residency in 2006 and opened a private practice in Brea, California, in 2007. Dr. Pullen became a Diplomate of the American Board of Endodontics in 2013. Disclosure: Dr. Pullen is a speaker for Dentsply Sirona.

Figure 6: TruNatomy

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Figure 7: ProTaper Ultimate™ file system

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cervical dentin, which can be critical in the long-term success of tooth retention.4 DCTaper™ (formerly VTaper) (SS White) is another popular file system that minimally shapes canals and preserves coronal dentin.5 A recently released file system called ProTaper Ultimate™ (Dentsply Sirona) (Figure 7) may change the way we perform endodontic therapy. ProTaper Ultimate was designed and created by Drs. Cliff Ruddle, John West, and Pierre Machtou. The new objective of this file system is to take the design and enhanced metallurgy from ProTaper Gold™ and produce a file system that safely shapes effectively, efficiently, and minimally. This article will discuss the new minimally invasive endodontic shaping system, ProTaper Ultimate, and discuss why it is a novel shaping system. ProTaper Ultimate starts with a whole new mindset — a mindset unfamiliar with most clinicians. The universal mindset that states, “Always explore and ‘secure’ the canal prior to introducing any nickel titanium shaping file,” has shifted to a new paradigm. This paradigm states that once the canals are located, move directly to the ProTaper Ultimate Slider. The Slider is a nickel-titanium file with a 0.16 tip, progressive taper made of M-Wire. In the majority of “simple to medium difficult” canal systems, it will negotiate down to estimated working length and, at the very same time, shape and cut an open glide path to aid in subsequent file usage. This is revolutionary in the fact that the canal is not first secured by a hand file, and that a coronal flare is not always necessary. In the more difficult cases, whether it is an access issue or a constricted, calcified canal system, the auxiliary SX should be used to open up the coronal third and remove the dentinal cervical triangle. The Slider runs at 400 RPMs and at 5.0 Ncm torque. It is recommended to hold the handpiece in the webbing of your hand and to let it slide down the canal (Figure 8). It is estimated that about 65% of the time, the Slider will advance down to estimated working length (in the author’s experience it is more 80% to 90% of the time in simple cases) in 1-3 passes. At this point, either attach an Electronic Apex Locator (EAL) clip to the handle of the Slider (Figure 9) and obtain an accurate working length, or remove it and attain a working length with a No.10 hand file. Either way, the goal of the Slider is to effectively and efficiently slide down the canal to working length, open the canal, and create a glide path. If these three pillars of endodontic treatment (negotiation to patency, accurate working length, and open glide path) can be accomplished safely in 30 to 60 seconds and without the need of a hand file, the treatment time and difficulty can be reduced. Less treatment time, with less shaping and with enhanced disinfection, could lead to a decrease in adverse treatment events (file separation, ledging, etc.) and a more efficient procedure. In the event of an apical curve or a constricted canal, and the Slider will not advance down to estimated working length, then remove it, and achieve negotiation and working length the traditional way, with hand files. The rule with the ProTaper Ultimate Slider is “restraint.” We must treat the canals as a painter treats a canvas — with elegant, gentle, deliberate brushstrokes. We are not construction workers hammering files into the canal. The key to this system is the Slider negotiating to patency, achieving an accurate working length, and creating an open glide path. Endodontic Practice US

Figure 8: Hold the handpiece in the webbing of your hand, and let it slide down the canal

Figure 9: Electronic Apex Locator (EAL)

Figure 10: EndoActivator

If this is done using gentle brushstrokes, then the rest of the painting (shaping) of the canals can be effortless. The technique is as follows: employ 4-5 engagement/disengagements (gentle in-and-outs), and if the Slider has not advanced to the estimated working length, remove it, irrigate with sodium hypochlorite, and then continue with Pass No. 2. If the Slider will not advance, and it feels like it is hitting a “brick wall,” then remove it and negotiate to working length with a No. 10 hand file. Once working length is achieved, run the Slider to the end (working length), and achieve an open glide path. Now we are off to the shaping races. It is time to finish painting the canvas and creating a

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beautiful endodontic minimally invasive work of art. The canal is now secure and is just waiting to be cleaned and shaped. The next step in the ProTaper Ultimate series is to use the Shaper. This is newly designed to reduce the shaping load by taking the ProTaper Gold S1 and S2 and combining it into one “super” Shaper. The shaper has a maximum file diameter of 1 mm verses the traditional 1.2 mm, aiding in conservation of cervical tooth structure, and it has a parallelogram cross section with a 0.20 tip. Typically, once the Slider advances to working length, the Shaper will also advance to the same area within one to two passes. The Shaper’s main job is to shape the coronal two-thirds of the canal system. Employ the same gentle shaping technique of 4-5 engagement/disengagements (pass No. 1). Then remove the Shaper, irrigate to remove the debris created during instrumentation with sodium hypochlorite, recapitulate, and move onto pass No. 2 until the Shaper reaches working length. Now complete the final shape with the ProTaper Ultimate Finisher 1 (F1- #20 tip size). The F1 will easily advance to working length (or just short of it) once the Slider and Shaper have cut the path down to or close to working length. These are your finishing brushstrokes on the endodontic canvas. At this point, as clinicians we must make a decision. For GentleWave or SWEEPS laser users, it is recommended to stop at F1 and 1 mm back from working length. The final touches or brush-ups on the endodontic canvas are achieved by using these enhanced disinfection protocols. If you do not use either of these devices, then examine the F1 apical flutes. Are they full of dentinal shavings? Did the F1 create deep apical shape? If so, then the apical shape is complete. If the apical flutes are relatively free of debris, then advance to the ProTaper Ultimate F2. In the majority of non-large canals, the clinician will finish with the F2. (In the author’s experience, if not using enhanced disinfection devices then the canals are usually finished with the F2.) In some larger canals, the ends of the apical flutes of the F2 will also be free of debris, and you will need to advance to the F3 (No. 30 tip size) or the FX (No.35 tip) or the FXL (No. 50 tip). Once shaping is complete, perform apical verification with the corresponding hand file, irrigate, recapitulate, and place

matching ProTaper Ultimate gutta-percha cones to working length. These new cones are flat ended, have an extended heat wave, and are precision-machined to fit the shape that was prepared. Once the cone-fit radiographs are completed, and if not using SWEEPS or GentleWave, then use of the sonically driven EndoActivator to enhance disinfection is utilized. (Figure 10). The new EndoActivator (sonic activation) is improved with increased cycles per minute, an elliptical movement pattern, and a newly designed polymer tip that acts as a paddle with fins. The MIE canvas is created by the dual brushstrokes of shaping and enhanced disinfection. Disinfection and cleaning of the root canal system entails removing necrotic tissue, biofilms, microbes, and the smear layer created by shaping. Once the smear layer is removed, single cone obturation can be used with the new AH-Plus® Bioceramic Sealer (Dentsply Sirona) (Figure 11). The bioceramic sealer has high radiopacity and demonstrates good anatomical fill of the prepared canal system (Figures 12 and 13). This sealer has greatly improved properties of traditional bioceramic sealers with an overall 4-hour set time and a 0.11% solubility rating (internal study, Dentsply Sirona). If you have had mixed results using bioceramic sealers, then complete the endodontic painting with your obturation of choice. I prefer warm vertical obturation using either Pulp Canal Sealer™ EWT (zinc oxide eugenol, Kerr Dental) or Ribbon® Root Canal Sealer (epoxy-resin, Dentsply Sirona). I prefer the black Gutta-Smart™ (Dentsply Sirona) heat tip (40/.025) to remove the coronal two-thirds gutta percha and the Dovgan Pluggers to gently push and form the gutta-percha apical plug into the foramen. I then use the 25 gauge tip on the backfill of the cordless Gutta-Smart with a pen grasp and backfill the canals one after the other in a very efficient manner. The ProTaper Ultimate file system is a new approach that represents a shift in the shaping paradigm. It is now recommended to start with a rotary, nickel-titanium shaping file (Slider) prior to securing the canal with hand files. This system, like others, comes with matching paper points, gutta-percha cones, and with gutta-percha obturators being introduced soon. In the end, the ultimate goal is to provide the clinician with a safe, effective, and efficient shaping system that can paint a beautiful endodontic canvas without undermining sound tooth structure. EP

REFERENCES

Figure 11: AH Plus Bioceramic Sealer

Vandrangi P, Basrani B. Multisonic Ultracleaning in Molars with the GentleWave® System. Oral Health. 2015;72-86.

Yang Q, Liu MW, Zhu LX. Micro-CT study on the removal of accumulated hard-tissue debris from the root canal system of mandibular molars when using a novel laser-activated irrigation approach. Int Endod J. 2019;53(4):529-538.

Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of Root Canal Debridement of Human Molars using the GentleWave System. J Endod. 2015;10:1701-1705.

Kumar M, Paliwal A, Manish K, et al. Comparison of Canal Transportation in TruNatomy, ProTaper Gold, and Hyflex Electric Discharge Machining File Using cone-Beam Computed Tomography. J Contemp Dent Pract. 2021;22(2):117–121.

Shenoi, P, Luniya, D, Badole, G, et al. Comparative evaluation of shaping ability of V-Taper 2H, ProTaper Next, and HyFlex CM in curved canals using cone-beam computed tomography: An in vitro study. Indian J Dent Res. 2017;28:181-186.

Figures 12 and 13: 12. Pre-op tooth No. 18. 13. Post-op (PT Ultimate F1/AH Plus Bioceramic Sealer)

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CASE REPORT

Apical sealing using a bioceramic material in apexification: a case report with 2-year follow-up Drs. Romina Chaintiou Piorno, Maribel Rocío Mamani Flores, Eugenia Pilar Consoli Lizzi, Paula Leticia Corominola, and Pablo Alejandro Rodríguez discuss how to treat immature permanent teeth with pulp necrosis ide paste and mineral trioxide aggregate have been used in the apexification treatment of teeth with open apex for a long time. At present, they are replaced by new, biocompatible materials with improved characteristics such as the new generation of hydraulic silicate cements.

Abstract Aim

Immature permanent teeth with pulp necrosis pose a challenge for endodontic treatment performance. Calcium hydrox-

Case report

Romina Chaintiou Piorno, DDS, graduated from the School of Dentistry of the University of Buenos Aires in 2012. She then specialized in endodontics at the University of Buenos Aires in 2014. Currently, she serves as Assistant Professor in the Department of Endodontics, School of Dentistry, University of Buenos Aires, Argentine Republic.

The objective of this paper is to present a case report in which the apical closure of the palatal root in the upper left maxillary first premolar, with an open apex and pulp necrosis, was regenerated by a bioceramic material (Biodentine®). After a 2-year follow-up, the tooth was found to be asymptomatic, and radiographic and computed tomographic studies revealed bone repair and root closure.

Maribel Rocío Mamani Flores, DDS, graduated from the School of Dentistry of the Cosmos Private Technical University Cochabamba in Bolivia in 2011. She then specialized in endodontics at the University of Buenos Aires in 2021. Now she serves as Assistant Professor in the Department of Endodontics, School of Dentistry, University of Buenos Aires, Argentine Republic.

Clinical implications Promotion of apical closure is sought in the treatment of immature permanent teeth that require endodontic treatment. A reasonable and predictive apexification technique with Biodentine can be employed to elicit an apical barrier or a plug promoting tissue regeneration.

Eugenia Pilar Consoli Lizzi, DDS, specialized in endodontics and graduated from the University of Buenos Aires in 2017. Currently, she serves as Assistant Professor in the Department of Endodontics, School of Dentistry, University of Buenos Aires, Argentine Republic.

