Endodontic Practice US - May/June 2014 - Vol7.3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews May/June 2014 – Vol 7 No 3

EXCELLENCE

ENDODONTICS

Endodontic retreatment of a lower right first molar with WaveOne® Dr. David C. Baker

Endodontics in 3D Dr. Richard Kahan

Practice profile Dr. Fleur A. Blethen

Conservative treatment of apical external resorption

Drs. Sebastiana Arroyo Boté and Javier Martínez Osorio

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ASSOCIATE EDITORS Julian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICD Richard Mounce DDS Clifford J Ruddle DDS John West DDS, MSD EDITORIAL ADVISORS Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A Baumann Dennis G Brave DDS David C Brown BDS, MDS, MSD L Stephen Buchanan DDS, FICD, FACD Gary B Carr DDS Arnaldo Castellucci MD, DDS Gordon J Christensen DDS, MSD, PhD B David Cohen PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen MS, DDS, FACD, FICD Simon Cunnington BDS, LDS RCS, MS Samuel O Dorn DDS Josef Dovgan DDS, MS Tony Druttman MSc, BSc, BChD Chris Emery BDS, MSc. MRD, MDGDS Luiz R Fava DDS Robert Fleisher DMD Stephen Frais BDS, MSc Marcela Fridland DDS Gerald N Glickman DDS, MS Kishor Gulabivala BDS, MSc, FDS, PhD Anthony E Hoskinson BDS, MSc Jeffrey W Hutter DMD, MEd Syngcuk Kim DDS, PhD Kenneth A Koch DMD Peter F Kurer LDS, MGDS, RCS Gregori M. Kurtzman DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd BDS, MSc, FDS RCS, MRD RCS Stephen Manning BDS, MDSc, FRACDS Joshua Moshonov DMD Carlos Murgel CD Yosef Nahmias DDS, MS Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot DCSD, DEA, PhD David L Pitts DDS, MDSD Alison Qualtrough BChD, MSc, PhD, FDS, MRD RCS John Regan BDentSc, MSC, DGDP Jeremy Rees BDS, MScD, FDS RCS, PhD Louis E. Rossman DMD Stephen F Schwartz DDS, MS Ken Serota DDS, MMSc E Steve Senia DDS, MS, BS Michael Tagger DMD, MS Martin Trope, BDS, DMD Peter Velvart DMD Rick Walton DMD, MS John Whitworth BchD, PhD, FDS RCS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com

AAE 2014 Annual Session: genuinely stunning technology and innovation, the bright future of our specialty

he new technology and innovation on display at the AAE 2014 Annual Session was genuinely stunning. New and improved cone beam technology, self-sealing obturation points, more nickel-titanium choices, improved cleaning technology — it was all there, and more. As an endodontist who graduated in 1991, it was like watching the future arrive, the opening of a door to a new era for our specialty, a more predictable and less technique-sensitive era for clinicians. For prospective patients, future endodontic procedures should be less anxiety provoking, leading to more procedures by the advances we are seeing. Whether controlled memory, superelastic, reciprocated clockwise, reciprocated counterclockwise, heat treated, rotated, and so on, our ability and choices in canal shaping have never been better, as evidenced by the offerings at the AAE. Obturation has once again seen a new competitor emerge to traditional methods in the form of the “self-sealing” CPoint™ introduced by EndoTechnologies, LLC. It will be interesting to see if CPoint becomes a dominant market player or just another commercial alternative to gutta percha in its traditional form. No predictions, but I admire their efforts. The above notwithstanding, in my view, for a number of reasons, the star of the AAE was Sonendo® (Sonendo.com). In the best sense of the words, Sonendo is disruptive technology, a quantum leap forward. Of all the technologies and instruments that have come on the scene in the past 2 decades, Sonendo’s GentleWave™ has the greatest capability to affect both the clinician and patient experience of endodontic treatment — in essence, to improve the quality of life for our patients and, ultimately, us. What do we want as clinicians? What do our patients want from us? For both clinician and patient, the answer is the same — safer, faster, and more predictable results. Based on the emerging evidence, it would appear, without exaggeration or embellishment, Sonendo delivers. Whether Sonendo eliminates the need to instrument canals remains to be seen, but what is clear is that based on the impressive research being accumulated, complex treatment algorithms using multiple files and significant tooth structure removal are likely to be a thing of the past. Minimal shaping followed by the use of the Sonendo protocol creates a cleanliness that is nothing short of breathtaking. As a clinician, this excites me. As a patient, this is what I would want done for me. One final note, as an exhibitor for my company (MounceEndo.com), one of the things I enjoyed most about our booth at the AAE was visiting with old friends, making new ones, and discussing clinical ideas, techniques, tips, and tricks with clinicians, especially endodontic residents. The future of our specialty is bright.

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© FMC, Ltd 2014. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. 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 or the publisher.

Volume 7 Number 3

Dr. Richard Mounce Dr. Mounce is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, an endodontic supply company also based in Rapid City. Dr. Mounce has no commercial interest in Sonendo. He can be reached at 605-791-7000 or RichardMounce@MounceEndo.com, MounceEndo.com, and Twitter: @MounceEndo.

Endodontic practice 1

INTRODUCTION

May/June 2014 - Volume 7 Number 3

TABLE OF CONTENTS Clinical Endodontic retreatment of a lower right first molar with WaveOne® Dr. David C. Baker uses a technique that facilitates quick and predictable results......................................... 13

Case report/Young Dentist Endodontic Award CY — An endodontic success

Practice profile

Dr. Fleur A. Blethen Empathy, tenacity, and perseverance are keys to this clinician’s flourishing practice

story Dr. Jamie Nelson, first-place winner of the Young Dentist Endodontic Award in the UK, demonstrates that no matter how bleak the outlook, there’s always a possibility for success ...................................... 16 Non-surgical endodontic treatment of the maxillary right central incisor with incomplete

Corporate spotlight

SS White Dental ®

SS White® Dental is addressing the general practitioner’s preference shifts impacting endodontics

2 Endodontic practice

root formation Dr. Rupal Shah, second-place winner of the Young Dentist Endodontic Award of the UK, examines the successful management of an anxious 10-yearold patient................................... 20

Volume 7 Number 3

simple, adaptable

endodontic solutions

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TABLE OF CONTENTS

Management of a tooth with a large radiolucency Case study Management of a tooth with a large radiolucency Dr. Nishan Odabashian discusses treatment of teeth with failing previous root canal treatment exhibiting large radiographic lucencies...................24

Technology

Endospective

tomography (CBCT) ......................37

Good times in the endo space or the end of reamin’ and dreamin’ as we know it? Dr. Rich Mounce shares his optimism on the specialty of endodontics.....48

Product profile

Legal matters

Planmeca ProMax 3Ds and 3D: New imaging mode for endodontics offers perfect visualization of the finest details . .....................................................41

2014 employment law updates every dentist should know Ali Oromchian examines some changes that can affect practices .....................................................50

Antimicrobial effect of super-oxidized water and sodium hypochlorite against

ChlorCid® and ChlorCid® V by Ultradent .....................................42

Endo insight

Enterococcus faecalis Drs. Giampiero Rossi-Fedele, José Antonio Poli de Figueiredo, Liviu Steier, Luigi Canullo, Gabriela Steier, and Adam P. Roberts compare the antimicrobial action of several substances to be used as irrigating solutions........................................32

Practice management

Diary ......................................53

Continuing education Conservative treatment of apical external resorption Drs. Sebastiana Arroyo Boté and Javier Martínez Osorio present a case report detailing conservative treatment of apical external resorption in a highrisk patient.....................................28

4 Endodontic practice

Endodontics in 3D Dr. Richard Kahan discusses case studies using cone beam computed

Secrets to financial and personal freedom for endodontists In part 1 of his series, Dr. Ace Goerig offers the first steps to becoming debt-free.......................................44

AAE promotes root canal awareness ..................................52

Materials & equipment .....................54 Industry news ............55 Volume 7 Number 3

ORTHOPHOS XG 3D The right solution for your diagnostic needs.

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Endodontists

Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning.

will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies.

will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.

General Practitioners will achieve greater diagnostic accuracy for routine cases.

ORTHOPHOS XG 3D

â&#x20AC;&#x153;With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, fractures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients. Combine that with the metal artifact reduction software that reduces distortions from metal objects, my treatment process is a lot less stressful. My patients benefit from the technology and my referrals appreciate the value.â&#x20AC;? ~ Dr. Kathryn Stuart, Endodontist - Fishers, Indiana

The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy.

For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977 www.facebook.com/Sirona3D

PRACTICE PROFILE

Dr. Fleur A. Blethen Empathy, tenacity, and perseverance are keys to this clinician’s flourishing practice What can you tell us about your background? I was born and raised in Seattle, Washington, and lived there until I was 13 years old. My family relocated to Danville in the Bay area of San Francisco when I was a freshman in high school, and we lived there for 4 years. My family returned to Seattle where I attended college and subsequently dental school and my endodontic residency. I obtained my Bachelor’s Degree in Biochemistry from the University of Washington in 2001. I graduated Summa Cum Laude with Departmental and College Honors. I attended dental school at the University of Washington as well and graduated second in my class. Upon graduation, I received the American College of Dentists Outstanding Student Leader Award, the Washington State Dental Association Student Award, and the Washington Association of Women Dentists award. At this time, I was invited to membership in Omicron Kappa Upsilon. I obtained my Endodontic Certificate and Masters of Science in Dentistry from the University of Washington under the direction of Dr. James J. Johnson, DDS, MS, FICD. During my residency, I was awarded the Dentsply Student Award for Oral Research Presentation at the AAE Annual Session. I did the research for my Masters Thesis under the direction of Dr. Martha Somerman, the current director of the National Institute of Dental and Craniofacial Research (NIDCR). My Masters project led to a publication titled “Ablation of systemic phosphate-regulating gene fibroblast growth factor 23 (Fgf23) compromises the dentoalveolar complex” in the journal The Anatomical Record Advances in Integrative Anatomy and Evolutionary Biology. I am in the process of board certification with the American Board of Endodontists and am currently board-eligible. I am Clinical Affiliate Faculty at the University of Washington and have instructed in both the graduate and undergraduate endodontics clinics. 6 Endodontic practice

Dr. Fleur A. Blethen, DDS, MSD — Valley Endodontics and Oral Surgery, Glendale, AZ

When did you become a specialist and why? I completed my specialty training in endodontics in 2008. During college, I volunteered at the University of Washington Medical Center and the School of Dentistry. I was placed in the endodontic clinics as a volunteer, and this was my first exposure to the specialty. I was fascinated by the art and science of endodontics, and my interest expanded from there during dental school when I experienced treating patients. I wanted to focus on one aspect of dentistry, and endodontics was a good fit for me because it requires thought, empathy, and strong fine-motor skills.

Is your practice limited solely to endodontics, or do you practice other types of dentistry? Yes, my practice is limited solely to endodontics. I had always dreamed of living in a sunny climate, so I relocated to Phoenix, Arizona in 2009. I have worked in several endodontic practices in the Valley of the Sun and have settled at Valley Endodontics and Oral Surgery at the Glendale, Arizona office. Our company has 10 specialty practices in Arizona. Three of our practices are a combination of endodontics and oral surgery, four are solely endodontics, and three are solely oral surgery. Our company Volume 7 Number 3

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sonendo.com

PRACTICE PROFILE

prides itself on providing quality treatment to patients and accepting a variety of insurance plans to accommodate patients as much as possible.

Why did you decide to focus on endodontics? I went into dental school with an open mind. I believed I wanted to specialize because I wanted to narrow my focus and become really proficient in one area. I was drawn to endodontics because of the diagnostic challenges we face in clinical practice, the attention to detail required to successfully treat cases, and the emergency-based nature of the specialty. I have always enjoyed working with my hands, and a high level of motor skill is required in endodontic practice. Sometimes patients present with complex symptoms and present a formidable diagnostic challenge. I find these cases especially interesting and enjoy solving the puzzle. Many patients have anxiety because they have never had root canal treatment, or they have had a bad experience during root canal treatment. I feel that I am empathetic to my patients’ needs and can put them at ease. I also had wonderful mentors in the Department of Endodontics at the University of Washington who encouraged me to pursue further training to enhance my skill set. I am so grateful for the opportunity because I truly enjoy what I do, and not many people can say that.

Do your patients come through referrals?

Dr. Fleur Blethen, Endodontist, and Dr. Robert Gorzelnik, Oral Surgeon, with staff

Our office has an office manager, receptionist/patient coordinator, and two dental assistants specific to endodontics.

What training undertaken?

have

you

In addition to my undergraduate and graduate studies at the University of Washington, I have taken several endodontic-specific training courses, including “The Art of Endodontics 2-day Laboratory Course” with Dr. Stephen Buchanan and “Nonsurgical Retreatment” with Dr. Cliff Ruddle. Of course, I also regularly take continuing education courses in a variety of aspects of dentistry.

Yes.

How long have you been practicing endodontics, and what systems do you use? I have been practicing endodontics for 6 years. I routinely perform a hybrid instrumentation technique using ProTaper® and Vortex® rotary files. During retreatment, I use ProTaper® Retreatment files and GT® Series X® files. I obturate using a warm vertical technique. I downpack with the System B heat source and backfill with the Calamus® obturation unit in most cases. Our office has three operatories dedicated to endodontics and three to oral surgery. Our endodontics operatories are equipped with microscopes, rotary motors, ultrasonics, and digital radiography. We utilize EndoVision® and DEXIS® software. 8 Endodontic practice

Who has inspired you? Although many people have inspired and influenced me, my biggest inspiration was my mother. She was a single mom with two children and a successful career in Commercial Real Estate. She put herself back through school obtaining her MBA and CPA when I was in grade school. My mom had an especially great challenge because my sister is disabled with Cerebral Palsy and other developmental disabilities, and thus required more time and attention than the average child. My mom never complained about her “lot in life.” She always emphasized the importance of a positive attitude and taught me that I could do whatever I put my mind to with effort. She was able to balance family and career and still make time for her personal

interests. My mother passed away in 2001, but she played an integral role in laying the foundation for me to have a successful educational and practice career.

What is the most satisfying aspect of your practice? I find helping people very fulfilling, and receiving a genuine thank you from a patient makes my day. Every patient is different, and I enjoy assessing patients’ needs and accommodating them to the best of my ability. Some people want to know every detail about the treatment you are providing and the science behind it, whereas other people don’t want to hear the intricacies as it increases their anxiety. I believe I have great responsibility to the patients I serve, and I make every attempt to provide quality treatment in a caring environment. A close second favorite aspect of my practice is seeing the final radiograph after completing a beautiful case.

Professionally, what are you most proud of? I am most proud of myself for my academic accomplishments. I had significant challenges on the road to where I am today. Both of my parents passed away during my first year of dental school, and I became the guardian of my younger sister, who is disabled. This undertaking consumed a fair amount of my time during my dental school career which required significant planning and time management on my part. Volume 7 Number 3

What advice would you give to budding endodontists? Dr. Blethen treating a patient using a Global Dental Operating Microscope

What do you think is unique about your practice?

What is the future of endodontics and dentistry?

I practice in an office that provides both endodontics and oral surgery services for patients. I have the privilege of working with an oral surgeon 3 days a week, which I have found to be tremendously helpful and educational. If a tooth cannot be retained due to non-restorability or other factors, my patients can often see the oral surgeon for consultation and sometimes treatment the same day.

Despite the advances in implant technology and their high success rate, most people are motivated to save their natural teeth when possible. The future of endodontics and dentistry is in tandem. Technology and education have empowered the patient to make an informed decision as to how to successfully maintain oral health. Technology has not only enabled the patient to receive better care but has also improved its access through enabling both specialists and general dentists to provide a standard of care that continues to improve. As endodontists, we need to embrace that general dentists are able to provide various levels of endodontic treatment, which is enhanced by a continued improvement in training and technology. Specialists are not only the general dentists’ partners in treating referred patients, but we are also there to provide feedback and guidance regarding patients they are treating whom we may never see in our practice. Longterm, this approach not only benefits my practice and relationships with dentists who entrust their patients’ care to me, but it improves the overall patient experience and access to quality dental care.

What has been your biggest challenge? Finding a work-life balance has probably been the hardest part of career development for me. In endodontics we are often faced with seeing patients early in the morning or at the end of the day to accomodate their schedules or fit them in on an emergency basis. With time and experience, I have learned techniques for time management in practice that have helped me to maintain a social life, a healthy lifestyle, and a flourishing practice.

What would you have been if you didn’t become a dentist? Probably a physician. I love science and math, and enjoy working with people. Medicine and dentistry are both problemsolving professions where these areas intersect.

What are your top tips for maintaining a successful specialty practice?

Don’t rush. Focus on quality, and efficiency will come with time. Try to learn something from every case, especially your “mistakes.” Take the time to hire and train good staff as it has a huge impact on your daily experience in practice.

What are your hobbies, and what do you do in your spare time? I am very active and enjoy snow skiing, wakeboarding, yoga, and running. I am learning how to golf, but that’s a work in progress. I enjoy traveling, reading, and going out to dinner with friends. I get a lot of personal satisfaction from philanthropic pursuits and hope to devote more time in the upcoming years to volunteering. Specifically I would like to spend more time working with special needs patients and others with lack of access to care issues. EP

Top TEN Favorites Endo-related 1. Vortex Blue® rotary files 2. Root ZX® 3. System B 4. Calamus® obturation unit 5. EndoActivator® Personal 6. Family 7. Sunshine 8. iPhone 9. Music 10. Vacation

There are several important aspects to maintaining a successful endodontic Volume 7 Number 3

Endodontic practice 9

PRACTICE PROFILE

practice. It goes without saying that you must provide a high quality of care. Establish and maintain good relationships with your referring dentists. This leads to more than just a working relationship and often to great friendships. Developing trust with those who refer to you is important as you are often considered an extension of their practice. Always accommodate emergencies to the best of your ability. If you are available and establish that as a precedent, you will be at the top of your referring offices’ list. To this end, it helps to hold time aside in your schedule each day for emergencies, have accommodating office hours, and be available Monday through Friday.

CORPORATE SPOTLIGHT

SS White® Dental Addressing the general practitioner’s preference shifts impacting endodontics

here are a number of major dental market trends which have led to a -7% annual growth rate for Endodontics over the past 2 years. They are as follows: • GPs have a shrinking pool of fully insured patients, resulting in business pressure to make up lost revenue by doing more RCT cases in-house. • Large clinic /DSOs refer less RCT cases outside, and they are at growing at 20% a year for the last 3 years. • A very aggressive, highly marketed implant movement has more referring GPs performing implants and previous RCT cases to Implantologists. • A growing GP concern over endodontically treated tooth fractures and other retreatments. As a restorative dental company serving both Endodontists and GPs, we constantly engage our customers in regards to their latest challenges and successes. We have discovered some very interesting facts on GP preferences for patient treatment options and their desires regarding performance and quality. Our research delved into questions like, “Why would GPs refer to an Implantologist?” “Why would they choose to refer to an Endodontist?” “How do they choose a referring Endodontist?” “What causes them to change Endodontists?” Some of the questions GPs ask themselves are —“How am I going to place the crown?” “Will this crown fracture?” The third leading reason Americans will lose a tooth in their life is due to tooth fractures. An RCT treated tooth fracture is often blamed on the Endodontist. This is amazing and scary for our industry — a real threat. It can be a hidden threat to the Endodontist because he/she will likely never hear about it from the GP. However, be certain the Implantologist will have the discussion with the patient and the GP. We’ve also had the opportunity to work with Endodontists who are growing their practices in excess of 20% a year. We benchmarked these top performers to pinpoint common traits and beliefs. 10 Endodontic practice

General Practitioner Beliefs: • General practitioners believe 10%-30% of endodontic procedures result in tooth fractures. • 87% of general practitioners are likely to stop referring cases to an Endodontist who returns patients with insufficient dentin. • 92% of general practitioners have experienced frustration with aggressively prepared teeth.