Introduction In several clinical studies, caries and dental trauma have been reported to be the most common cause when assessing the etiology of pulp necrosis.1-3 When pathosis progresses, natural root development of the permanent teeth can be affected, resulting in arrested apical root development and an open apex.4 The complete root development and apical closure of a tooth is estimated to occur 3 years after its eruption;5,6 therefore, it is important to consider the moment the tooth is involved. Several clinical challenges are posed by the endodontic treatment of nonvital immature teeth, with or without periradicular lesion, when the chemomechanical debridement and obturation techniques are performed, due to the thin walls and the presence of an open apex. In order to maintain these teeth, an intervention focused on the biological or artificial sealing of the delicate apical portion is needed. This treatment is known as apexification7 — “a method to induce a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root

Paula Leticia Corominola, DDS, graduated from the School of Dentistry at the University of Buenos Aires in 2007. She then specialized in endodontics at the University of Buenos Aires in 2012. She now serves as Associate Professor in the Department of Endodontics, School of Dentistry, University of Buenos Aires, Argentine Republic. Pablo Alejandro Rodríguez, DDS, PhD, earned his degree in dentistry from the University of Buenos Aires in 1991. He graduated with the Specialization in Endodontics and the Specialization in Prosthodontics in 2007; he finished his PhD in 2016. Currently, he serves as the Head Professor of the Department of Endodontics and is the Director of the Specialization in Endodontics. Dr. Rodriguez is also Professor of Prosthodontics in the School of Dentistry of the University of Buenos Aires. Dr. Rodríguez is the actual Dean of the School of Dentistry of the University of Buenos Aires in the Argentine Republic. Disclosure: This paper was conducted within the framework of the Project: “Design and evaluation of strategies for the prevention in high social vulnerability populations’’ (2019-2024), as part of the School of Dentistry, University of Buenos Aires integrated research support program.

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in teeth with necrotic pulps.”8 The apexification with a calcium hydroxide (CH) paste in multiple visits and the single-visit apexification procedure with mineral trioxide aggregate (MTA) are two technically different therapeutic options, being the treatment of necrotic permanent teeth with immature apices their common goal. Today other materials that can be employed to elicit an apical barrier or a plug in a single clinical appointment are available such as hydraulic silicate cements.9 Moreover, revascularization aimed at controlling the infection and promoting continued root development is considered an effective regenerative treatment option for necrotic immature teeth.10,6 Biodentine® (Septodont, Lancaster, Pennsylvania) is a bioceramic material exhibiting adequate handling characteristics with acceptable mechanical and bioactivity properties.11 The single-visit apexification procedure with a bioceramic material is a useful tool to treat teeth in which the apical anatomy is complex due to its amplitude.12 The aim of this paper is to display the clinical management of a first maxillary premolar with a diagnosis of pulp necrosis and an open apex, treated by a single-visit apexification procedure with Biodentine.

Laboratory, CABA, Argentina) was administered into the buccal vestibule and by palatine before rubber dam application. The coronal restoration of the isolated tooth was removed with a carbide bur in a high-speed handpiece, an access cavity was created, and the canal orifices identified. After scouting, the access was prepared with ProTaper Gold® system SX file (Dentsply Sirona, Tulsa, Oklahoma). Working length was determined with a hand K-File (Dentsply Maillefer, Ballaigues, Switzerland), and an apex locator was utilized and verified with a periapical radiograph (Figure 2A). The canals were chemomechanically debrided with further instrumentation with ProTaper Gold S1, S2, F1, F2, and F3 in the buccal canal, while in the palatal canal, the F4 and F5 files were used as well as hand instrumentation with K-Files Nos. 55 and 60. A 2.5% sodium hypochlorite irrigation throughout the entire treatment was used, followed by irrigation with 17% EDTA and then final irrigation with saline. Placement of a rubber stopper 2 mm short of the apical foramen on the files was carefully done during the irrigation process to prevent the solution extrusion and a hypochlorite accident. After the root canal was dried with sterile absorbent paper points, Biodentine was prepared according to the manufacturer’s instructions and carried into the palatal root canal to be finally condensed with hand pluggers to form an apical plug.

Case report

A 10-year-old male patient was referred for endodontic treatment of the maxillary left first premolar. Accompanied by his mother, the patient presented at the Department of Endodontics, School of Dentistry, University of Buenos Aires. Leakage in the composite coronal restoration was noted, and pain on percussion with pain on palpation was revealed during the clinical examination. A sensitivity test to cold was performed with a negative pulpal response. A radiological examination consisted of a preoperative radiograph (Figure 1A). A preoperatory CBCT scan was requested (Figure 1B), which revealed incomplete apex formation and a periradicular radiolucent lesion. The clinical diagnosis of the tooth was pulpal necrosis with a chronic alveolar A. B. abscess, and the clinicians decided to perform a single-visit apexification procedure with Biodentine. Figures 1A and 1B: 1A. Preoperative radiograph of the maxillary left first premolar. 1B. Local anesthesia (carticaine hydrochloride 4% Cone-beam tomography, coronal, sagittal, axial slices, and 3D reconstruction. The open apex and associated periradicular lesion are indicated by the yellow arrows L-Adrenaline 1: 100,000, Totalcaína Forte, Bernabó

Figures 2A-2C: 2A. Working length radiograph. 2B. Master cone radiograph. 2C. Immediate postoperative radiograph

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A master cone radiograph was taken (Figure 2B), and condensation of the bioceramic material was verified. A lateral condensation technique with gutta-percha cones and AH-26 sealer (Dentsply Sirona) was performed to finish the obturation. An immediate postoperative radiograph was taken (Figure 2C) in which the obturation quality was observed without extrusion of obturation material periapically. After 12 months (Figure 3), the patient was recalled for a follow-up, and the resolution of the lesion was noted. The treated tooth was also clinically reviewed after 24 months, a periapical radiograph was taken, and the patient presented with a CBCT scan requested by his orthodontist. The tooth remained asymp-

Figure 3: A 12-month follow-up

C. Figures 4A-4C. A 24-month follow-up. 4A. Clinical image. 4B. Periapical radiograph. 4C. Cone-beam tomography — coronal, sagittal, and axial slices and 3D reconstruction. Tissue regeneration is shown by the yellow arrows

Endodontic Practice US

tomatic, and the continuity in the periodontal ligament space with absence of periapical radiolucency was observed (Figures 4A, 4B, and 4C).

Discussion The objective of endodontics is apical periodontitis prevention and/or elimination,13 and the promotion of apical closure is also sought in the treatment of immature permanent teeth9,14 as has been achieved in the present case report. It is of utmost importance to seal and prevent bacterial reinfection in the majority of apexification protocols for human immature permanent teeth with apical periodontitis15 by placing an apical plug. For many years, calcium hydroxide apexification has been the treatment of choice, although this technique requires many visits, and the weakening of the tooth walls due to long-term use was reported.16 The time between the first visit and the end of treatment varies because multiple visits are needed — a difficult issue to overcome if there is no continuous patient follow-up, along with the presence of a provisional coronal restoration capable of eliciting a root canal reinfection.17,18 Because of these complications, the calcium hydroxide apexification procedure has been replaced by MTA apexification.19 The antibacterial effects of MTA are given by its high pH and the fact that it is biocompatible, induces hard tissue formation, and is slightly more radiopaque than the dentine.20,21 Torabinejad and Chivian22 suggested an alternative apexification to the calcium hydroxide technique. It consisted of cleaning the root canal system and sealing the open apex with MTA in one or two visits to minimize the risk of overfilling and to promote apical repair. The outcomes of a one-step procedure in teeth with open apices and periradicular lesions were assessed by Lin, et al.,23 who concluded that it may be a reasonable and predictable treatment alternative. However, the prolonged setting time, the difficult handling, and possible coronal discoloration associated with MTA20 had led to the search of other materials such as the new generation of hydraulic calcium silicate cements. Biodentine is a bioactive cement with excellent biological properties as well as good color stability.24 The absence of genotoxicity25 and its low cytotoxicity26 make it an ideal material to be used in endodontic practice. The possible shortcoming of Biodentine is its low radiopacity.27,28 The use of Biodentine as well as MTA in contact with mesenchymal stem cells was suggested by Lee, et al.,28 to induce osteoblast differentiation. The importance of a combination between a specific local biological microenvironment and the circulation of soluble calcium and levels of inorganic calcium to obtain bone regeneration was shown by several studies.29,30 This microenvironment in the presence of calcium-silicate cements is able to induce the apical papilla stem cell and the signaling factors cell differentiation31,32,33 to enhance the apical closure. Just as shown by other case reports with successful long-term resolution,34,9,14 herein the remission of the associated lesion in the radiographic follow-up was observed 1 year after the completion of treatment. Likewise, tissue regeneration and a continuity of the periodontal ligament space, the absence of periradicular radiolucency and the presence of a fine layer of calcified tissue Volume 15 Number 1

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apical to the Biodentine plug were seen in It is of utmost importance to seal and prevent the 24-month follow-up CBCT. The possible achievement of treatment bacterial reinfection in the majority of apexification success by different apexification proceprotocols for human immature permanent teeth dures, even without promoting continued root development leaving thin dentinary with apical periodontitis by placing an apical plug. walls prone to fracture, is demonstrated by the literature.6,9 Therefore, the development of a therapeutic alternative such as pulp revascularization to enhance continwith Roots Having Open Apices Managed Nonsurgically Using 1-step Apexification ued root formation can be an option.35 However, the decision Based on Platelet-rich Fibrin Matrix and Biodentine Apical Barrier: A Case Series. J Endod. 2018;44(1):179-185. to perform an apexification procedure in the present case report 15. Holland GR. Periapical response to apical plugs of dentin and calcium hydroxide in was sustained on the root development (Nolla 9 stage)5 of the ferret canines. J Endod. 1984;10(2):71-4. doi: 10.1016/S0099-2399(84)80040-0. involved tooth. 16. Shabahang S. Treatment options: apexogenesis and apexification. Pediatr Dent. 2013 Biodentine was chosen as a material able to produce apical Mar-Apr;35(2):125-8. PMID: 23635980. closure due to its favorable characteristics — namely, a 12-min17. Abbott PV. Apexification with calcium hydroxide--when should the dressing be ute initial setting time that enables the completion of the root changed? The case for regular dressing changes. Aust Endod J. 1998;24(1):27-32. canal treatment in a single visit and precludes possible root 18. Rafter M. Apexification: a review. Dent Traumatol. 2005;21(1):1-8. canal system reinfection. Other advantages were its easy han19. Guerrero F, Mendoza A, Ribas D, Aspiazu K. Apexification: A systematic review. J Conserv Dent. 2018;21(5):462-465. dling and working time reduction. Although its radiopacity is low, making radiograph visualization difficult, the adequate seal 20. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review — Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. obtained through the favorable evolution and the achievement 2010;36(3):400-443. of predictable medium-term outcomes are emphasized. 21. Duarte MAH, Marciano MA, Vivan RR, et al. Tricalcium silicate-based cements: properties and modifications. Braz Oral Res. 2018;18;32(suppl 1):e70.

Conclusion The one-step apexification procedure performed with Biodentine proved to be a versatile option for a tooth with a very wide apex, promoting tissue regeneration. EP

22. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod. 1999;25(3):197-205. 23. Lin J, Zeng Q, Wei X,et al. Regenerative Endodontics Versus Apexification in Immature Permanent Teeth with Apical Periodontitis: A Prospective Randomized Controlled Study. J Endod. 2017;43(11):1821-1827.

Bender IB. Pulpal pain diagnosis--a review. J Endod. 2000;26(3):175-179.

24. Rajasekharan S, Martens LC, Cauwels RGEC, Anthonappa RP. Biodentine™ material characteristics and clinical applications: a 3-year literature review and update. Eur Arch Paediatr Dent. 2018;19(1):1-22. Erratum in: Eur Arch Paediatr Dent. 2018;15; Erratum in: Eur Arch Paediatr Dent. 2021;22(2):307.

Chen MY, Chen KL, Chen CA, et al. Responses of immature permanent teeth with infected necrotic pulp tissue and apical periodontitis/abscess to revascularization procedures. Int Endod J. 2012;45(3):294-305.

25. Vallés M, Mercadé M, Duran-Sindreu F, Bourdelande JL, Roig M. Influence of light and oxygen on the color stability of five calcium silicate-based materials. J Endod. 2013;39(4):525-528.

Koç S, Del Fabbro M. Does the Etiology of Pulp Necrosis Affect Regenerative Endodontic Treatment Outcomes? A Systematic Review and Meta-analyses. J Evid Based Dent Pract. 2020;20(1):101400.

Lauridsen E, Hermann NV, Gerds TA, Kreiborg S, Andreasen JO. Pattern of traumatic dental injuries in the permanent dentition among children, adolescents, and adults. Dent Traumatol. 2012;28(5):358-363.

26. Opacic-Galic V, Petrovic V, Zivkovic S, et al. New nanostructural biomaterials based on active silicate systems and hydroxyapatite: characterization and genotoxicity in human peripheral blood lymphocytes. Int Endod J. 2013;46(6):506-16. doi: 10.1111/ iej.12017.

REFERENCES

Nolla C. The development of the permanent teeth. J Dent Child 1960;27:254-66.

Flanagan TA. What can cause the pulps of immature, permanent teeth with open apices to become necrotic and what treatment options are available for these teeth. Aust Endod J. 2014;40(3):95-100.

Timmerman A, Parashos P. Delayed Root Development by Displaced Mineral Trioxide Aggregate after Regenerative Endodontics: A Case Report. J Endod. 2017;43(2):252-256.

AAE. Glossary of Endodontic Terms. Ninth Edition. 2015.

Vidal K, Martin G, Lozano O, et al. Apical Closure in Apexification: A Review and Case Report of Apexification Treatment of an Immature Permanent Tooth with Biodentine. J Endod. 2016;42(5):730-734.

10. AAE. Clinical Considerations for a Regenerative Procedure. 2018. 11. Domingos Pires M, Cordeiro J, Vasconcelos I, et al. Effect of different manipulations on the physical, chemical and microstructural characteristics of Biodentine. Dent Mater. 2021;37(7):e399-e406.. 12. Bajwa NK, Jingarwar MM, Pathak A. Single Visit Apexification Procedure of a Traumatically Injured Tooth with a Novel Bioinductive Material (Biodentine). Int J Clin Pediatr Dent. 2015;8(1):58-61. 13. Chugal N, Mallya SM, Kahler B, Lin LM. Endodontic Treatment Outcomes. Dent Clin North Am. 2017;61(1):59-80. 14. Sharma S, Sharma V, Passi D, et al. Large Periapical or Cystic Lesions in Association

Endodontic Practice US

27. Kaur M, Singh H, Dhillon JS, Batra M, Saini M. MTA versus Biodentine: Review of Literature with a Comparative Analysis. J Clin Diagn Res. 2017;11(8):ZG01-ZG05. 28. Lee BN, Lee KN, Koh JT, et al. Effects of 3 endodontic bioactive cements on osteogenic differentiation in mesenchymal stem cells. J Endod. 2014;40(8):1217–1222. 29. Tziafas D, Pantelidou O, Alvanou A, Belibasakis G, Papadimitriou S. The dentinogenic effect of mineral trioxide aggregate (MTA) in short-term capping experiments. Int Endod J. 2002;35(3):245-254. 30. Gandolfi MG, Shah SN, Feng R, Prati C, Akintoye SO. Biomimetic calcium-silicate cements support differentiation of human orofacial mesenchymal stem cells. J Endod. 2011;37(8):1102-1108. 31. Lin NH, Gronthos S, Bartold PM. Stem cells and future periodontal regeneration. Periodontol 2000. 2009;51:239-251. 32. Gandolfi MG, Ciapetti G, Taddei P, et al. Apatite formation on bioactive calcium-silicate cements for dentistry affects surface topography and human marrow stromal cells proliferation. Dent Mater. 2010;26(10):974-992. 33. Sanz JL, Forner L, Almudéver A, Guerrero-Gironés J, Llena C. Viability and Stimulation of Human Stem Cells from the Apical Papilla (hSCAPs) Induced by Silicate-Based Materials for Their Potential Use in Regenerative Endodontics: A Systematic Review. Materials (Basel). 2020;13(4):974. 34. Khetarpal A, Chaudhary S, Talwar S, Verma M. Endodontic management of open apex using Biodentine as a novel apical matrix. Indian J Dent Res. 2014;25(4):513-516. 35. Diogenes A, Ruparel NB. Regenerative Endodontic Procedures: Clinical Outcomes. Dent Clin North Am. 2017;61(1):111-125.

Volume 15 Number 1

Go From This

To This in 4 Months

Endodontic Fellowship Are you a General Dentist looking to radically improve your clinical skills? Are you looking to apply for residency in the future and want to bolster your clinical experience? Are you open to joining a fast-growing Endodontic Group? Cornerstone Training Institute is now offering a 4-month Fellowship Program with the Clinical Rotation facilitated by Cornerstone Group. This program is focused on helping General Dentist who enjoy doing Root Canals take their training to the next level. Career opportunities upon graduation with tuition reimbursement

Course includes: All Instruments, Supplies, Handpieces, Equipment, Materials, Bench Work Supplies, and a minimum of 150 Root Canals completed upon graduation.

Dedicated Training Facility with 14 Wet/Dry Microscope fitted simulation stations, 3 Live Surgery Operatories, and J Morita CBCT.

Training Includes: Extensive Review of the latest research and Publications Didactic classroom training How to interpret and diagnose using CBCT Schedule Management Working with a Microscope Clinical techniques honed by a group of clinicians who have performed 1 million + RCT treatments All Clinical root canals performed under direct mentorship by a practicing Endodontist in a dynamic clinical environment For Information call Dr. Hamid Abedi at 949-471-0233

SPECIAL SECTION

Avalon Biomed

AAE SPECIAL SECTION

valon Biomed is a rapidly growing, fiercely independent, family-owned company dedicated to manufacturing high-quality bioactive bioceramic/MTA-based products. The company is located in Houston, Texas, making it the ONLY manufacturer of premixed dental bioceramic cements and sealers in the United States. Today Avalon Biomed is delivering better evidence-based bioceramic technology, while the big endodontic materials companies are content with the status quo. The materials used in Avalon Biomed’s products are based on the same tested and trusted bioactive bioceramics that have been successfully used and extensively researched for more than 20 years. Avalon Biomed heavily invests in R&D to introduce new products that improve the standard of patient care. Since 2014, Avalon Biomed has introduced four new

products, each state-of-the-art in its category. Avalon Biomed has an agile team, which allows them to invent, manufacture, and market new products at a rate uncommon for larger bureaucratic companies. With Avalon Biomed’s newest generation of bioactive materials, clinicians can perform virtually all endodontic procedures, including sealing and obturation, with fewer products, less waste, and higher efficiency than ever before. In 2020, built on the success of NeoMTA Plus, Avalon Biomed launched three brand new products: NeoSEALER® Flo, NeoPUTTY®, and NeoMTA® 2. Avalon Biomed is committed to giving you the flexibility to perform Endo Your Way. The Neo family of bioactive bioceramic products can be used synergistically for complete endodontic care.

Visit Avalon Biomed at AAE Booth No. 825

NeoSEALER

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avalonbiomed.com info@avalonbiomed.com

Endodontic Practice US

Volume 15 Number 1

SPECIAL SECTION

Triton®

maximum clinical efficiency. Unlike traditional irrigants or other 2:1 solutions, Triton works differently by avoiding the use of EDTA and CHX altogether. 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. The non-NaOCl components in Triton proactively dissolve the dentinal debris, allowing for a lower concentration of NaOCl (also included in Triton) to be exposed to organic debris without as much buffering. With Triton, irrigation is no irritation at all.

Visit Brasseler USA at AAE Booth No. 713

BY YOUR SIDE

ALL-IN-ONE IRRIGATION SOLUTION ✓ Multi-functional single irrigation solution reduces chair time, procedural steps, and overall irrigation costs ✓ Simultaneous organic and inorganic debris removal ✓ Patent-pending composition allows for a lower concentration of NaOCl to be used while also delivering improved efficacy ✓ More effective at smear layer removal vs. NaOCl with EDTA† ✓ Dissolves organic tissue up to 1.7x faster than traditional NaOCl‡

It’s time to simplify your irrigation protocol. Learn more at BrasselerUSA.com/Triton.

† https://bit.ly/TritonResearchSummary ‡ https://bit.ly/TritonDHF

endopracticeus.com

Volume 15 Number 1

AAE SPECIAL SECTION

espite the introduction of several unique devices to aid in endodontic irrigation, the fact remains that NaOCl is buffered when it comes into contact with inorganic dentinal debris. EDTA not only aids in dentinal debris dissolution but also buffers NaOCl. So, clinicians must use high volumes of multiple irrigation solutions, which require additional steps, irrigants, syringes, and needles. But now there is a solution with Triton. Triton is a patent-pending all-in-one irrigation solution that allows for synergistic and simultaneous dissolution of organic and inorganic debris. Triton permits clinicians to use lower volumes of irrigation solution and ensures

SPECIAL SECTION

EdgeEndo® PRO™ gives your practice access to the future of endodontics and an edge in winning more referral business.

AAE SPECIAL SECTION

EdgeEndo® has launched the EdgePRO™ system for endodontists seeking a more effective cleaning and disinfection alternative within root canal procedures. The new laser-assisted microfluidic irrigation device offers an advanced solution to current cleaning and disinfection techniques. EdgePRO™ lets “You be You” — shape and obturate the canals the way you want without the need to change your technique. EdgePRO™ offers the potential for streamlined workflow and one-visit treatment resulting in reduced treatment time and patient visits. EdgePRO™ has state-of-the-art technology at more affordable pricing that is as low as 1/3 the cost of other irrigation devices. Edge-

About EdgeEndo® Our mission is to deliver dental products and solutions at a substantially lower cost, which in turn benefits practitioners and patients everywhere. Innovation is the heart of EdgeEndo®. We are dedicated to the pursuit of bringing leading-edge products to the industry. We believe premium technology shouldn’t have to come with a premium price tag. We sell direct to dental professionals without unnecessary costs.

Visit EdgeEndo at AAE Booth No. 901

EdgePROTM Elevates Root Canal Cleaning, Debridement, and Disinfection. Easy to use Up to 1/3 the cost No difficult build-ups Decreased treatment time(2) Option for one-visit treatment Takes up minimal operatory space Shape and obturate canals how you want Removes infected tissue, biofilm, and smear layer (1,2,3,4) Outstanding cleaning, debridement, and disinfection (1,2,3,4) Kills up to 99% of bacteria commonly found in the root canal (1,2)

The Irrigation Company

EdgePROEndo.com • 1-855-TO CLEAN (862-5326)

1) Christo JE, Zilm PS, Sullivan T, Cathro PR. Efficacy of low concentrations of sodium hypochlorite and low-powered Er,Cr: YSGG laser activated irrigation against an Enterococcus faecalis biofilm. International Endodontic Journal. 2016;49(3):279-286. doi:10.1111/iej.12447 2) Gordon W, Atabakhsh VA, Meza F, et al. The antimicrobial efficacy of the ErCrYSGG laser with radial emitting tips on root canal dentin walls infected with E faecalis. JADA. 2007;138(July):992-1002. doi:10.14219/jada.archive.2007.0297 3) Internal data, FDA 510(K) 4a) 1. Schoop, U et al. “The Impact of an ErCrYSGG Laser with Radial-Firing Tips on Endodontic Treatment.” Lasers in medical science 24.1 (2009): 59–65. Web. 5 Dec. 2011. 4b) Arnabat, Josep et al. “Bactericidal Activity of Erbium, Chromium: Yttrium–scandium–gallium–garnet Laser in Root Canals.” Lasers Medical Science 25 (2010): 805–810. Web.

Endodontic Practice US

Volume 15 Number 1

SPECIAL SECTION

Endo Mastery

isit our booth to meet our team and other doctors in our lounge who have succeeded with practice coaching. Find out how coaching can help your practice! At this year’s meeting, we’re pleased to sponsor the entire Practice Management Educational Track. Teamwork, scheduling, marketing, growth, finances — these are topics we love! As a show special, you can get our lowest tuition rate of the year. For just $795 ALL-IN (includes doctor and all team members), join our June 2-day livestream seminar, “Mastering the Effortless Endodontic Practice.” That’s $500 off! We are also sponsoring the AAE Career Fair to help residents and new endodontists get started. We have associate-ready clients, so our Career Fair table is a one-stop shop! We’re also launching our FREE Career Start Membership for

Dr. Ace Goerig: Endo’s top practice growth and financial coach

residents and new endodontists. Get complimentary access to webinars and online resources about buying or starting a practice or finding the best associate positions. Finally, Dr. Ace Goerig, owner, is speaking: “SP-14 Steps to Create Personal and Financial Freedom in Endodontics” on Thursday, April 28, at 4:30 p.m. Come by our booth No. 725 to sign up for our seminar show special, career start membership, and more surprises! See you in Phoenix!