General Practitioner Expectations of Modern Endodontics: • Think about the whole tooth. Not just the lower apical third. • Reduce my complexities, time, and concerns with placing this crown. • Leave enough healthy dentin for a long lasting crown and a second crown when necessary, 10-15 years out • Help me provide more options for my patient.

Traditionally, we have conflicting vantage points — The Endodontist looks at the lower apical third, and the GP looks at the upper apical third. Today’s modern RCT approach takes a holistic view of the entire tooth. Endodontists embracing the modern approach are growing dramatically

in the marketplace. Why? Simply put, they’re giving their GPs what their GPs want: more periocervical dentin for a stronger long life restoration with less time and complications during the restorative procedure. If you were to go to a GP and show

Volume 7 Number 3

Straight-Line Access to Root Canals

Actual Size EG1A

The Minimally Invasive Bur Access System

EG1

SS White® EndoGuide® carbide burs are specifically designed for endodontic

EG2

access and root canal exploration. Their unique micro-diameter tips act as a

EG3

self-centering guide for straight-line access to canals, maximizing efficiency

EG4

and preserving precious peri-cervical dentin. Round burs, in contrast, tend to EG5

“run off” which may lead to gouging and potential perforation. EndoGuide®

EG6

burs also produce smooth surfaces, making hidden

EG7

canal orifices easier to detect. EndoGuide® burs enlarged to show detail

1. U.S.Patent No. 6,257,889 B1

“Put away your round burs and Gates Glidden Burs, and pick up the SS White EndoGuide Burs. They eliminate bur run-off and create a guidance system that finds canals much more effectively and conservatively.” - David J. Clark, DDS ®

simply better endodontics

™

Visit us on the web at www.sswhiteburs.com

CORPORATE SPOTLIGHT

“

The tool should serve the concept/ technique, the tool should not drive the concept/technique.” Dr. Eric Herbranson, Endodontist, San Leandro, CA

them the preceding images, which one do you think they would have done on them? Which one do you think they want done on their patients? Which one are they currently getting from you or from your peers? The market research states that GPs prefer the minimally invasive approach 5:1.

87% of general practitioners are likely to stop referring cases to an Endodontist who returns patients with insufficient dentin. SS White is the only endodontic manufacturer that designs its products with dentin conservation as the focal point of its instrumentation. No matter what your clinical methodology, our instruments easily match your treatment goals. Using our specially designed burs for access, canal location, and pulp chamber refinement in combination with our V-Taper H2 endodontic files, you will be maximizing the conservation of healthy dentin 4 mm above and 4 mm below the orifice. Our RCT instruments serve your technique; they don’t dictate the technique. This full

12 Endodontic practice

SS White is the only endodontic manufacturer that designs its products with dentin conservation, general practitioner preference and lifetime restoration as the focal point of its instrumentation. No matter what your clinical methodology, our instruments easily match your treatment goals. system we developed contains carbides, diamonds, files, and obturation material. The SS White Endo system will have GPs thanking their Endodontists and providing more referrals. These Endodontists know they’re helping create a longer lasting restoration and better patient outcomes. The strength is left in the tooth because as you know, the perio cervical dentin is the source of strength. What SS White has done is work with GPs and Endodontists to incorporate the minimally invasive techniques common to Endodontics. This new approach helps you create longer life restorations, loyal GPs, and better patient outcomes. To learn more about what GPs prefer, or how we can help you conserve healthy

tissue and grow your practice, please contact SS White through the options below. EP info@sswhitedental.com 800-535-2877 Marketing communications info Upcoming events Webinar: June 12, 5:00 PM (PST) Viva Learning “Practice Building with Modern Endodontics” This information was provided by SS White Dental.

Volume 7 Number 3

Dr. David C. Baker uses a technique that facilitates quick and predictable results Patient history The patient is a 34-year-old female who was referred by a local colleague. She had broken her lower right first molar and complained of some general discomfort. The tooth had received root canal treatment some years earlier. The patient was fit and well, but was a little anxious about the treatment.

Examination Upon examination, it was found that LR6 had a fractured restoration, with a silver point sitting proud out of the fracture. The tooth was slightly tender to percussion and had mild buccal tenderness. Circumferential pocket probing revealed a maximum of 2-mm pocketing. Extraoral and intraoral examination showed no swelling or obvious lymphadenopathy. The soft tissues were of normal texture and color, oral hygiene was good, and the teeth were generally well maintained. Images were taken using indirect digital radiographs with a beam-aiming device (Figure 1). The radiograph identified a root-filled, lower first molar tooth. The two mesial canals had been obturated with silver points, and the distal suggested a short gutta-percha filling. There were apical

Figure 1: Preoperative periapical radiograph

Figure 2: Angled preoperative periapical radiograph

Figure 3: Start-X tips

Figure 4: WaveOne motor

radiolucencies associated with both roots and possibly some apical resorption on the distal root. The marginal bone was sound, and both roots had a slight curvature.

radiograph (Figure 2) was taken, showing the more difficult remaining silver point.

Diagnosis Diagnosis of a fractured tooth with chronic apical periodontitis due to a failed root treatment was established.

David C. Baker, BDS (Hons), MJDF RCS (Eng), PgDip Endo, qualified in 2004 with Honors from the Liverpool Dental School. He undertook General Professional Training in Liverpool and worked as a Senior House Officer in Dental Surgery at Liverpool Dental Hospital. He is a member of the British Endodontic Society and achieved his membership of the Joint Dental Faculties of the Royal College of Surgeons in 2011. David has worked at UCLAN Dental School, teaching undergraduates Clinical Dentistry, and has also been involved more recently in post-graduate training in the North West. He completed a certificate followed by a post-graduate diploma in Endodontics, both with Distinction including Distinction for his clinical cases and is currently working towards his Masters Degree in Endodontics. David practices as an Associate Dentist at Hob Hey Dental Centre in Culcheth, Warrington, where he accepts referrals for endodontic treatment from several local dentists.

Volume 7 Number 3

Treatment options Several treatment options were discussed with the patient: • Extraction and/or replacement with an immediate denture, bridge, or implant. • Root canal retreatment followed by provision of a cuspal coverage protective restoration. As the patient wished to save the tooth, success rates of root canal retreatment and the difficulties associated with removing silver points were discussed. One of the silver points was so proud that it was removed then and there with tissue forceps. A new angled periapical

Treatment details After an inferior alveolar dental block with a buccal infiltration, the tooth was isolated using a rubber dam, with a single number seven molar clamp on LR7 and a reversed premolar clamp on LR5. Access to the three canals was established with a highspeed air turbine under magnification with a microscope. The pulp chamber was refined and tidied up with a No. 2 Start-X™ Dentsply ultrasonic tip (Figure 3). The access cavity was flooded passively using a side-venting monoject needle with 3% sodium hypochlorite. Using a No. 3 Start-X tip, space was made around the remaining silver point in the mesiobuccal canal. Once space was made, a Hedstrom file was able to slide alongside the silver point and help tease it out completely. A size 10 stainless steel K-file was used to gently scout each of the three canals. Endodontic practice 13

CLINICAL

Endodontic retreatment of a lower right first molar with WaveOne®

CLINICAL

Figure 5: Cone fit radiograph

Figure 9: Post-op angled periapical radiograph

Figure 6: AH Plus sealer

Figure 10: Post-op periapical radiograph

The size 10 file moved fairly easily in all three canals to approximately two-thirds of the estimated length. A WaveOne速 Primary 25:08 file was selected and mounted on a WaveOne motor. The WaveOne program was selected (Figure 4) for each of the three canals. Initially working the file into the coronal half of each canal, slight pressure was applied apically for three or four motions before removing the file for cleaning, irrigation, and recapitulation. The file removed the coronal gutta percha in the distal canal. With copious irrigation and recapitulation, the size 10 file was able to slowly approach the estimated canal length from the preoperative radiographs. An Apex locator zero reading was used to establish the position of the apical foramen, with the chosen working length in each canal 0.5 mm from this. The glide paths were confirmed to the working lengths of each canal. The working lengths were 19.5 mm for the mesial canals, and 19 mm for the distal canal. The mesial canals merged into the apical 2 mm. A WaveOne Primary file was used again in each canal, this time to the full working lengths. The WaveOne file reaches working lengths in this sort of canal fairly easily, but is best removed after three to four progressive motions to clear the debris from the file and irrigate the canal with recapitulation. Apical patency was 14 Endodontic practice

Figure 7: Calamus dual unit

Figure 11: 3-month review periapical radiograph

maintained throughout with a size 10 hand file. The gutta percha from the distal canal was removed uneventfully,* and no solvents were required. At this stage, the tooth was medicated with non-setting calcium hydroxide and dressed with PTFE and a glass ionomer temporary restoration. The patient returned 10 days later to have the treatment finished. She reported mild discomfort for a day or so after the first appointment, but this had since settled. Once again local anesthetic was administered, and the rubber dam was applied as before. The temporary dressing was removed, and the canals were irrigated as they were previously. A size 10 K-file confirmed patency once more, and a size 25 hand K-file was checked for the previously agreed length and for apical gauging. Tug back was confirmed with matching guttapercha points, and a cone fit radiograph was taken to confirm the prepared lengths (Figure 5). Once again the canals were irrigated with 3% sodium hypochlorite. This was followed by sonic irrigation with the EndoActivator速, using the number 2 red tip. The canals were washed with 17% EDTA for 1 minute, dried, and irrigated with 2% chlorhexidine gluconate before being dried for a final time. The canals were obturated with

Figure 8: WaveOne gutta-percha points

warm vertical compaction using AH Plus速 (Dentsply) (Figure 6) and the Calamus速 Dual Filling system (Figure 7) with matching WaveOne gutta-percha points (Figure 8). The black tip 40:30 was chosen for the mesial canals and the yellow tip 05:50 for the distal canal. After obturation, excess sealer and gutta percha was removed from the access cavity, and the tooth was sealed with glass ionomer. The occlusion was checked. Two appropriately angled radiographs (Figures 9 and 10) were taken to confirm an adequate obturation with a small distal puff of sealer. The obturation showed a continuous taper of all canals. The patient was given postoperative advice regarding pain relief and advised to contact her referring dentist. The dentist was advised to provide a crown to the tooth to maintain a sound coronal seal and prevent future fracture as soon as possible. The patient was reviewed 3 months later, and a new periapical radiograph (Figure 11) showed good signs of healing. The patient has since been asymptomatic.

Conclusions This treatment was carried out and completed using just one reciprocating file. WaveOne offers a simple technique that provides quick and predictable results. The complete system ensures that matching paper points and gutta percha are available in either obturators or cones. Although there are three files to choose from in the system (Small 21:06, Primary 25:08 and Large 40:08), the majority of cases can be completed with a single WaveOne Primary file 25:08. The reciprocating motion of the rotary file massively reduces the risks of cyclic fatigue. The instruments, which are manufactured out of M-Wire NiTi, are also more resilient to fracture. EP Volume 7 Number 3

a shift up in performance PROTAPER NEXT features the same variable tapered performance as the original PROTAPER, but is refined with: • Unique rotary motion that further enhances PROTAPER canal-shaping efficiency • Proven M-Wire® NiTi alloy for increased flexibility and resistance to cyclic fatigue • Rectangular cross-section design for greater strength

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CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

CY – An endodontic success story Dr. Jamie Nelson, first-place winner of the Young Dentist Endodontic Award in the UK, demonstrates that no matter how bleak the outlook, there’s always a possibility for success Young Dentist Endodontic Award 2013 — UK The three winners of the Young Dentist Endodontic Award 2013 were announced at a reception at the Harley Street Centre for Endodontics in London, England on the evening of October 10, 2013. All of the winners showed exceptional commitment to saving teeth. Between them, they won £3,500 (equivalent to $5,825 US) worth of prizes, which were sponsored by Dentsply, QED, and SybronEndo. The three winning entries involved young patients for whom the loss of a tooth would have been extremely detrimental. In each case, the dentist kept the patient confident and compliant. Speaking at the event at the Harley Street Centre for Endodontics, Dr. Julian Webber, creator of the award, said, “All endodontists face challenges and possible failures, and what matters is that the judgment you make in the heat of the moment leads to the best result.”

Abstract This article is an account of a patient on whom I performed an endodontic treatment in general practice. It reports the examination findings, demonstrates the thought process behind the treatment planning, and describes the treatment as well as the results.

Case details Patient details: Name: CY Date of birth: 12/05/1989 (24 years old) Gender: female Medical history: asthma (never been hospitalized for it) Dental history: an irregular patient at a different practice Social history: smoker (10 a day) and light drinker (socially 4-5 units a week). Presenting complaint: CY attended the practice initially for a second opinion, as the patient had been informed that the tooth was unable to be saved and would require extraction. The patient was also getting pain from her LRQ; the pain itself was characterized as follows: Site: LRQ — posterior region Onset: worse when eating, but usually spontaneous Character: dull ache, sometimes feels like the tooth is throbbing The son of a dentist and a former Kings College student, Dr. Jamie Nelson works part-time in two practices. He trained at The Bromley Road Dental Surgery in Colchester, where he carried out the case which made him one of the winners of the award. He also works at a private practice in Basildon where his colleagues assign most endodontic cases to him.

16 Endodontic practice

Radiation: has on occasion radiated up to her ear Exacerbating/relieving factors: painkillers take the edge off the pain, but don’t eliminate it Severity: a constant 5/10, but can jump up to a 9/10 at times HPC: The patient initially had pain from the tooth 1 month ago, but the pain then subsided for a bit, to return much worse 1 week prior to the initial examination. Patient’s wishes and expectations: I always like to gauge what the patient wishes to gain from the experience and make a habit of sitting with them for 5 to 10 minutes, trying to gain the information required to help with any difficult decisions. This patient was very concerned about losing the tooth, since she had a minimally restored dentition — only 2 existing fillings on the LR6 and UL6. However, the patient, came in with the mindset that she would most likely require extraction with local anesthetic (XLA); therefore, anything we could do would be a bonus. Examination findings: Extraoral (EO) • right submandibular lymphadenopathy with mild tenderness Intraoral (IO) • soft tissues — tenderness to buccal palpation LR6 • hard tissues — LR6 TTP and grade 1 mobile — occlusal caries seen LL6, LL7, and LR6 • perio — BPE — 222, 422 (9 mm pocket mesial LR6), OH — poor, 50% plaque score

Special tests • vitality (sensibility) —– LR6 nonresponsive to Endo-Frost (-50ºC) • radiographs requested — RBW, LBW, PA LR6 • Justification for radiographs — caries detection and periapical pathology analysis of LR6 Radiographic report • Site: right and left, upper and lower, distal of 7’s to mesial of 4’s • Justification: caries detection • Exposure: 0.25 ms, 60 mA, 60 kV • Grade: 1 • Report - Caries — occlusal radiolucencies LR6, LL6, and LL7 - Path — furcation obliteration LR6 - Perio — good bone levels; no subgingival calculus

Figure 1: Right bitewing

Figure 2: Left bitewing Volume 7 Number 3

Treatment plan Figure 3: Long cone periapical radiograph (LCPA) LRQ

Radiographic report • Site: LR6 • Exposure: 0.2 ms, 6 mA, 60 kV • Grade: 1 • Report - Caries — occlusal radiolucency LR6 - Path — large PA area with furcation obliteration LR6 - Perio — good bone levels; no subgingival calculus; PDL space widening around mesial portion of the tooth

Acute phase: Extirpate the LR6, course of antibiotic — 500 mg amoxicillin TDS 5 days (due to systemic involvement of the lymph nodes). Stabilization phase: Treat the periodontal issues, avoiding root scale debridement (RSD) on the LR6, in case of a perio-endo origin, in which cell damage caused by the RSD can limit the regeneration potential for the endodontic treatment.2 OHI, diet advice, fluoride application, smoking cessation, and a fluoride toothpaste prescription (5,000 ppm). Restorative phase: Restore carious lesions in LL6 and LL7. Complete root treatment on LR6, due to degree of

tooth tissue remaining if a conservative access can be cut; restore with GIC and composite. Maintenance phase: Review RCT and perio at 3, 6, and 12 months. Recall phase: Caries risk — high; perio risk — high; oral cancer risk — medium; 3 monthly CE

Treatment completed First visit — LR6 extirpation A minimally invasive access was cut into the LR6 by preserving as much tooth tissue as possible. It greatly improves the chances of a long-term successful endodontic treatment. Ideally, all four sides of the tooth need to remain intact; this allows for better isolation and a stronger external tooth structure. Four canals were located and cleaned to the EWL at an ISO size 20 hand file with copious amounts of 2% sodium hypochlorite, and then dressed with Ledermix® and restored with GIC. A good access is key to locating canals quickly and by spending slightly longer to

Summary of the findings The patient attended with a grade 1 mobile LR6, which was TTP, had a 9-mm pocket mesially and was negative to sensibility testing. The LCPA radiograph of the LR6 showed a very large periapical radiolucency surrounding the root of the LR6, external root resorption around the mesial root, widening of the periodontal ligament (PDL) space mesially, and furcation obliteration. With all of this in mind, it leads us to a differential diagnosis of the following (as originally outlined by Simon, et al.1): • Purely endodontic lesion • Perio-endo lesion - primary perio - primary endo - true perio-endo • Radicular cyst With all the symptoms taken into account, I came to a provisional diagnosis of an acute flare-up of chronic periapical periodontitis in which sinus drainage had been established through the mesial pocket.

Prognosis Due to size of periapical (PA) area, mobility, 9-mm pocket, communication with oral cavity, and mesial external root resorption, the prognosis for this tooth is relatively poor, especially as mineral trioxide aggregate (MTA) was not available to me at the practice. All options were Volume 7 Number 3

Endodontic practice 17

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

discussed with the patient, and she wished for the RCT to be done here at the practice and completed by me, though I have a very keen interest in endodontics, but no specialist training. So a treatment plan was drawn up, and the patient was happy for treatment to begin.

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

Figure 4: Access cavity

Figure 5: Access cavity

Figure 6: Working length radiograph with size 15 hand files

Figure 7: Apical removal of GP

Figure 8: Composite restoration

Figure 9: Postoperative radiograph of the RCT on the LR6

Figure 10: 9-month post-op RCT LR6

make it as neat as possible. It can really help. (Photos of the access are shown in Figures 4 and 5.)