Visit Endo Mastery at AAE Booth No. 725

LIFE-CHANGING ENDONDONTIC SUCCESS DR. ACE GOERIG Owner, Endo Mastery

Incredible teamwork, efficiency and growth

Effortless daily flow and high productivity

Amazing profitability and work/life balance

1-800-482-7563 SEMINARS AND PRACTICE COACHING

WWW.ENDOMASTERY.COM

Get the best seminar deal of the year during the AAE meeting! Visit our meeting booth #725, virtual booth or website! endopracticeus.com

AAE SPECIAL SECTION

Get your questions answered at our AAE 2022 Meeting Booth No. 725

Volume 15 Number 1

SPECIAL SECTION

Endo1 Partners

AAE SPECIAL SECTION

Endo1 Partners is the original, fastest-growing endodontic partnership organization (EPO) dedicated specifically to supporting endodontists Endo1 Partners founders

s an endodontic partnership organization (EPO) that is majority owned and led by endodontists, Endo1 Partners uniquely understands the specific needs of endodontists. Its vision is to partner with endodontists around the country in building a world-class organization they can count on for the resources and support they need. As part of the Endo1 Partners network, members will have access to centralized services, exclusive resources, shared back-office support, group benefits, and discounts. Endo1 Partners was founded and is still led by endodontists Matthew Haddad, DMD; Daryl Dudum, DDS; Mark Haddad, DDS; and Darron Rishwain, DDS. This team of industry-leading professionals remains committed to practicing, so they can

continue to identify best practices that will help streamline, optimize, and improve your business. Established in October 2019 with six locations and operations in Texas and California, Endo1 Partners experienced rapid growth across several markets during its first full year in operation. The company expanded into 13 new states in 2021, while strengthening its position in existing markets. In total, Endo1 Partners has formed new partnerships with over 136 distinguished specialty practices and added over 230 new specialists to the network. Endo1 Partners will be at the AAE22 Annual Conference in April. Come visit us at Booth No. 100 to learn more about the first-of-its-kind EPO.

Visit Endo1 Partners at AAE Booth No. 100

230+ 22+ 136+ PRACTICES SPECIALISTS STATES 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 Endodontic Practice US

Endo1partners.com

Volume 15 Number 1

SPECIAL SECTION

US Endo Partners

AAE SPECIAL SECTION

hen you share ideas, foster a growth mindset, and pursue excellence as a team, success quickly follows. This is the spirit of US Endo. The spirit

of US. “Partnering with US Endo is so much more than a great business opportunity. Our culture is about growth in every aspect of our lives — from improving our communication skills to leadership training, to advanced clinical training courses, and beyond. Being a part of US Endo offers the chance to become not only a better endodontist, but also a better boss, a better spouse, and a better friend. What we are building is unique; I’m truly thrilled to get to be a part of it.” — Jeremy M. Young, DDS, MMSc, and US Endo Partners Operational Excellence Leader When it’s time to talk, talk to the first and only SDSO with proven financial results and a supportive, growth-minded culture — Talk to US.

Visit US at the AAE in Phoenix! You’ll find: • Dynamic presentations on timely topics from industry leaders Dr. Bruno Azevedo “The Cone Beam Guy,” Dr. Diwaker Kinra, Dr. Ryan Facer, and others; • A coffee bar and space to relax and connect with other top-tier endodontists; • Live recordings of our new podcast, “The Endo Files™”; • And one-of-a-kind sweepstakes you won’t want to miss!

Visit US Endo Partners at AAE Booth No. 112

endopracticeus.com

Volume 15 Number 1

SPECIAL SECTION

ZEISS

Check out our AAE event page!

AAE SPECIAL SECTION

ake sure to stop by AAE Booth No. 813 for dedicated sessions with experts to learn how ZEISS microscopes not only can enhance your view, but also advance your practice. We want to help find the best scope for you. Already an EXTARO 300® or PROergo® user? Swing by for some tips and tricks. Sessions are 15 minutes and no reservations needed. Transform the way you work.

Visit ZEISS at AAE Booth No. 813

Experiencing the power of digital communication. ZEISS EXTARO 300

I SS T ZE VISI A AE! AT

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_0190I © Carl Zeiss Meditec, Inc., 2022. All rights reserved.

ZEISS-EXTARO300-Ad-DigitalComms-7.375x4.875in-CAP-en-US_30_030_0190I.indd 1

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Volume 15 Number 1

3/8/22 11:13 AM

MATERIALS & EQUIPMENT

Bien-Air’s Nova delivers new standard in electric handpieces

Bien-Air Dental has launched Nova, a new contra-angle engineered for practical innovation, optimal ergonomics, and extreme reliability. Highlights follow: • Nova’s small head and slim handle enhance the dentist’s field of vision and guarantee easier access in the mouth. The Accu-Spray Quattro Mix system focuses four asymmetrical air/water sprays on the end of the bur with laser precision to ensure optimal irrigation in the working area. Connected to one of BienAir’s LED motors, a multi-strand optical glass conductor simulates daylight conditions for exceptional visibility. • Nova’s stainless steel construction makes it the lightest handpiece in the Bien-Air portfolio. The perfectly optimized gears, and monobloc handle reduce vibrations and the sound level for improved user comfort. • The use of stainless steel significantly reduces wear on the handpiece and makes it 4 times more resistant to shocks. The chuck system features a new PVD coating that makes the opening/closing system more reliable and extends the service life by 30% compared to a conventional handpiece. The Cylcro gears are designed to reduce friction and protect against wear. • Risks of cross contamination are reduced thanks to the non-return valve and the Sealed Head protection. Additionally, the patented Cool Touch+™ heat-arresting technology integrated in the ceramic push-button prevents the buildup of heat to reduce the risk of burns to patients. For more information, visit bienairusa.com/choosenova.

Ultradent introduces MTApex™ bioceramic root canal sealer

Ultradent Products, Inc., has launched its new endodontic product — MTApex™ bioceramic root canal sealer. For clinicians performing root canal treatments requiring obturation, MTApex bioceramic root canal sealer can be used with any endodontic obturation method. It features an extra smooth consistency, which when mixed, is designed to be delivered through Ultradent’s 29 ga Single Sideport NaviTip™ tip. The proprietary gel and tricalcium silicate powder mixture releases calcium ions, stimulating bone repair and increasing the pH of the canal. This helps avoid postprocedure bacterial growth and root resorption. Each kit of MTApex bioceramic root canal sealer contains enough powder and gel to seal approximately twenty canals. For information, call 800-552-5512 or visit ultradent.com.

Face shield liners from NoSweat

Face shields have become medical workers go-to PPE due to being able to reuse them, but many are experiencing distracting issues, such as sweat, fog, and discomfort, while wearing them over long periods of time. NoSweat face shield liners stick to the forehead band of any shield to instantly wick away sweat. The face shields have the following benefits: • Minimize risk of sweat in the sterile field • Promote healthy skin hygiene • Keep sweat out of eyes • Lock-in odor and face oils • Extend life of face shield • Reduce fogging of eyewear • Increase face shield comfort For more information, visit https://nosweatco.com/products/ face-shield-liner.

endopracticeus.com

Enhanced ultrafiltration technology makes dental office water safer

Toppen Dental, an innovator in dental office disinfection and water treatment solutions, has launched its UltraSafe™ ultrafiltration platform. UltraSafe provides a chemical-free answer to keeping dental unit water lines in compliance with CDC and ADA recommendations that protect patients and staff from waterborne microorganisms known to cause disease. UltraSafe incorporates Toppen’s proprietary Energized Fiber Matrix (EFM) technology that imparts an electro-adhesive charge to a specially adapted nanofiber filtration structure. The charged nanofibers form a barrier membrane that removes microorganisms, including bacteria, viruses, and fungi, from dental office water. UltraSafe with EFM has been incorporated into a line of products that includes UltraSafe Micro Straws for chairside bottles and UltraSafe In-Line Cartridges that can be connected directly to dental chair water lines. The UltraSafe Whole Office system treats multi-operatory practices at the point of entry. To learn more, visit toppendental.com.

Volume 15 Number 1

CONTINUING EDUCATION

The dental operating microscope through the years: past, present, and future Dr. Andrew R. Steidley offers insights into the history, uses, and benefits of the dental operating microscope (DOM)

ver approximately the past 30 years, the dental operating microscope (DOM) has made a revolutionary impact on the field of endodontics. While the first clinician to experiment with the DOM was Bowles in 1907, earlier forms of the microscope were unable to gain a foothold due to an overall poor ergonomic design.1,2 One of the earliest studied uses of the DOM in endodontics was written by Dr. Howard Selden back in 1989 when he reported its use for calcified canal identification from a nonsurgical perspective.3 In January 1997, the Commission on Dental Accreditation (CODA) agreed to integrate the DOM into the curriculum of endodontic programs nationwide. However, despite this addition, 2 years later Dr. Pete Mines found that only 52% of clinicians had access to and used the DOM. It was clinicians such as Dr. Gary Carr who helped modify the DOM’s design along with promoting its use that really transformed it from a utilization rate of 52% back in 1999, to 90% in 2009, and 96% as of 2018 (Figure 1).4,5,6

Educational aims and objectives

This self-instructional course for dentists aims to review the history, basic features, clinical benefits, and future of the dental operating microscope (DOM) as it pertains to endodontic treatment.

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: • Describe a brief history of the microscope within endodontics. • Identify the various components that make up the microscope. • Realize how these various components of the microscope impact the field of view and magnification. • Recognize the additions that can be implemented with the microscope and how these can impact a clinical practice. • Describe how the microscope improves a clinical practice and the impact it has shown to have on outcomes.

2 CE CREDITS

There are three major components of the DOM, including the support system, body of the microscope, and the light source. The support system is generally found in three various forms that include a ceiling mount, a wall mount, or a floor mount. The type of mount desired is in large part predicated on the operatory layout, although in general, it is preferred to use either a wall or a ceiling mount system as the fixed position allows easier adjustment and use. The body of the microscope is composed of eyepieces, binoculars, magnification adjusters, and objective lenses (Figure 2). The eyepiece is found in powers of 6.3x, 10x (most used), 12.5x (most used), 16x, and 20x with adjustable rubber cups to allow for glasses and a diopter (-5 to +5) that is used for ocular accommodation. The binoculars allow for adjustment of interpupillary distance, and they should be adjusted until the two divergent circles of light combine. The binoculars have three types of configurations that include straight, inclined, or inclinable and can have short or long focal lengths. The inclinable version is currently more widely utilized at the present time.

Figure 1: DOM use through the years

Andrew R. Steidley, DMD, MS, Dipl. ABE, is currently practicing endodontics in a private practice within the town of Yakima, Washington. He obtained his dental degree from Nova Southeastern University and commissioned directly into the US Army. He practiced for 3 years as a general dentist, including a 6-month rotation to Kosovo. He obtained his endodontic certificate at Fort Bragg. He completed his service by working as an endodontist and helped to start and teach a 1-year AEGD. After completing his time in the U.S. Army, Dr. Steidley moved back home to Washington State where he currently resides. Disclosure: The author reports no conflicts of interest for this article.