Hand files were then placed into each canal measured to the EWL, and a diagnostic radiograph was taken. When taking a diagnostic radiograph on multirooted teeth, I use a mesial swing on the tube head in order to ensure each file is in a separate canal. This is shown in the diagnostic radiograph (Figure 6). Once the diagnostic radiograph has been taken, the tooth is dressed with non-setting calcium hydroxide and again sealed with GIC. The radiograph then confirmed the working lengths for each canal as follows: • MB — 18 mm (OA)* • ML — 18 mm (OA) • DB — 21 mm • DL — 21 mm

Table 1: Patient’s review appointments — summary of improvements

Second visit — The patient reported she was out of pain after the extirpation was completed, which meant we could proceed to stabilize all other active disease. A supraand sub-gingival scale was completed on all teeth except LR6 (in case of perio-endo lesion2, smoking cessation given, amalgam restorations placed on LL6 and LL7 occlusally, and fluoride applied to all teeth. Third visit — RCT stage 1 LR6 The temporary restoration was removed and all four canals relocated using hand files. Once relocated, the access to each canal was improved using Gates Glidden burs, a size 2 to 1/3 estimated working length (EWL), size 4 mm to 3 mm short of that, and finally, a size 6 counter sunk into each canal by no more than half the depth of the bur around 3 mm. (Doing this procedure also makes creating Nayyar cores much easier, as once the bulk of the GP has been removed, the size 6 Gates Glidden bur can be counter-sunk once again, providing a space for the Nayyar core to be placed.) Each canal was then prepared to 2/3’s EWL using ProTaper rotary instruments sizes S1, S2, F1, and F2.3 18 Endodontic practice

* (OA) indicates open apex

Fourth visit — RCT stage 2 LR6 The obturation stage for this tooth brings its own challenges as there is no guarantee that a seal can be achieved with an open apex present, which is why, conventionally, MTA is used to close the open area and allow for an effective seal. This is what I would have done had MTA been available. Instead, I adopted a technique that had never been formally taught to me and prepared the mesial canals 1 mm past the radiographic apex in order to ensure effective cleaning at the open apex. All of the canals had been prepared to their

08/25/2012

06/06/2013

Plaque score 50%

12%

BPE

222, 422

101, 011

Caries risk

High

Low

Perio risk

High

Medium

LR6 Mobility

08/25/2012

06/06/2013

Grade 1

Mesial pocket 9 mm depth

1.5 mm

PA area

11 mm x 13 mm

Prognosis

Guarded

Very good

EWLs to size F2 ProTaper3 with thorough irrigation of 2% sodium hypochlorite. (The irrigant used is warmed to increase effectiveness,4 and after placement, a hand file is used to ensure the irrigant reaches the apex.) The total time the irrigant spends in the canals accumulatively is 10-plus minutes; this combined with the time of the procedure exceeds 40 minutes.5 Obturation A single point obturation technique was used with an 8% ISO 25 F2 ProTaper point — again a technique never taught to me. I placed the GP point beyond Volume 7 Number 3

The patient attended her 3-, 6-, and 9-month review appointments and has demonstrated a huge improvement as summarized in Table 1. Also during the 9-month review, the 9-month post-op endodontic radiograph was taken (Figure 10). The radiograph showed an almost complete resolution of the pathology and has demonstrated a successful endodontic treatment.

breakdown of the LR6 comparing the pre- and posttreatment results. Figure 11 shows both preoperative and 9-month postoperative radiographs. This case demonstrates that no matter how bleak the outlook, there’s always a possibility for success. I myself treat difficult cases with an attitude summed up very nicely by Henry Ford: “Obstacles are those frightful things you see when you take your eyes off your goal.” EP

Results Taking into account all of the information presented, Table 1 shows a clinical

References 1. Simon JH, Glick DH, Frank AL. The relationship of endodontic- periodontic lesions. J Periodontol.1972;43(4):202–208. 2. Singh P. Endo-Perio Dilemma: A Brief Review. Dent Res J (Isfahan). 2011; 8(1): 39–47. 3. Ruddle C. The ProTaper Technique: Shaping the Future of Endodontics. Endodontic Topics. www.endoruddle. com. Accessed May 16, 2014.

Figure 11: Radiographic state — preoperative (top) compared to 9-month postoperative (bottom)

the apex until an apical twist back/tug back could be achieved (resistance to rotational or vertical displacement of the point once in place). Once that was achieved, the point was marked at the coronal end. This leaves the point long, essentially overshooting beyond the apex, but giving an apical seal. This “overshoot” is then removed by once again measuring the GP and simply snipping off the excess from the apical end (Figure 7). The shortened GP has essentially a custom thickness at the apex now and fits snuggly into the canal, hopefully, achieving an apical seal. The canals were then lined with TubliSeal™ (SybronEndo) and the GP cemented into each canal. GIC was used to line the GP as this provides a dynamic bond with the tooth, reducing the risk of GP contamination.6 The restoration is shown in Figure 8. Once the restoration was complete, the postoperative radiograph was taken (Figure 9). The radiograph shows that the GP is to length, has a good taper and good density, and does not show any voids.

Volume 7 Number 3

4. Cunningham WT, Joseph SW. Effect of temperature on the bactericidal action of sodium hypochlorite endodontic irrigant. Oral Surg Oral Med Oral Pathol. 1980;50(6):569571. 5. Siqueira J, Rocas I, Favieri A, Lima K. Chemomechanical reduction of the bacterial population in the root canal after instrumentation and irrigation with 1 %, 2.5 %, and 5.25 % sodium hypoclorite. J Endod. 2000;26(6):331–4. 6. Diaz-Arnold AM, Wilcox LR. Restoration of endodontically treated anterior teeth: an evaluation of coronal microleakage of glass ionomer and composite resin materials. J Pros Dent. 1990; 64(6):643-646.

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Endodontic practice 19

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

Review stage

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

Non-surgical endodontic treatment of the maxillary right central incisor with incomplete root formation Dr. Rupal Shah, second-place winner of the Young Dentist Endodontic Award of the UK, examines the successful management of an anxious 10-year-old patient Introduction This report discusses the successful management of an anxious 10-year-old patient, who required root canal treatment of her immature upper right central incisor, following a previous history of trauma. She was initially referred to the pediatric department at Birmingham Dental Hospital by her general dental practitioner. Following assessment and diagnosis, she underwent root canal therapy of her upper right central incisor, which was deemed to be non-vital and had an open apex. Patient details 10-year-old female, school pupil

History Presenting complaint The patient’s chief complaint was her “fractured front teeth,” which she did not like the appearance of. History of presenting complaint History of presenting complaint revealed that she had suffered trauma in November 2011, when she had fallen in the school playground and knocked her front teeth on metal railings. Both upper central incisors had fractured, but there was no obvious displacement at the time of injury. No loss of consciousness or head injuries had been noted, but there was a laceration to the upper lip. She initially attended Heartlands Hospital in Birmingham, England, from which she was referred to Birmingham Children’s Hospital for a chest X-ray, as the tooth fragments had not been accounted for. The chest X-ray reported no abnormalities. The patient then saw her general

Figure 1.1: Preoperative periapical radiographs

practitioner one day after the injury and had adhesive composite restorations placed on the UR1 and UL1. However, these were subsequently lost after 6 weeks and were not replaced. Medical history The patient suffers from asthma, for which she uses Ventolin® and Becotide™ inhalers, as and when required. She has not had any previous hospitalizations due to her asthma.

Hard tissues Teeth present were: 6EDC21 12CDE6 6EDC21 12CDE6 Unrestored enamel-dentin fractures were evident on the UR1 and UL1, with the UL1 fracture being fairly extensive. Caries was noted on the LLD.

Dental history There is no history of any other previous trauma. Cooperation appeared to be reduced, as the patient had not had any previous extensive dental treatment and was therefore quite nervous.

Occlusion Occlusal analysis revealed a class 1 incisor relationship with class 2 right molars and class 1 left molars.

Examination Rupal Shah was on duty at Birmingham Dental Hospital’s pediatric department in April 2013. A foundation dentist (in her second year of training), she had to treat a 10-year-old patient who was returning to the hospital for endodontic treatment on her UR1.

20 Endodontic practice

Intraoral Soft tissues Oral hygiene was fair, but some gingival inflammation was present.

Extraoral Scarring was noted in the midline of the patient’s upper lip; she had sustained a laceration to this area at the time of injury.

Special investigations All maxillary incisors responded positively to ethyl chloride. The UR2, UL1, and UL2 responded positively to an electric pulp tester while the UR1 tested negative. None of the maxillary incisors were tender

Volume 7 Number 3

Radiographic examination Periapical radiographs Long cone periapical radiographs UR21, UL12 (Figure 1.1) revealed open apices on all maxillary incisors, and PDL widening around the apex of the UR1. It also showed the unrestored enamel-dentin fractures on both maxillary central incisors. Upper standard occlusal radiograph This radiograph confirmed PDL widening around the UR1, with associated periapical pathology. It also shows the open apices of all 4 upper incisors, as well as the presence of maxillary canines.

Figure 1.2: Upper standard occlusal radiograph

Figure 1.3: Soft tissue radiograph of upper lip

Soft tissue X-ray The soft tissue radiograph of the upper lip revealed no abnormalities and no evidence of any tooth fragments in the lip (Figure 1.3). Diagnoses 1. Enamel-dentin crown fractures UR1 and UL1 2. Likely non-vital UR1; chronic apical periodontitis secondary to trauma 3. Caries LLD 4. Anxious patient Treatment options 1. Test cavity UR1, and proceed to nonsurgical root canal therapy with MTA apical plug if non-vital +/- RA sedation (Birmingham Dental Hospital). The patient was quite nervous, so the use of RA sedation was discussed; a RA sedation information sheet was given to the patient. 2. Extraction of the UR1 with or without prosthetic replacement (GDP). Treatment plan 1. Immediate: cover exposed dentin UR1 and UL1 with glass ionomer cement (GIC) (Birmingham Dental Hospital) 2. OHI, dietary analysis and advice, bitewing radiographs (GDP) 3. Scale and polish, restore caries LLD, fissure seal 1st permanent molars (GDP) 4. Test cavity UR1 and proceed to root canal treatment if non-vital +/- RA sedation. Dress with non-setting calcium hydroxide until stable. (Birmingham Dental Hospital) 5. Adhesive composite restorations UR1 Volume 7 Number 3

Figure 1.4: Diagnostic radiograph to determine working length; 21 mm

and UL1 +/- RA sedation (Birmingham Dental Hospital) 6. Review (Birmingham Dental Hospital) Treatment protocol Appropriate verbal and written consent was obtained prior to commencing treatment. As a test cavity was carried out on the UR1, no local anesthetic was required. Isolation was achieved with dry dam, wedgets, and OraSeal速 (Ultradent) caulking material. The tooth, as expected, was found to be nonvital, and extirpated and dressed with nonsetting calcium hydroxide as an intracanal medicament. A temporary dressing of a cotton wool pledget, and GIC was placed in the access cavity. This initial management was carried out under RA sedation. At two subsequent visits, the GIC fillings on the UR1 and UL1 were removed

Figure 1.5: Master cone periapical radiograph plus

and replaced with adhesive composite restorations, and the UR1 root canal was further prepared. The root canal length was determined radiographically (Figure 1.4), and the working length was measured as 21 mm. Chemo-mechanical cleaning of the canal was carried out using K-flex handfiles, interdental brushes, and 2.5% sodium hypochlorite irrigation. The final apical size of the canal was 80, due to the immature apex and lack of apical barrier. An apical stepback technique was used to prepare the wide canal. The canal was again dressed with non-setting calcium hydroxide, a cotton wool pledget, and GIC in the access cavity. After this visit, the patient felt less anxious and opted to have future treatment without RA sedation. At the next visit, the patient mentioned Endodontic practice 21

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

to percussion, and no labial sinus or tenderness, discoloration, or mobility was noted.

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

Figure 1.6: 4 mm MTA apical

the tooth had been symptomatic. Therefore, it was decided to re-access and re-irrigate with 2.5% sodium hypochlorite solution. The tooth was again temporarily dressed with calcium hydroxide, a cotton wool pledget, and GIC. At the following appointment, the patient was asymptomatic. The canal was re-irrigated with sodium hypochlorite and dried with paper points. A master cone periapical radiograph was taken (Figure 1.5) to confirm the length, and a 4 mm apical plug of mineral trioxide aggregate was placed using the Micro Apical Placement System (Figure 1.6). The remaining canal space was obturated with thermoplasticized GP (Obtura) and sealer using warm vertical compaction. A Vitrebond™ (3M™ ESPE™) lining was placed over the GP, and the access cavity was restored with composite resin to create an effective coronal seal (Figure 1.7).

Review The patient recently attended for a 6-month review, which reported no symptoms associated with the UR1. With regards to the UL1, there was a query whether there was some periodontal ligament widening; however, the sensibility tests were inconclusive, and the tooth was asymptomatic. It was therefore decided to continue to monitor the UL1 for now, and review the patient again in a further 6 months. 22 Endodontic practice

Figure 1.7: Postoperative radiograph

Discussion The patient’s traumatic incident had resulted in pulpal necrosis of the UR1 and, consequently, an incomplete formation of the root. Effective cleaning of the canal walls was achieved with large K-flex handfiles, inter-dental brushes, and sodium hypochlorite irrigation. The MTA technique allowed for successful obturation of the maxillary central incisor with an open apex. I successfully completed this treatment in an anxious 10-year-old girl, who had not had any previous extensive dental treatment. I overcame this by using different behavior management techniques, including tell-show-do, and ensuring that all appointments were not of too long a duration. This meant compliance was not lost. In fact, the patient initially began treatment under RA sedation due to her anxiety, but at subsequent visits, decided she no longer wanted it, and appeared to cope well without it. Finally, I decided to submit this case, because I feel that I obtained an excellent final outcome, both clinically and radiographically. The tooth was symptom free at the 6-month review appointment at Birmingham Dental Hospital. The 4 mm MTA apical plug was to the correct length, and radiographically, there were no voids in the thermoplastic GP. The access cavity was sealed with a Vitrebond lining, followed by adhesive composite restoration, ensuring a good coronal seal.

The endodontic prognosis for this tooth is good; however, the patient is fully aware of the long-term consequences of trauma, and the subsequent need for regular dental monitoring and sensibility testing of the traumatized upper incisor teeth. EP

References 1. Byström A, Sundqvist G. Bacteriologic evaluation of the efficiency of mechanical root canal instrumentation in endodontic therapy. Scand J Dent Res. 1981;89:321-328. 2. Kawashima N, et al. Root canal medicaments. International Dental Journal. 2009;59(1):5-11. 3. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review—Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413. 4. Ng YL, Mann V, Gulabivala K. Tooth survival following non-surgical root canal treatment: a systematic review of the literature. Int Endod J. 2010;43:171–189. 5. Pitt Ford TR. Harty’s Endodontics in Clinical Practice. 5th ed. London: Elsevier Limited; 2004. 6. Williams JV, Williams LR. Is coronal restoration more important than root filling for ultimate endodontic success? Dent Update. 2010;37(3):187193. 7. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod. 2008;34(10):1171-1176. 8. Zehnder M. Root canal irrigants. J Endod. 2006;32(5):389-398.

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Perforation repaired

1 year post-op healing of perforation repair

Images are courtesy of Dr. Robert Levin, DDS of Huntington Beach, California “Response of Human Dental Pulp Capped with Biodentine and Mineral Trioxide Aggregate.” Journal of Endodontics. Elsevier, 15 Apr. 2013. Web. “In Vitro Microleakage of Biodentine as a Dentin Substitute Compared to Fuji II LC InCervical Lining Restorations.” National Center for Biotechnology Information. U.S. National Library of Medicine, Dec. 2012. Mesut Enes Odabaş, Mehmet Bani, and Resmiye Ebru Tirali, “Shear Bond Strengths of Different Adhesive Systems to Biodentine,” The Scientiﬁc World Journal, vol. 2013, Article ID 626103, 5 pages, 2013. doi:10.1155/2013/626103 Human tooth culture: a study model for reparative dentinogenesis and direct pulp capping materials biocompatibility. Odile Téclès, Patrick Laurent, Virginie Aubut, Imad About, J Biomed Mater Res B Appl Biomater. 2008 April; 85(1): 180–187. doi: 10.1002/jbm.b.30933 Chmilewsky, F., C. Jeanneau, P. Laurent, M. Kirschﬁnk, and I. About. “Pulp Progenitor Cell Recruitment Is Selectively Guided by a C5a Gradient.” Journal of Dental Research 92.6 (2013): 532-39. Print.

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CASE STUDY

Management of a tooth with a large radiolucency Dr. Nishan Odabashian discusses treatment of teeth with failing previous root canal treatment exhibiting large radiographic lucencies Introduction A healthy 53-year-old male presented to our office on May 9, 2011, after being referred by a friend who was treated at our office. He was advised that he needed to have tooth No. 19 removed, and the extraction site grafted with bone and soft tissue. After 4 months, he needed to have the area evaluated for implant placement. Otherwise, his options were to place a 4-unit fixed partial denture (FPD), or a removable partial denture (RPD). The implant route was cost-prohibitive for him, and he was desperately seeking someone who would try to save his tooth.

Pre-op 5/9/11

Pre-op bitewing

Pre-op clinical

Access

Clinical and Radiographic Examination Clinical findings: The patient had a 3-unit FPD on the left mandibular molar area extending from the second premolar, mesially, to the second molar (18-20) distally. A slight swelling was present, buccal to tooth No. 18, and the probing depths were surprisingly within normal limits, even when probed under anesthesia. Patient reported pain on chewing, percussion, and palpation. Radiographic findings: Periapical and bitewing radiographs were taken. (Today, a CBCT scan would also be taken as part of the radiographic examination.) The preoperative PA radiograph showed a 3-unit prcelain fused to metal (PFM) FPD extending from tooth No.18 to tooth No. 20. Tooth No. 18 had previously treated root canals with a cast metal post extending into the distal root, while tooth No. 20 did not have previous endodontic treatment. A large (~15 mm in diameter, see PA radiograph) PA lucency was present on the mesial root of tooth No. 18, extending midway to tooth No. 20, extending from

Nishan Odabashian, DMD, graduated from Tufts University School of Dental Medicine in 1991. After 8 years of practicing general restorative dentistry, he received a certificate of specialty and a Master’s Degree in Endodontics from Loma Linda University School of Dentistry (LLUSD) where he is a part time Assistant Professor of Endodontics. He practiced in Las Vegas, Nevada, and Bakersfield, California, and in 2008, he returned to Glendale, California, and established Glendale MicroEndodontics (GME).

24 Endodontic practice

the osseous crest to the level of the root apex of tooth No. 18.

Medical history Non-contributory. Patient was prescribed amoxicillin 500 mg TID for 2 days by his general dentist.

Diagnosis • Pulpal: Previously treated pulp • Periapical: Symptomatic periapical abscess

Differential diagnosis • Lesion of endodontic origin • PA cyst • Lateral periodontal cyst • Odontogenic keratocyst

Immediate treatment plan • Incision and drainage (I and D) • Initiate retreatment, and based on results, send for biopsy or continue with endodontic retreatment.

Treatment Treatment was initiated with an I and D of the buccal swelling. The patient’s antibiotic regimen was changed to clindamycin 300 mg, sig 1 tab TID for 5 days. Retreatment followed by accessing the distal abutment of the 3-unit FPD. The cast post and

Mesial part of cast post removed

existing gutta percha were removed. The canals were cleaned, shaped, and dressed with calcium hydroxide for a total period of 7 months. In the interim, there were three calcium hydroxide changes after the internal aspect of the tooth was cleaned — first at 1 month, second at 3 months, and then at 5 months. The internal aspect of the crown was cleaned, and restored using Encore® paste (see photo). At the end of the endodontic treatment, the 3-unit FPD was removed, and a temporary bridge was made using the original impression taken at the first appointment. The patient was referred back to the referring doctor with a temporary bridge and the lucency considerably reduced. Recall radiographs were taken at 3 months, 6 months, 1 year, 2 years, and very recently 3 years from the initiation of treatment. We will continue to recall patient every year for an indefinite period of time. Volume 7 Number 3

CASE STUDY

Mesial canals

CH in mesial canals

CaOH 5/9/11

Healing of buccal I and D

Chamber decay removed

Distal part of cast post removed

GP spacers in canals

Composite injection into chamber

GP spacers removed

CaOH 11/7/11

Final canal C and S

GP obturation

Core buildup

Removal of existing bridge

Existing bridge removed

Volume 7 Number 3

Endodontic practice 25

CASE STUDY

Prep under SOM

Preparation

Temp bridge

Post-op 1/2/12

3-month recall

1-year recall

2-year recall

2-year recall bitewing

3-year recall post treatment initiation

Discussion

isolation. This will eliminate one of the links that may lead to failure of the treatment. Another way that the endodontist can control a possible problem with his/her treatment is paying close attention to the occlusion of the patient during the recall appointment after placement of the final restoration. As a case in point, at the 3-month recall appointment, this patient returned with a 3-unit FPD placed. Upon radiographic examination, a widened PDL space was noted on the mesial aspect of tooth No. 18. This was not present at the postoperative radiograph. An occlusal evaluation revealed a working side interference in lateral excursive movement. The interference was adjusted, and the patient showed a normal PDL space at the next recall appointment. Obviously, treatments such as these require much more time than a single appointment that is needed for a vital molar tooth. However, the satisfaction of saving such teeth and seeing what is possible with meticulous coordinated

dental treatment is immeasurable. A tooth such as this in no way can satisfactorily financially compensate us for the time that is expended on it. However, not everything is measured by money! As the MasterCard® commercial says, these are “priceless.”