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Magnification adjusters are available in 3-, 4-, 5-, and 6-steps via either manual or power zoom. The general layout of the internal body follows: two lenses that project down to two separate prism assemblies, which in turn project down to two binocular objectives that funnel down to one monocular objective that finally projects down to the object as beautifully outlined in Dr. Carr’s 2010 paper.2 One of the keys to any DOM’s design is a light path that is in alignment with the visual path, which in turn results in better illumination overall. The light source is commonly Figure 2: DOM body overview either halogen or LED with an internal fan to avoid overheating. Earlier versions often would utilize xenon light sources, although those have become less prevalent with time due to high costs for replacement bulbs and a relatively short life span of the bulbs (~500-700 hrs). The light exits as two separate beams that result in a stereoscopic effect, which is most important for depth of field. LED light Figure 3: Clinical example of image capture techsources have a brilliant white light nology (ICT) for documentation (Courtesy of Dr. Figure 4: Does ICT improve the ability of others to that tend to last longer, require less Jessica Roeber) appreciate endodontics? power, but suddenly fail at the end of their life span. In contrast, halogen light sources tend to create a bright, white, concentrated light comparing the DOM and loupes, it has been shown that the that turns more yellow as it ages until it finally expires. A recent DOM can improve magnification by a factor of about 4 to 10, 2020 article by Nakira, et al., showed that both the LED and depending on the type of microscope and loupes being utilized. halogen lights within the DOM resulted in similar user fatigue This improved visualization was confirmed via a 2002 study, pre- and post-op.7 Despite this study, the LED light source curwhich found that the identification of canal orifices was more rently seems to be utilized more among clinicians due in large likely via DOM use when compared to visualization via loupes.8 part to better light stability and longer life span as mentioned In fact, the DOM has been shown to improve a clinician’s ability previously. to distinguish 2 various points by a factor of approximately 33.2 How can clinicians accurately determine the total magnifiConstant advancements in technology and many new innocation of their DOM, and how that compares to conventional vations have led to expanded use of the DOM. The use of image loupes? The answers can be found when evaluating the equation capture technology (ICT) and assistant viewing binoculars in discussed in 2010 by Dr. Carr and Dr. Castellucci. This equation combination with the DOM was first described by Dr. Carr in follows: TM = (FLB/FLOL)x EPx MF where TM is total magnifica1992.9 His review of this topic included the science behind tion, FLB is the binocular focal length, FLOL is the focal length of the DOM along with potential uses for these new technolothe objective lens, EP is the eyepiece, and MF is the magnificagies. In 2009, a review of the basic components needed for tion factor of the changer.2 A quick analysis of the equation and ICT concluded that it is an ever-changing field with constant its ramifications reveals that an increase in the power of the eyeadvancements and innovations.10 As time has passed, ICT has piece, the focal length of the binocular, and the magnification experienced an increase in quality with a decrease in cost. factor of the DOM all result in an increased magnification and Further, ICT has become directly incorporated into the DOM a decreased field of view. In contrast, an increase of the focal and is therefore more convenient for clinical use. While the addilength of the objective lens results in a magnification decrease tion of the assistant side scope has been around for many years, and a field-of-view increase. Overall, the main conclusion that it is currently not widely adopted as only 16% of respondents can be drawn from this is that every time the magnification had reported its use in a 2018 study. This same study found that increases, the depth of field and illumination decrease.2 When 61% of clinicians currently utilized ICT in some form. Of those endopracticeus.com

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CONTINUING EDUCATION

Figure 5: Image exposed via ICT with the DOM (Courtesy of Dr. Jessica Roeber)

Figure 6: Images showing identification of fractures (Courtesy of Dr. Matthew Kinstler [left] and Dr. Rebekah Schott [right])

that reported its use, 68% of them stated that they used this tool for documentation purposes in general (Figure 3). Overall, most respondents reported that they found the images produced from ICT to be beneficial to their clinical practice (Figure 4).6 While these additions are utilized for slightly different reasons, both will require the addition of a beam splitter to the DOM that allows the light to be shared among the various components. With an understanding of these components, we can start to evaluate how the DOM has changed practices within the endodontic community. An early study from 2010 demonstrated that while fine motor skills are significantly improved along with improved proficiency, it is an acquired skill that takes time to learn and implement within a clinical practice.11 This steep learning curve likely explains why early on there was resistance to Figure 7: This series of images displays tooth No. 3 with a PARL in the furcation (Figure 7A) that was the DOM use, and why CODA’s adoption of treated via a conservative 2-point access (Figure 7B), due to a recently placed crown, and resulted in the DOM within the endodontic curriculum a lateral canal fill (Figure 7C). A 1-year recall of this same case has healing of the furcation defect with has been so instrumental in its current accepapical tissues remaining stable (7D). (Case completed by Dr. Steidley) tance rate of 96%.6 The increased usage of the DOM in the field of endodontics has led to a reported DOM. Further, there was a significant association between missed increase in both clinical efficiency and proficiency as well as a MB2s and periapical radiolucencies if no DOM was used, while decrease in iatrogenic related events.4,5,12 Specifically, the DOM, those who used the DOM experienced no association between when utilized nonsurgically, has been shown to provide clinimissed MB2s and periapical radiolucencies.15 A separate study cians with an improved ability to: discovered that MB2s were more often located when the DOM • identify cracks (figure 6), extra anatomy (figure 5), and was utilized by about 20% in maxillary first molars and 10% in calcified canals maxillary second molars.16 Thus, the use of the DOM has been • remove obstructions demonstrated to result in better overall outcomes for maxillary • treat dental anomalies molars. Surgically, the DOM has shown an improved ability to: • remove root fillings and sealers • identify extra canals, cracks, and resorption • identify and repair of perforations (Figures 5 and 6)3,13,14 • allow improved root end preperarion A recent study showed that the mesiobuccal (MB) root was • allow improved root endo filling17,18 3 times more likely to have a periapical radiolucency at a recall Regarding nonsurgical outcomes, there are precious few visit if the initial treatment was rendered without the use of the studies that truly evaluate success for DOM versus non-DOM Endodontic Practice US

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treatments. Of those that are present, Over approximately the past 30 years, the we discover mixed results. While the dental operating microscope (DOM) has made a Del Fabbro, et al., studies were unable to identify any difference, the Monea, et revolutionary impact on the field of endodontics. al., study, completed in 2015, showed a 12% increase in success at 6 months and an 8% increase at 18 months when the DOM was utilized.19,20,21 In contrast, surgical outcomes have a few well publicized meta-analyses from how strategically important dentin is around the cementoenamel Setzer, et al., that help to illuminate the importance of the DOM. junction (CEJ) for the structural stability of a tooth.29 All of these The combined results of these studies showed a success of 59% conservative modifications tend to require extra fine motor skills without magnification, 88% with magnification via loupes, and and better visualization, both of which the DOM has shown the 94% with magnification via the DOM.22,23 In 2013, Tsesis, et al., ability to improve.2,9,18 Based on this recent shift within the endfound a success rate of 92% when the DOM was utilized, which odontic community toward conservative techniques and studhelped to confirm the importance of the DOM for surgical endies, which show improved clinical outcomes and an increased odontic outcomes.24 prevalence of DOM use overtime, I think it is fair to say that the So, what is the future of the DOM within endodontics? I microscope continues to have a bright future.4,6,19,22,23,24,25,26,27,28,29 believe it is important to review recent trends in endodontic literature and within the clinical setting, which show a tendency Acknowledgments toward more conservative access designs (Figure 7).25,26,27,28 I want to thank the Fort Bragg endodontic residency, Drs. Jessica Further, traditional shaping techniques have also started to be Roeber, Claire Anderson, and Thomas Jahnke for their help in obtainreplaced by more minimalist designs, especially in the coronal ing the images shown throughout this article. I also want to extend a third, to reduce the incidence of fractured teeth. Drs. Khademi special thanks to Drs. Daniel Kersten and Steven Delgado for being the best mentors an endodontist could ask for. EP and Clark coined the term “pericervical dentin” to illuminate

REFERENCES 1.

Bowles SW. A New Adaptation of the Microscope to Dentistry. Dental Cosmos. 1907;49(4):358-362.

16. Stropko JJ. Canal morphology of maxillary molars: clinical observations of canal configurations. J Endod. 1999;25(6):446-450. 17. Rashad B, Lino Y, Ebihara A, Okiji T. Evaluation of crack formation and propagation with ultrasonic root-end preparation and obturation using a digital microscope and optical coherence tomography. Scanning. 2019.

Carr GB, Murgel CA. The use of the operating microscope in endodontics. Dent Clin North Am. 2010;54(2):191-214.

Selden HS. The role of a dental operating microscope in improved nonsurgical treatment of “calcified” canals. Oral Surg Oral Med Oral Pathol. 1989;68(1):93-98

Mines P, Loushine RJ, West LA, Liewehr FR, Zadinsky JR. Use of the microscope in endodontics: a report based on a questionnaire. J Endod. 1999;25(11):755-758.

19. Monea M, Hantoiu T, Stoica A, Sita D, Sitaru A. The impact of operating microscope on the outcome of endodontic treatment performed by postgraduate students. Eur Sci J. 2015;305-311.

Kersten DD, Mines P, Sweet M. Use of the microscope in endodontics: results of a questionnaire. J Endod. 2008;34(8):804-807.

20. Del Fabbro M, Taschieri S, Lodi G, Banfi G, Weinstein RL. Magnification devices for endodontic therapy. Cochrane Database Syst Rev. 2009;(3).

Steidley A, Kersten D, Delgado S, Mines P, Beltran T. Use of the microscope in endodontics: A questionnaire-based study [abstract]. In: J Endod. 2018;44(3): Abstract PR50.

21. Del Fabbro M, Taschieri S, Lodi G, Banfi G, Weinstein RL. Magnification devices for endodontic therapy. Cochrane Database Syst Rev. 2015;(12).

Nakahira K, Mutoh N, Fuchida S, et al. Effects of different light sources used for dental operating microscope illumination on the visual function of operators. J Oral Biosci. 2020;62(4):363-371.

Yoshioka T, Kobayashi C, Suda H. High detection rate of root canal orifices under a microscope. J Endod. 2002;28(6):452-453.

Carr GB. Microscopes in endodontics. J Calif Dent Assoc. 1992;20(11):55-61.

10. van As GA. Digital documentation and the dental operating microscope: what you see is what you get. MICRO: The International Journal of MicroDentistry. 2009;1(1):30-41. 11. Bowers DJ, Glickman GN, Solomon ES, He J. Magnification’s effect on endodontic fine motor skills. J Endod. 2010;36(7):1135-1138.

18. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006;32:601-623.

22. Setzer FC, Kohli M, Shah S, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature — Part 2: Comparison of Endodontic Microsurgical Techniques With and Without the Use of Higher Magnification. J Endod. 2012;38:1-10. 23. Setzer FC, Shah S, Kohli M, Karabucak B, Kim S. 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. 24. Tsesis I, Rosen E, Taschieri S, et al. Outcomes of surgical endodontic treatment performed by a modern technique: an updated meta-analysis of the literature. J Endod. 2013;39(3):332-339. 25. Plotino G, Grande NM, Isufi A, et al. Fracture strength of endodontically treated teeth with different access cavity designs. J Endod. 2017;43(6):995-1000.

12. AAE Colleagues for Excellence. The Dental Operating Microscope in Endodontics. American Association of Endodontics. Winter 2016.

26. Abou-Elnaga MY, Alkhawas MAM, Kim HC, Refai AS. Effect of truss access and artificial truss restoration on the fracture resistance of endodontically treated mandibular first molars. J Endod. 2019;45(6):813-817.

13. Baldassari-Cruz LA, Wilcox LR. Effectiveness of gutta-percha removal with and without the microscope. J Endod. 1999;25(9):627-628.

27. Mooktiar H, Hedge V, Srilatha S, Chopra M. Conservative endodontics: a truss access case series. Int J Appl Dent Sci. 2019;5(4):213-218.

14. Daoudi MF. Microscopic management of endodontic procedural errors: perforation repair. Dent Update. 2001;28(4):176-180.

28. Krishan R, Paque F, Ossareh A, et al. Impacts of conservative endodontic cavity on root canal instrumentation efficacy and resistant to fracture assessed in incisors, premolars, and molars. J Endod. 2014;40(8):1160-1166.

15. Khalighinejad N, Aminoshariae A, Kulid JC, et al. The effect of the dental operating microscope on the outcome of nonsurgical root canal treatment: a retrospective case-control study. J Endod. 2017;43(5):728-732.

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29. Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clinic North Amer. 2010;54(2):249-273.