Management of teeth with previous root canal treatment that is failing requires more than just performing endodontic retreatment or surgery. The treating clinician must evaluate the cause of failure. These causes can range from being endodontic, restorative, periodontic, occlusion, patient’s habit (i.e. tongue ring), trauma, etc. Often, teeth with prior root canal treatment that present with large radiolucencies require a commitment from the patient and the treating doctor. Without this understanding and firm commitment to see the treatment through, it is not possible to see outcomes such as the one presented here. The endodontist has a responsibility of not only performing the endodontic retreatment, but to also make sure that the restorative treatment will be appropriate in order to ensure a long-term success. One of the ways that the endodontist can control a more positive outcome of his treatment is to place the core buildup after completing the endodontic treatment, under rubber dam 26 Endodontic practice

Summary I thought this case study would serve a few purposes: • To show that teeth with large radiolucencies can be treated/retreated endodontically • To demonstrate that large amount of bone can be regenerated without any bone grafts • That it takes a committed patient and clinician to see cases such as this through to successful treatment • That teeth that would otherwise be extracted can be saved • To expand our hypothesis space when treatment planning a failing root canal treated tooth. EP

Volume 7 Number 3

CONTINUING EDUCATION

Conservative treatment of apical external resorption Drs. Sebastiana Arroyo Boté and Javier Martínez Osorio present a case report detailing conservative treatment of apical external resorption in a high-risk patient

oot resorption is a pulp-periapical disease. It can have different causes and be the result of cell activity in various tissues, for example, either from the inside of the pulp (internal resorption) (Fuss, et al., 2003) or from outside the tooth (external resorption) due to the activity of osteoclastic cells. Resorption can be either temporary in nature — this is then a self-limiting process that can barely be detected in X-rays (Nair, Nair, 2007) — or progressive, which often results in the loss of the tooth (Trope, 2002). External resorption can be due to a variety of clinical problems (Pohl, et al., 2005; Tredwin, et al., 2006; Mohandesan, et al., 2007; Patel, Dawood, 2007): jaw tumors and cysts; poor control of orthodontic forces; dental traumatology (Malikaew, et al., 2006); periodontal diseases; pulp diseases; cracks in the tooth; systemic diseases (Kravitz, et al., 1992); and, occasionally, diseases that are idiopathic in origin (Kleoniki, 2002). These are mostly linked to the accretion of bone tissue that replaces the resorbed root (Fuss, et al., 2003). In other cases, external cervical resorption may be initiated (Gulsahi, et al., 2007). In the former case, these are not normally associated with symptoms and are in very different destructive states at the time of diagnosis (Kamburoglu, et al., 2008a; Kamburoglu, et al., 2008b). It is sometimes not possible to preserve the tooth. However, occasionally, the process can be stopped, and the tooth can be restored. In this case, a personal biological disposition for the development of root resorption was proven (Abuabara, 2008), assumedly due to a genetic predisposition. Based on studies involving twins,

Dr. Sebastiana Arroyo Boté is associate professor in the Dentistry Faculty of the University of Barcelona, Spain. He is in private practice in Barcelona. Dr. Javier Martínez Osorio is associate professor in the Dentistry Faculty of the University of Barcelona, Spain. He is in private practice in Barcelona, specializing in oral surgery and implantology.

28 Endodontic practice

Educational aims and objectives The aim of this article is to discuss the conservative treatment of external root resorption in a high-risk situation. Expected outcomes Endodontic Practice US subscribers can answer the CE questions on page 31 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Discuss some causes of external root resorption. • Identify some methods for detection. • Explain possible clinical treatment for this condition.

Figure 1: OPG for assessment

Figure 2: Diagnostic X-ray

Harris, et al., 1997, concluded heredity of approximately 70% and did not identify any gender- or age-related differences. Moreover, preventive treatments involving hormones, antibiotics, and antiinflammatory drugs (Shirazi, et al., 1999; Ong, et al., 2000) were administered to sensitive patients undergoing orthodontic procedures; these resulted in extremely promising results in terms of the prevention of this pathology.

or periapical lesions, as well as a root canal treatment on the LL6 with minor radiological findings on the mesial root and apical resorption of the distal root with bone apposition in its place. Based on the X-ray of root resorption on the LL6, a clinical interview was conducted. The patient reported that root treatment had been performed on this tooth more than 20 years ago. The tooth subsequently became increasingly cracked without resulting in pain or inflammation. In light of this clinical situation (given the patient’s medical condition, restoration with tooth implants was not recommended) and its significance (after all, we were dealing with the last molar in the third quadrant), we decided to opt for another endodontic intervention, a dental reconstruction with a glass fiber post and a prosthetic cover. The periapical X-ray showed overfilling of the mesial canals and severe damage to the distal root (Figure 2). Neither cement nor gutta-percha residue was detected outside of the canals. The clinical picture showed the destroyed crown with the exposed root canals up to the oral cavity (Figures 3 and 4). The repeat intervention was performed in one treatment session using a combination of a manual technique

Clinical case A 70-year-old male patient presented for a general dental examination and requested restoration of the third quadrant. This was a high-risk patient who was undergoing treatment for an adenocarcinoma in the colon. During the exam, various restorations; full crowns in the first, second, and fourth quadrants; and severe damage to the LL6 were detected. There were no active caries lesions, nor was there increased tooth mobility, or any injury to the mucous membranes. An orthopantomography was performed to get a better understanding of this case (Figure 1). This showed earlier prosthetic treatments and no current disease, root treatments on the UR3 and UR6 without radiolucent root lesions

Volume 7 Number 3

symptoms, in a second treatment session, the coronal reconstruction was completed. The Rebilda® Post System (Voco) was chosen for the core buildup, and a glass fiber post with a coronal diameter of 1.2 mm was placed in the mesial root (Figure 7). After cleaning the cavity and isolation (Figure 8), the restorative material in the mesiolingual canal was removed in order

layer by layer and light-cured each time. Polymerization in hard-to-reach areas was ensured via the chemical curing of Rebilda DC. The matrix was removed (Figure 12), and the buildup was light-cured again. The isolation was then removed, and the core was shortened and polished (Figure 13). Using a periapical X-ray, the correct fit of the post and reconstruction margins were checked (Figure 14).

Figure 3: Occlusal view of LL6

Figure 4: Vestibular view of LL6

Figure 5: Direct X-ray control

Figure 6: Temporary filling of LL6

Figure 7: Drills used for placing the post

Figure 8: Cleaning of the cavity and isolation of LL6

Figure 9: Canal preparation

Figure 10: Checking of the fit of the post

Figure 11: Shortening and cementing of the glass fiber post

instrumentation was performed from the crown downwards using the files of conicity 06 and 04 and ISO 40, 35, 30, and 25. This was repeated until the correct working length was reached. In the mesial canals, a master file ISO 30 was used, and in the distal canals, an ISO 40 file was used. The canals were continuously rinsed with 2.5% sodium hypochlorite. After the final rinse, the canals were dried and filled with AH Plus® sealer (Dentsply), guttapercha tips, and lateral condensation (Figure 5). The crown was filled with temporary cement until final reconstruction (Figure 6). Given the absence of clinical

to insert the post (Figure 9). The fit of the post in the intraradicular preparation (Figure 10) was checked, a circular AutoMatrix® (Dentsply) was attached, and the post was shortened to the correct height and cemented (Figure 11). Prior to the cementing of the post, this was wetted with Ceramic Bond (Voco) in order to ensure better adhesion. Rebilda® DC dentin (Voco), in combination with the dual-curing selfetch adhesive Futurabond® DC single dose (Voco), was used as the post fixation and core build-up material. To build up the core, Rebilda DC dentin was applied

In a further clinical session, the core was prepared (Figure 15), and the impression was made using the silicone Fit Test C & B (Voco) to produce a full crown, which was subsequently placed and then cemented using Bifix SE (Voco), a dual-curing, self-adhesive, compositebased luting system. This resulted in the complete restoration of the functionality of the LL6 (Figure 16). The patient suffered no symptoms after the treatment. X-rays were taken at 3 months (Figure 17) and at 1 year (Figure 18) after completion of treatment, and showed no signs of periradicular inflammation.

Volume 7 Number 3

Endodontic practice 29

CONTINUING EDUCATION

and rotation technique with K3 files (SybronEndo). The motor TCM Endo III (Nouvag AG) was used with a rotating speed of 300 rpm and a torque of 30 Ncm. The clinical treatment was initiated with the removal of the restorative material from the canals using Gates-Glidden drills and by determining the working length with K-files (No. 20); 2.5% sodium hypochlorite (NaOCl) was used for rinsing. Mechanical

CONTINUING EDUCATION

Figure 15: Vestibular view of the prepared tooth stump

Figure 14: Periapical X-ray

Figure 13: Removal of the isolation

Figure 12: Filling of the cavity

Figure 16: View of the fit of the crown

Discussion Early detection is the best treatment measure (Patel, et al., 2009). For this, intraoral dental X-rays with various projections and scanners can be used. The latter delivers better diagnosis data (Kamburoglu, et al., 2010; Kamburoglu, et al., 2011; Liedke, et al., 2009), particularly in the initial phase. In order to avoid apical root resorption caused by orthodontic treatments, some authors suggest carrying out X-ray exams every 3 or 6 months after the start of treatment. Anti-inflammatory drugs could also reduce resorption (Abuabara, 2008). In this clinical case, resorption was very far advanced. The diagnosis was

References Abuabara A. Aspectos biomecánicos de la reabsorción radicular externa en terapia ortodóncica. Odontología Clínica. 2008;1:2125. Fuss Z, Tsesis I, Lin S. Root resorption-- diagnosis, classification and treatment choices based on stimulation factors. Dent Traumatol. 2003;19(4):175-182.