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Continuing Education Quiz The dental operating microscope through the years: past, present, and future STEIDLEY

1. While the first clinician to experiment with the DOM was ______ in 1907, earlier forms of the microscope were unable to gain a foothold due to an overall poor ergonomic design. a. Bowles b. Selden c. Mines d. Carr

2. In January 1997, the Commission on Dental Accreditation (CODA) ________ into the curriculum of endodontic programs nationwide. a. decided it was not necessary to integrate the DOM b. agreed to integrate the DOM c. mandated only specific types of DOMs to be integrated d. agreed to integrate only DOMs of specific designs

AGD Code: 070

n To receive credit: Go online to https://endotpracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers. Date Published: March 10, 2022 Expiration Date: March 10, 2025

3. The DOM’s light source is commonly ________ with an internal fan to avoid overheating. a. halogen b. LED c. incandescent d. both a and b

2 CE CREDITS

distinguish 2 various points by a factor of approximately ______. a. 16.3 b. 33.2 c. 54.6 d. 78.4 8. The use of __________ in combination with the DOM were first described by Dr. Carr in 1992. a. image capture technology (ICT) b. assistant viewing binoculars c. the Carr and Castellucci equation d. both a and b

4. _______ light sources have a brilliant white light that tend to last longer, require less power, but suddenly fail at the end of their life span. a. Xenon b. Halogen c. LED d. Incandescent

9. A recent study showed that the mesiobuccal (MB) root was ______ more likely to have a periapical radiolucency at a recall visit if the initial treatment was rendered without the use of the DOM. a. 3 times b. 5 times c. 7 times d. 10 times

5. ________ light sources tend to create a bright, white, concentrated light that turns more yellow as it ages until it finally expires. a. Halogen b. LED c. Incandescent d. Xenon

10. Surgical outcomes have a few well publicized meta-analyses from Setzer, et al., that help to illuminate the importance of the DOM. The combined results of these studies showed a success of 59% without magnification, 88% with magnification via loupes, and ______ with magnification via the DOM. a. 88% b. 90% c. 94% d. 98%

6. A quick analysis of the equation and its ramifications reveals that _________ result(s) in an increased magnification and a decreased field of view. a. an increase in the power of the eyepiece b. the focal length of the binocular c. the magnification factor of the DOM d. all of the above 7. In fact, the DOM has been shown to improve a clinician’s ability to

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

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Practical considerations for utilizing Prescription Drug Monitoring Programs (PDMPs) — a primer Nikki Sowards, PharmD; Michael O’Neil, PharmD; and Tyler Dougherty, PharmD; discuss how prescription drug monitoring programs play an important role in monitoring controlled substances Introduction Although not first-line therapy, prescription opioids play an important role in the management of acute dental pain. However, all medications carry risks, which in the case of opioids can lead to misuse, physiologic dependence, and diversion. Additionally, opioid use disorder may lead to overdose and death. According to the CDC, from 1999 to 2019, an estimated 247,000 deaths in the United States were attributed to overdoses involving prescription opioids.1 In dental practice, the majority of opioids prescribed are immediate-release formulations with a higher potential for misuse and diversion.2 Data also suggests that dentists prescribe more opioids than considered necessary

Educational aims and objectives

This self-instructional course for dentists aims to present an overview of prescription drug monitoring programs (PDMPs) and their considerations for use in dental practice.

Nikki Sowards, PharmD, earned her Doctor of Pharmacy degree in 2012 from the University of Tennessee College of Pharmacy in Memphis, Tennessee. She completed a PGY-1 Pharmacy Practice residency in Knoxville, Tennessee. Dr. Sowards joined South College School of Pharmacy as an Assistant Professor in 2013. In 2015, Dr. Sowards worked as a Director of Hospital Pharmacy in Knoxville, Tennessee. Dr. Sowards is currently an Assistant Professor of Pharmacy Practice at South College School of Pharmacy. She practices at Blount Memorial Hospital where she focuses on pharmacy operations and pharmacy management. Michael O’Neil, PharmD, received his Doctor of Pharmacy from the University of North Carolina at Chapel Hill, North Carolina. Dr. O’Neil has extensive experience in pain management, substance misuse, and medication diversion. Dr. O’Neil was editor and lead author for the American Dental Association’s book titled The ADA Practical Guide to Substance Use Disorders and Safe Prescribing, published in 2015. Dr. O’Neil has served as a consultant for prescription drug misuse and diversion for several entities including the Federal Drug Enforcement Agency. He is currently Professor and Chair of Pharmacy Practice at South College School of Pharmacy in Knoxville, Tennessee. Tyler Dougherty, BA, PharmD, BCACP, received his Bachelor of Arts degree in Biochemistry from Maryville College in 2011 and his Doctor of Pharmacy degree from the University of Tennessee College of Pharmacy in 2015. He completed a postgraduate residency at South College School of Pharmacy in 2016. Dr. Dougherty is a Clinical Community Pharmacist and Assistant Professor of Pharmacy Practice where he specializes in community pharmacy practice and teaches ethics and pharmacy law. Dr. Dougherty is an invited speaker for healthcare professionals teaching ethics and law with emphasis on medication management.

endopracticeus.com

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: • Identify key components of the PDMP. • Outline steps to access the state’s PDMP. • List reasons how utilizing the PDMP can protect dental practices. • List limitations to the PDMP. • Complete a query utilizing the PDMP to evaluate a patient’s controlled substance record. CREDITS

2 CE

for managing postprocedural acute pain.3 Over the past 10 years, many medical and dental boards as well as professional organizations have recommended or required routine use of prescription drug monitoring programs (PDMPs). The American Dental Association recommends dentists register and utilize their state’s PDMP to promote the safe and appropriate use of controlled substances.4 Currently, all 50 states have implemented a PDMP, and dental practitioners may access the following link for more information related to their state PDMP: https://www.pdmpassist. org/State.5,6 Dental practitioners must be fully knowledgeable of their own state’s PDMP. This article will serve as a primer and

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give a general overview for dental practitioners to optimize utilization of their state’s PDMP.

Use of the PDMP by dental practitioners Historically, data has indicated that out of 805 members of the National Dental Practice-Based Research Network, only half of respondents reported having accessed a PDMP. Both lack of awareness and lack of knowledge regarding its use were the most common reasons cited for not using the database. Of those individuals who did report utilizing the PDMP, 33.5% indicated that their usage led them not to prescribe an opioid, while 25.5% reported usage led them to prescribe fewer opioid doses. Figure 1: An example report from the Tennessee Controlled Substance Monitoring Database of dispensed Overall, the findings of this research controlled substances for a mock patient did suggest that a majority of dentists do find the PDMP helpful in their decision-making regarding the prescribing of controlled substances. Table 1: Commonly Used Names and Acronyms for PDMPs Many states now mandate prescribers access the PDMP prior CSD Controlled Substance Database to prescribing controlled substances in defined circumstances.4

PDMP basics Prescription Drug Monitoring Programs (PDMPs) store outpatient controlled prescription medication information and are designed to track these prescriptions through an internet-accessed database maintained at the state level. Classes of controlled substances required to appear in the PDMP are determined by individual states. Of note, PDMPs are commonly referred to in a variety of ways depending on the state of origin. Table 1 lists commonly used terminologies that are equivalent to the PDMP. The main components of the PDMP include tracking of a patient’s prescribed controlled prescriptions, prescriber tracking of prescriptions utilizing their DEA number, and surveillance/ monitoring systems to detect trends and allow for statistical analysis. Controlled substances dispensed by community pharmacies and outpatient clinics are entered into the patient’s prescription record. When these prescriptions are dispensed, information associated with the prescription is uploaded to the PDMP at a time determined by the state with many pharmacies and clinics uploading at the immediate point-of-sale or dispensing. The PDMP report contains the patient’s name, date of birth, any addresses associated with that patient, and any prescriptions for controlled substances that have been dispensed by a pharmacy or outpatient clinic. Specific information typically available for each prescription follows: • medication name • medication strength • quantity filled • number of days’ supply • the prescriber’s DEA number • the date the prescription was written Endodontic Practice US

CSMP

Controlled Substance Monitoring Program

CSMD

Controlled Substance Monitoring Database

CSMPD

Controlled Substance Monitoring Program Database

PMP

Prescription Monitoring Program

PDMP

Prescription Drug Monitoring Program CSMD=CSMP=CSMPD=PMP=PDMP

• the prescription number • the pharmacy that filled the prescription. Some PDMPs are more advanced and may contain additional information such as total daily morphine milligram equivalents (MME), dispensed naloxone, and payment type.6,7 Figure 1 represents a typical report generated from the state of Tennessee PDMP. This database is maintained by the Tennessee Board of Pharmacy, which is a division of the State’s Public Health Department.8 It is critical for practitioners to recognize that information uploaded to the PDMP comes directly from pharmacies or outpatient clinic records. Medication information is entered into the pharmacy’s or clinic’s computers by a variety of personnel. None of this data is ever validated prior to being uploaded to the PDMP other than by personnel entering the data. Any entry errors by practitioners, pharmacists, technicians, or staff get uploaded to the database. Therefore, it is critical to recognize that the PDMP report is not evidence of a crime and should be used only as a starting point to verify potential concerns or “red flags” found in the report. The PDMP ultimately serves to inform clinical practice and improve prescribing. When utilized in a timely manner, PDMPs can prevent dangerous combinations of medications, limit preVolume 15 Number 1

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scribing of unnecessary or duplicate prescriptions, and prevent doctor shopping as well as other types of medication diversion.

Accessing PDMPs Accessing PDMPs requires the prescriber to register with the state organization responsible for managing the database. Like most internet-based restricted sites, passwords are initially assigned by the regulating body and can be changed to a more convenient password later by the user. The database should only be accessed to evaluate a specific provider’s patient records “near time” of the scheduled appointment unless the prescriber is investigating potential fraud or diversion. Information provided in the PDMP must be handled the same as other patient information, which requires following all requirements of The Health Insurance Portability and Accountability Act (HIPAA).9 Accessing the PDMP to ascertain information about friends, families, other practitioners, or patients not part of the prescriber’s immediate practice is usually considered a violation of state and federal law that may result in prosecution. Prescribers are not usually obligated to provide patients with a copy of their PDMP report. However, if a copy of the report is placed in a patient’s medical record, the patient or insurance agencies may have access to the report. Additionally, caution should be used when placing the PDMP report in the chart since it potentially may contain another patient’s information depending on how the patient’s information was queried. Access to the PDMP is restricted to prescribers, pharmacists, the DEA, and law enforcement entities executing a warrant or who are part of a defined drug task force. However, most states allow the PDMP registered user to grant access to PDMP records to a limited number of users in the practice. In most cases this requires the user to use the registrant’s password. Ultimately, the PDMP registrants are responsible for any queries by any allowed users that use their password even if it is not for legitimate purposes. When “allowed users” leave the practice, passwords must be changed immediately to prevent misuse of the database. Some states now identify “allowed users” through special registrations linked to the PDMP registrant or allow support staff to have their own login code.10 Many medical practices and pharmacies have a separate login to the state’s PDMP that is often utilized by everyone in the practice. It is key that every licensed user use his/her own login to access the PDMP. Multiple users put the practice and individual login owners at risks for violations made by individuals using the facility’s login information inappropriately. Many patients live in areas that border multiple states, allowing patients to access practitioners and pharmacies in different states. Some states’ PDMPs provide a link to other nearby states’ PDMP. To date, there is not a single, nationally controlled PDMP that integrates all patient information for all 50 states.

For example, a patient named “Michael O’Neil” should not be entered as “Mike O’Neil” or vice versa. To avoid missing records that may have been entered using an abbreviated name, a more advanced search can be easily performed by using only the first initial of the patient’s first name and his/her last name. Caution is warranted when this method is used since any person named “O’Neil” whose first name starts with the letter “M” and has the exact birthdate will appear in the results. Spellings and datesof-birth must be exact; otherwise, they will not be found in the report. Dental practitioners should also be vigilant for the potential for multiple patients who have the same last name and date of birth. The timeline of the search is also required. For practitioners treating an active patient, searches generally only need to go back 6 months to 1 year because practitioners are making a real-time clinical decision. When investigating patients for potential fraud or diversion, longer time periods may be warranted. Although patient addresses can be entered, patients frequently move, and listing a specific address in the query may limit the findings in the report. Errors entered into patient profiles that end up in the PDMP usually requires a formal request to the PDMP managing agency to correct the misinformation. Simply changing the information in the patient profile will not change the information in the PDMP. Once the PDMP report has been generated for the designated patient and the defined timeline, select the most recent prescription listed, and track on the timeline any medications within the same medication class. Look for any potential “red flags.” Repeat this process for any additional medications.

Identifying and evaluating “red flags” A “red flag” may be defined as any observation that provokes the user of the PDMP to evaluate the need, safety, or legitimacy of a prescribed medication. Identifying a “red flag” does not mean to immediately refuse to prescribe, but rather to ask questions and verify information before prescribing. Ultimately, refusing to prescribe often becomes a common action by the prescriber if controversial information is identified and verified.11

Table 2: Common Potential “Red Flags” Patients traveling extremely long distances between dental practicehome-pharmacy Early refills Utilizing multiple prescribers (emergency medicine, dental practices, hospitals, private practices) Out-of-state patients Random, escalating-de-escalating doses of opioids or benzodiazepines Common “cocktails” consisting of opioids, benzodiazepines, muscle relaxants, and sedative hypnotics

Querying the PDMP After logging into the PDMP, the patient’s name and date of birth must be entered. Ideally this information should come from a government-issued identification such as a driver’s license, but this sometimes is not possible. The patient’s proper name should be used. Nicknames or abbreviated names should be avoided. endopracticeus.com

Morphine-Equivalent Daily Doses (MEDD) exceeding 90 mg/day Patients presenting “old” dental injuries as “new” injuries Utilizing only cash payments for medications

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When reviewing the PDMP, general observations that may be identified as “red flags” include the following: early medication refills, duplicate medications, utilization of multiple pharmacies or multiple providers, extremely long distances traveled from a patient’s home-pharmacy-dental practice, persistent use of similar medications, including random escalating-de-escalating doses, variation in products, and concerning medication combinations, also commonly referred to as “cocktails.” Table 2 lists common “red flags” that may require further questioning.11,12

Limitations to the PDMP Equally as important to the information provided in the PDMP is the information not found in the PDMP that potentially impacts prescribing. The PDMP report will not reflect any verbal changes that have been communicated to the patient such as increasing usage of a prescription. As previously mentioned, errors may occur when prescriptions are processed then uploaded to the database. Because Veterans Administration Medical Center patients receiving medical care are under federal regulation, prescriptions for controlled substances, including methadone and buprenorphine products, are not required to be reported to the PDMP. However, some Veterans Administration Medical Centers do voluntarily report to the PDMP. The PDMP does not usually contain patient diagnosis for the medications prescribed. Finally, all PDMPs are subject to the variety of connectivity issues that commonly occur with accessing information through an internet connection.

Reporting suspected diversion or fraud behavior When suspicious findings in the PDMP have been confirmed to be attempts to divert controlled substances or commit fraud, most states require reporting to a specific drug enforcement agency. This may include the dental practitioner’s local police department, regional drug task force, or regional DEA office. The DEA requires the reporting of any suspicious activities surrounding controlled substances. Regardless, specific information

including the time, date, patient’s name, address, date of birth, suspected illegal activity, medications indicated, and the verification process used to confirm the information in the PDMP should be reported. All information collected surrounding the suspected case should be documented in the patient’s medical record.13

Best practices Recommendations to help optimize a dental practitioner’s use of the PDMP include: • Logging in to the PDMP often to stay familiar with passwords and to stay current with any PDMP changes. • Training staff to run the PDMP report and to have the report ready for review when your patients arrive. • Maintain positive relations with local pharmacies and law enforcement since they are frequently the first to identify potential problems and can help protect your practice. • Evaluate PDMP reports every 6 months with your office manager using your DEA registration number to identify fraudulent prescriptions that have been issued using your DEA number. • Evaluate the PDMP for any brand new patient requiring a controlled substance.

Summary In summary, PDMPs are an effective tool for detecting and deterring controlled substance fraud and diversion. Querying the PDMP requires exact name and date of birth. “Red flags” require further questioning and verification before prescribing or refusing to prescribe since information contained in the PDMP is not evidence of a crime. Sharing of PDMP login passwords should be limited. Although there are some limitations to PDMP, most information is accurate. Dental practitioners prescribing controlled substances should access the PDMP to stay familiar with their passwords and to be kept up-to-date on major changes to their state’s PDMP. Confirmed suspicions or fraud or diversion must be reported per state and federal laws. EP

REFERENCES 1.

Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2020. http://wonder.cdc.gov. Accessed 1/7/22

McCauley JL, Hyer JM, Ramakrishnan VR, et al. Dental opioid prescribing and multiple opioid prescriptions among dental patients: administrative data from the South Carolina prescription drug monitoring program. J Am Dent Assoc. 2016;147(7):537-544.

Maughan BC, Hersh EV, Shofer FS, et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: a randomized controlled trial. Drug Alcohol Depend. 2016;168:328-334.

McCauley JL, Gilbert GH, Cochran DL, et al. Prescription Drug Monitoring Program Use: National Dental PBRN Results. JDR Clin Trans Res. 2019;4(2):178-186.

Herion P, office GP, Marshall Cof J. Missouri becomes 50th state to introduce Prescription Drug Monitoring Database. KOMU 8. https://www.komu.com/news/state/missouri-becomes-50th-state-to-introduce-prescription-drug-monitoring-database/article_6e944f90-c7b8-11eb-a6ff-8742499b65dd.html. Published June 7, 2021. Accessed January 7, 2022.

State PDMP Profiles and Contacts. https://www.pdmpassist.org/State. Accessed January 7, 2022.7. Appriss, Inc. - Tennessee state government - tn.gov. https://www.tn.gov/content/dam/ tn/health/healthprofboards/csmd/TNDataCollectionManual.pdf. Accessed January 7, 2021.

Image Courtesy Tennessee Department of Public Health.

Health Insurance Portability and Accountability Act of 1996 (HIPAA). Centers for Disease Control and Prevention. https://www.cdc.gov/phlp/publications/topic/hipaa.html#:~:text=The%20Health%20Insurance%20Portability%20and,the%20patient’s%20consent%20or%20knowledge. Published September 14, 2018. Accessed January 7, 2022.

FAQ’s. https://www.tn.gov/health/health-program-areas/health-professional-boards/csmd-board/csmd-board/faq.html. Accessed January 7, 2022.

10. Prescription Medication Diversion: Detection and Deterrence. J Calif Dent Assoc. 2019;47(3):180-181. 11. O’Neil M, Winbigler B, Sowards A. Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. 143-149; 2015:144-147. 12. Suspicious orders report system (sors). https://www.deadiversion.usdoj.gov/sors/index.html#:~:text=On%20October%2023%2C%202019%2C%20DEA,115%2D271). Accessed January 7, 2022.

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Continuing Education Quiz Practical considerations for utilizing Prescription Drug Monitoring Programs (PDMPs) — a primer SOWARDS/O’NEIL/DOUGHERTY

1. According to the CDC, from 1999 to 2019, an estimated _________ deaths in the United States were attributed to overdoses involving prescription opioids. a. 50,000 b. 134,000 c. 247,000 d. 456,000

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 866579-9496, or visit https://endopracticeus.com/subscribe/ to subscribe today. n To receive credit: Go online to https://endopracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers.

2. Currently, ________ have implemented a PDMP. a. 16 states b. 34 states c.. 46 states d. all 50 states

AGD Code: 157 Date Published: March 10, 2022 Expiration Date: March 10, 2025

3. Of those individuals who did report utilizing the PDMP, _________ indicated that their usage led them not to prescribe an opioid, while 25.5% reported usage led them to prescribe fewer opioid doses. a. 33.5% b. 52% c. 65% d. 71%

2 CE CREDITS

ally considered a violation of state and federal law that may result in prosecution. a. friends and families b. other practitioners c. patients not part of the prescriber’s immediate practice d. all of the above

4. The main components of the PDMP include tracking of a patient’s prescribed controlled prescriptions, prescriber tracking of prescriptions utilizing their _______, and surveillance/monitoring systems to detect trends and allow for statistical analysis. a. Social Security number (SSN) b. DEA number c. driver’s license number d. Employee Identification Number (EIN)

8. For practitioners treating an active patient, searches generally need to go back _______ because practitioners are making a real-time clinical decision. a. 6 months to a year b. 2 to 3 years c. 4 to 5 years d. 6 to 10 years

5. It is critical for practitioners to recognize that information uploaded to the PDMP comes directly from _______. a. pharmacies or outpatient clinic records b. the patient c. the insurance company d. the pharmaceutical manufacturer

9. A “red flag” may be defined as any observation that provokes the user of the PDMP to evaluate the _____ of a prescribed medication. a. need b. safety c. legitimacy d. all of the above

6. When utilized in a timely manner, PDMPs can prevent _________. a. dangerous combinations of medications b. limit prescribing of unnecessary or duplicate prescriptions c. prevent doctor shopping as well as other types of medication diversion d. all of the above

10. As part of “best practices” process: Evaluate PDMP reports every ______ with your office manager using your DEA registration number to identify fraudulent prescriptions that have been issued using your DEA number. a. 3 months b. 6 months c. 9 months d. 12 months

7. Accessing the PDMP to ascertain information about ________ is usu-

endopracticeus.com

Volume 15 Number 1

SERVICE PROFILE

Endo Mastery Endodontic practice coaching to transform your practice and life!

ndo Mastery was founded with a mission to help every endodontist achieve incredible professional and personal success. Now celebrating 25 years, we are the most experienced endodontic coaching team with a proven track record. Dr. Ace Goerig and the Endo Mastery team have educated and coached more than 20% of endodontists and their teams nationwide.

Endodontic pitfalls There isn’t a 3rd year of residency that teaches you how to be highly successful in the business of endodontics. It’s no wonder then that the average endodontist completes only 3 to 4 cases per day, often Dr. Ace Goerig: Endo’s top practice growth and financial coach accompanied by daily stress as well as financial stress. Debt is an ever-present burden for many doctors. Plus, endodontists tend to work more than most dental speDebt-free, high-wealth freedom cialists — often hesitant to take time off in order to be available Practice growth of that magnitude transforms your entire life. for urgent referrals. Very quickly, you can eliminate all debt. You can improve your Many endodontists suspect their practices are underachievlifestyle, live without any financial stress, and put yourself on ing in teamwork, efficiency, and profitability. They sense sometrack for accelerated financial freedom. thing is missing, they’re not having fun, and they leave each Incredible practice success also unlocks options for future day feeling overtaxed. That can lead to burnout, which takes an associate-based strategies. Achieve fantastic time freedom and emotional toll professionally and in family life. lifestyle while you maintain your income, working only 3 days per week for 40 weeks per year. The rest of the time, enjoy Effortless endodontics your life! Endo Mastery focuses on eliminating barriers, empowering your Ultimately, your vision can evolve to “retire-in-practice” by vision, and achieving clinical excellence in a highly profitable, working only the days you want (80 days per year or less) while team-driven environment. We help you achieve the following: the practice continues to generate high profits. • Master clinical efficiency with high productivity • Elevate teamwork, eliminate drama, and have fun Get life-changing results • Create a growth-driven, flow-optimized schedule Our coaching program helps you and your team grow tre• Eliminate daily stress and inefficient busyness mendously while eliminating stress and creating financial and • Strengthen and grow referral relationships time abundance. The No. 1 comment from our clients is that they • Eradicate debt and financial stress quickly never imagined it would be so easy to be so much more success• Work less, earn more, and live a better life ful with their teams. Clients wish they had begun years ago! Our customized systems and strategies work in endo pracWe offer a free practice analysis to show you the possibilities tices of every kind and size, and with teams at all levels. Ninety that can be achieved with practice coaching. Or to learn more, percent of practice growth is driven by the team, rather than the visit our website to view a free 90-minute webinar or to sign up doctor, and we excel at training endo teams to master the pracfor our doctor and team 2-day livestream seminar, “Mastering tice’s opportunities. the Effortless Endodontic Practice.” Endo Mastery clients typically add $200,000 to $500,000 For more information, visit www.endomastery.com, email to their annual revenues by following our systems. That’s why info@endomastery.com, or call 1-800-482-7563. EP we can confidently offer a risk-free, money-back guarantee on This information was provided by Endo Mastery. coaching! Endodontic Practice US

Volume 15 Number 1

We’ve got your back while you take care of your patients.

I SS T ZE VISI A AE! AT

ZEISS EXTARO 300 An ergonomically designed microscope helps to • Reduce neck and back pain • Sit in a comfortable, neutral posture • Reduce musculoskeletal injuries • Fully focus on your patient and increase your productivity CAP-en-US_30_030_0192I ©2022 Carl Zeiss Meditec, Inc. All rights reserved.

PRODUCT PROFILE

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

“B

uilt to Last. Built for You. Built by Boyd!” is more than a tagline; it signifies the commitment that everyone at Boyd makes to every one of our customers. Best known for the durability and reliability of our award-winning products — including treatment chairs, mobile storage, and clinical cabinetry — we combine over 60 years of design and manufacturing expertise to perfectly fit your unique space and personal style. The Boyd team takes great pride in the craftsmanship and longevity of all products built at our U.S.-based facility, so you can take pride in your office for years to come.

Featured product: S3100LC Endodontic Treatment Chair Designed specifically for your needs, the S3100LC chair for endodontists combines ergonomic, reliable functionality with elegant design. Like most Boyd Industries’ products, the S3100LC chair can be personalized to best suit your office, just as its design will best suit your specialization’s needs.

What makes the S3100LC design unique? • Features a lockable swivel base — capable of 90 degrees of rotation from center — for patient positioning and entry/egress. • Lift column base allows the S3100LC chair to be raised or lowered in a fixed field of view. • The tapered-back design facilitates closer assistant positioning while maintaining patient comfort. • Low-profile, double-articulating headrest ensures proper positioning of the patient’s head. • Easy-to-access membrane switches are located on left and right chair sides to control both base and back adjustments. These come with three programmable settings for one-touch control to articulate the chair to frequently used positions with a “Home” button, which returns the chair to the lowered, upright position for patient egress. • Ultraleather Pro™ fabric and memory foam come standard to support maximum patient comfort. Ultraleather Pro is ink- and stain-resistant with antimicrobial disinfecting ingredients. • Features a detachable foot control, leverrelease drop-down arms, and a fixed toe with clear plastic protective cover.

S3100LC Endodontic Treatment Chair

Standard features • Removable plastic top designed for easy cleaning, in addition to dual slide-out surfaces for added workspace. • 5" easy-rolling wheels allow for a smooth transit from patient to patient. Wheels lock for stability. • Durable scratch-resistant, nylon-reinforced polycarbonate bumper protects the cart’s wheels and exterior from wear-and-tear over time. • Auto-closing, ball-bearing drawers. • Features four 3" drawers, one 6" drawer, and one 9" drawer. The Boyd team has made every effort to create specialized products that are truly “Built for You.” These featured endodontic products can be combined with Boyd’s custom clinical and office cabinetry — with nearly limitless combinations of color and print laminates — to create a fully cohesive office space. To learn more, visit us at www.boydindustries. com, or stop by AAE 2022 Booth 627 in April! You can also follow us on Facebook, Instagram, and Twitter @BoydIndustries. Boyd Industries is an ISO 13485:2016 certified company. EP

Featured product: Endodontic Cart Like the S3100LC, this mobile operatory cart is prepared to perfectly fit into your endodontic practice. The Prestige Endodontic Cart is fitted with a lightweight aluminum body and all the features you need: aseptic surfaces for easy cleaning, sectioned drawers for intuitive organization, and a sleek, contemporary esthetic. Endodontic Cart Endodontic Practice US

This information was provided by Boyd Industries.

Volume 15 Number 1

Our S3100LC Treatment Chair and Endodontic Supplies Cart help you provide quality care to patients.

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

Boyd Industries oﬀers the widest range of durable and customizable endodontic products. We focus on your functional and ergonomic needs so you can focus on your patients’ needs.

Give us a call today to start building the oﬃce of your dreams. BoydIndustries.com | 727-471-5072 |

SERVICE PROFILE

A comprehensive solution for the life of your business Dr. Christopher Sabourin built Endodontic SuperSystems (ESS) for quality of life.

fter more than 16 years leading a practice in California’s Central Valley and growing it from early stages to high profitability, Dr. Christopher Sabourin realized that the digital playbooks he developed for the life of his business could be replicated and shared with his peers. These “Practice DNA” playbooks have enabled Dr. Sabourin to streamline his own practice, where he routinely performs between 4 to 13 treatments per day, radically freeing up time to focus on patients and mentor his team. The Endodontic SuperSystems (ESS) team applied a 3-year, complex R&D process to standardize and map top 0.1% practices into a complete Software as a Service (SaaS) platform bespoke to small and midsize business (SMB) industries. Running an independent endodontic practice has several potential pitfalls. Learn Do Improve Plan dashboard — https://endosupersystems.com/ Without a foolproof process and well-trained team, the endodontist is pulled into all aspects of the fort level in new roles, ESS use improves retention and practice. Burnout is a challenge. performance. “An endodontist as the leader of a small business is under a lot of pressure,” says Dr. Sabourin. “We’re medical professionals trained to focus on people and procedures. Most of us aren’t, Process and flow and shouldn’t have to be, organizational experts with MBAs. • The platform shares proven process maps, workflow The common fixes for practice challenges — such as consultants videos, and charts based on the DNA of practices in the or independent learning — are patchwork solutions that aren’t 0.1% nationally. ESS use builds efficiency and removes always a good fit.” bottlenecks, increasing cost savings and facilitating Enter Endodontic SuperSystems. The comprehensive platgrowth. form provides 24/7 online access to process maps, workflows, and educational modules that guide staff and streamline an Professional growth and knowledge-sharing entire practice. Using ESS orchestrates the life of an endo prac• ESS is a growth resource for team members, practices, tice team — giving visibility into bottlenecks and reinforcing and the endodontic community at large. The platform learning, growth, and efficiency. It means an improved day-toincludes professional development modules, continual day experience for every team member. refinements from a vetted knowledge community, and access to events.

The ESS platform supports the following: Onboarding and training

Data and tracking

• The platform offers best-in-class modules, courses, and videos for training and certification. Beyond a typical learning management system, ESS helps new employees master their roles quickly — practices using the software onboard new employees in 3 to 8 weeks rather than a potential 6 to 8 months.

• ESS provides access to anonymized, industry-specific data analytics and individual practice benchmarks. This feature supports data-informed decisions. Dr. Sabourin believes that, like other industries, endodontics can be transformed through SaaS innovation. “Our field is all about people,” he says. “We provide greater quality of life for our patients, and ESS is made for the business of life. It helps us get the work done well and efficiently, so we can enjoy our own quality of life.” EP

Recruitment and retention • ESS provides access to hiring scripts, work performance improvement, and peer feedback modules. By helping to identify ideal team members and build their comEndodontic Practice US

This information was provided by Endodontic SuperSystems (ESS).

Volume 15 Number 1

A Daily Flow that Works. Following the ESS model of high production practice DNA, the endodontist’s focus is on patients, treatments, and leadership. The ESS workflow means the dentist will spend half as much time in operatory, freeing them up to see more patients including emergency cases, as many as 11-13 people per day instead of 3-5. Its structure for a more productive and profitable practice. Ask how we can help you today.

Visit our website to learn more www.EndodonticSuperSystems.com

SMALL TALK

Authoritarianism is a double-edged sword Drs. Joel C. Small and Edwin McDonald show how leadership styles affect practices’ productivity

s practice owners, we are in a position of authority. How we choose to use that authority will directly impact the nature of our practice culture. Doctors and practice managers who rely on their authority alone can create highly productive practices, but how sustainable are cultures driven by authority? Furthermore, how does our staff react to authority? For example, authoritarians may have highly productive staff, but staff respond to authoritarians and their directives out of fear. The job is getting done according to the doctor’s directives, but a culture driven by fear is a culture of compliance as opposed to commitment. Compliant cultures tend to stagnate over time as team members lose their will to think independently and no longer offer creative feedback that is vital for practices to thrive. We have observed that cultures of compliance are unstable and unsustainable — typified by blame, low staff morale, and increased turnover. Influencers are a different breed of leaders. Like authoritarians, they can create highly productive practices, and a casual observer would have trouble distinguishing between the two types of cultures. This is where the similarities end, however. A more discerning observer would quickly and easily notice significant differences between the two leadership styles and the cultures they create. Whereas staff submit and comply with the directives of an authoritarian out of fear, the followers of an influencer act out of trust and their belief in the leader. Their culture is one of commitment and is typified by collaboration, cohesiveness, shared values, and their belief in a well-defined future vision. To be clear, there are significant distinctions between “authority” and “authoritarianism” that must be recognized. Authoritarianism is defined as tyrannical, autocratic, and even dictatorial, whereas authority is defined as the power to give orders or make decisions. Being in a position of authority, like practice owners or office managers, has many benefits, not the least of which is the ability to act quickly on decisions and affect change. Leaders who combine their authority with a high degree of influence are by far the best leaders and get the most out of their followers. Numerous studies have validated this assertion.

Drs. Joel C. Small and Edwin (Mac) McDonald have a total of over 75 years of dental practice experience. Both doctors are trained and certified Executive Leadership Coaches. They have joined forces to create Line of Sight Coaching, a business dedicated to helping their fellow dentists discover a better and more enjoyable way to create and lead a highly productive clinical dental practice. Through their work, clients experience a better work/life balance, find more joy in their work, and develop a strong practice culture and brand that positively impact their bottom line. To receive their free ebook, 7 Surprising Steps to Grow Your Practice Through Leadership, go to www.lineofsightcoaching.com.

Endodontic Practice US

The sad and unfortunate truth is that many doctors and managers would prefer to be influencers but operate as authoritarians due to a multitude of blind spots. Simply put, many of us are unaware of how we show up for our staff, and we fail to see alternative forms of leadership that would better serve our needs and our staff’s needs. To this point, the greatest service a leadership coach can provide for a client is to facilitate a high degree of personal self-awareness. As we become more self-aware, we are able to adopt a more realistic vision of how we show up for others. Assessments, like the LCP 360 (www.leadershipcircle.com), are valuable aids in developing personal self-awareness. These assessments are often the very first time doctors/managers get to view their leadership through the eyes of those they lead. We get a close-up view of ourselves from the other side of the mirror and learn what our followers view as our strengths as well as our reactive tendencies that are creating barriers and diminish our influence with our staff. Armed with these valuable insights, we can work to diminish our reactive tendencies, leverage our strengths, and expand our influence — all of which can occur simultaneously. The day of the command-and-control authoritarian leader is long past. What may have worked during the Industrial Revolution is, at best, no longer effective and, at worst, extremely destructive. Societal changes have altered the nature of effective leadership over time, and those of us that remain stuck in an authoritarian mindset do so at our own peril. Influence now trumps authority, but combining both is the secret sauce to becoming the very best and most effective leader. It is important to realize that authority is not a prerequisite for influence. Anyone can be an influencer no matter what position they occupy. Some of the most influential people in healthcare practices hold no position of authority, yet their coworkers and even their doctors will seek their counsel and look to their input and guidance when making important decisions. Doctors and office managers should consider seeking buy-in of their team’s influencers before introducing change to their staff. These are the people who will most likely determine how change is perceived by the entire team. Making influencers early adopters of a change initiative will often determine whether it is successful or not. As an exercise, take a moment to reflect on the most impactful people in our lives — those who helped shape who we are. Were they authoritarians or influencers? What are we bringing forward into our current reality because of their impact? You can bet that some aspects of their impact are being manifested in our leadership. Which manifestations do we want to keep, and which would we like to discard? Sometimes leadership is as much about letting go as it is about acquiring new skills. Letting go of an authoritarian mindset would be a wonderful first step in becoming the effective leader that we were meant to be. EP

Volume 15 Number 1

Success Built on

Collaboration. Proven Financial Results The nation’s first endodontic DSO to enjoy a successful equity event

Culture Driven Value Clarity, alignment and unity of purpose define our culture and create value

Share Ideas Partner with clinicians that make you better

When Dr. Linden began looking for a supportive endodontic partner, collaboration was important. And when he learned about US Endo Partners’ customized support from domain experts and their endodontic-led collaborative model, he was sold. When you share ideas, foster growth and pursue excellence, success quickly follows. This is the spirit of US Endo. The spirit of US.

“With their collaborative model, US Endo Partners moves me in a better direction for myself and for my patients.” – Dr. Jeffrey Linden, DDS, Advanced Endodontic Specialists

The Spirit of US

www.USEndoPartners.com/Success

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