Figure 17: X-ray at 3 months

made by means of an X-ray. A variety of materials and techniques are available (Hommez, et al., 2006) in cases in which the resorption process can be stopped and the necrotic tissue removed. Endodontic interventions are sometimes necessary (Smidt, et al., 2007), which result in clinical success in a considerable number of cases. When choosing the treatment method, it is important to make an assessment of the periodontal state of (and reconstruction options for) the tooth (Schwartz, et al., 2010). In this case, we opted for restorative treatment in light of the patient’s overall condition. The chosen treatment was indicated as the problem here was apical external resorption with

Figure 18: X-ray at 1 year

bone tissue apposition, and consequently, increased tooth mobility was not evident. Furthermore, sufficient supragingival hard dental tissue was available, guaranteeing a suitable basis for a prosthetic restoration.

Conclusion In many cases, root resorption is diagnosed by means of X-rays or on the basis of symptoms of an extremely advanced pathological nature, which results in the loss of the tooth. Given this pathology, which is due to a great variety of reasons, it is expedient to firstly consider the options available for stopping this process and restoring the tooth. EP

Kamburoğlu K, Kurşun S, Yüksel S, Oztaş B. Observer ability to detect ex vivo simulated internal or external cervical root resorption. J Endod. 2011;37(2):168-175.

Ong CK, Walsh LJ, Harbrow D, Taverne AA, Symons AL. Orthodontic tooth movement in the prednisolone-treated rat. Angle Orthod. 2000;70(2):118-125.

Kamburoğlu K, Tsesis I, Kfir A, Kaffe I. Diagnosis of artificially induced external root resorption using conventional intraoral film radiography, CCD, and PSP: an ex vivo study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(6):885-891.

Patel S, Dawood A. The use of cone beam computed tomography in the management of external cervical resorption lesions. Int Endod J. 2007;40(9):730-737. Patel S, Kanagasingam S, Pitt Ford T. External cervical resorption: a review. J Endod. 2009;35(5):616-625.

Gulsahi A, Gulsahi K, Ungor M. Invasive cervical resorption: clinical and radiological diagnosis and treatment of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(3):e6572.

Lyroudia KM, Dourou VI, Pantelidou OC, Labrianidis T, Pitas IK. Internal root resorption studied by radiography, stereomicroscope, scanning electron microscope and computerized 3D reconstructive method. Dent Traumatol. 2002;18(3):148-152.

Harris EF, Kineret SE, Tolley EA. A heritable component for external apical root resorption in patients treated orthodontically. Am J Orthod Dentofacial Orthop. 1997;11:301-309.

Kravitz LH, Tyndall DA, Bagnell CP, Dove SB. Assessment of external root resorption using digital subtraction radiography. J Endod. 1992;18(6):275-284.

Schwartz RS, Robbins JW, Rindler E. Management of invasive cervical resorption: observations from three private practices and a report of three cases. J Endod. 2010;36:1721-1730.

Hommez GMG, Browaeys HAA, De Moor RJ. Surgical root restoration after external inflammatory root resorption: A case report. J Endod. 2006;32(8):798-801.

Liedke GS, da Silveira HE, da Silveira HL, Dutra V, de Figueiredo JA. Influence of voxel size in the diagnostic ability of cone beam tomography to evaluate simulated external root resorption. J Endod. 2009;35(2):233-235.

Shirazi M, Dehpour AR, Jafari F.The effect of thyroid hormone on orthodontic tooth movement in rats. J Clin Pediatr Dent. 1999;23(3):259-264.

Kamburoğlu K, Murat S, Yüksel SP, Cebeci AR, Horasan S. Detection of vertical root fracture using cone-beam computerized tomography: an in vitro assessment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(2):e74-81. Kamburoğlu K, Barenboim SF, Kaffe I. Comparison of conventional film with different digital and digitally filtered images in the detection of simulated internal resorption cavities-- an ex vivo study in human cadaver jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(6):790-797.

30 Endodontic practice

Malikaew P, Watt RG, Sheiham A. Prevalence and factors associated with traumatic dental injuries (TDI) to anterior teeth of 11-13 year old Thai children. Community Dent Health. 2006;23(4):222-227. Mohandesan H, Ravanmehr H, Valaei N. A radiographic analysis of external apical root resorption of maxillary incisors during active orthodontic treatment. Eur J Orthod. 2007;29(2):134-139.

Pohl Y, Filippi A, Kirschner H. Results after replantation of avulsed permanent teeth. I. Endodontic considerations. Dent Traumatol. 2005;21(2):80-92.

Smidt A, Nuni E, Keinan D. Invasive cervical root resorption: treatment rationale with an interdisciplinary approach. J Endod. 2007;33(11):1383-1387. Tredwin CJ, Naik S, Lewis NJ, Scully C. Hydrogen peroxide tooth-whitening (bleaching) products: review of adverse effects and safety issues. Br Dent J. 2006;200(7):371-376. Trope M. Root resorption due to dental trauma. Endod Topics. 2002;1(1):79-100.

Nair MK, Nair UP. Digital and advanced imaging in endodontics: a review. J Endod. 2007;33(1):1-6.

Volume 7 Number 3

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Conservative treatment of apical external resorption 1. It (root resorption) can have different causes and be the result of cell activity in various tissues, for example, either from the inside of the pulp (internal resorption) or from outside the tooth (external resorption) due to the activity of ______. a. osteoblasts b. osteoclastic cells c. osteocytes d. lining cells 2. In this case, a personal biological disposition for the development of root resorption was proven assumedly due to a genetic predisposition. Based on studies involving twins, Harris, et al., 1997, concluded heredity of approximately ____ and did not identify any gender- or age-related differences. a. 50% b. 60% c. 70% d. 80% 3. Moreover, preventive treatments involving ______ were administered to sensitive patients undergoing orthodontic procedures; these resulted in extremely promising results in terms of the prevention of this pathology. a. hormones b. antibiotics c. anti-inflammatory drugs d. all of the above

Volume 7 Number 3

4. ____ is the best treatment measure. a. Early detection b. Extraction c. Restoration with implants d. Canal rinsing with saline 5. For this (early detection), ______ can be used. a. digital photographs b. intraoral dental X-rays with various projections and scanners c. palpation d. light curing the buildup 6. In order to avoid apical root resorption caused by orthodontic treatments, some authors suggest carrying out X-ray exams every _____ after the start of treatment. a. 1 or 2 months b. 3 or 6 months c. 7 or 8 months d. 9 or 10 months 7. ______ could also reduce resorption. a. 5% sodium hypochlorite b. Rebilda速 DC c. Anti-inflammatory drugs d. A prosthetic cover

8. When choosing the treatment method, it is important to make an assessment of _____ the tooth. a. the periodontal state of b. the reconstruction options for c. the age of d. both a and b 9. The chosen treatment indicated as the problem here was apical external resorption with bone tissue apposition, and consequently, increased tooth mobility _____. a. was very evident b. was not evident c. was somewhat evident d. was felt upon palpation 10. Furthermore, sufficient supragingival hard dental tissue was available, _____ a prosthetic restoration. a. negating all possibility for b. guaranteeing a suitable basis for c. indicating a need to delay d. indicating the need for surgical intervention before

Endodontic practice 31

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Antimicrobial effect of super-oxidized water and sodium hypochlorite against Enterococcus faecalis Drs. Giampiero Rossi-Fedele, José Antonio Poli de Figueiredo, Liviu Steier, Luigi Canullo, Gabriela Steier, and Adam P. Roberts compare the antimicrobial action of several substances to be used as irrigating solutions Abstract Ideally, root canal irrigants should have, among other properties, antimicrobial action associated with a lack of toxicity against periapical tissues. Sodium hypochlorite (NaOCl) is a widely used root canal irrigant; however, it has been shown to have a cytotoxic effect on vital tissue, and therefore, it is prudent to investigate alternative irrigants. Sterilox’s Aquatine Alpha Electrolyte® belongs to the group of the super-oxidized waters; it consists of a mixture of oxidizing substances and has been suggested to be used as root canal irrigant. Super-oxidized waters have been shown to provide efficient cleaning of root canal walls and have been proposed to be used for the disinfection of medical equipment. Objective: To compare the antimicrobial action against Enterococcus faecalis of NaOCl, Optident Sterilox Electrolyte Solution® and Sterilox’s Aquatine Alpha Electrolyte® when used as irrigating solutions in a bovine root canal model. Methodology: Root sections were prepared and inoculated with E. faecalis JH2-2. After 10 days of incubation, the root canals were irrigated using one of three solutions (NaOCl, Optident Sterilox

Giampiero Rossi-Fedele,DDS, MClinDent, is from the Department of Microbial Diseases, UCL Eastman Dental Institute, London, United Kingdom. José Antonio Poli de Figueiredo, DDS, MSc, PhD, is from the Pontifical Catholic University of Rio Grande do Sul - PUCRS, Porto Alegre, RS, Brazil. Liviu Steier, is Honorary Clinical Associate Professor, Warwick Medical School, University of Warwick, United Kingdom. Luigi Canullo, DDS, is in Private Practice in Rome, Italy. Gabriela Steier, BA, is in Private Practice in Mayen, Germany. Adam P. Roberts, BSc (Hons), PhD, is from the Department of Microbial Diseases, UCL Eastman Dental Institute, London, United Kingdom.

32 Endodontic practice

Educational aims and objectives The aim of this article is to explore the antimicrobial action of several solutions for use as irrigating solutions. Expected outcomes Endodontic Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some properties of endodontic irrigants. • Recognize some of the positive effects of various irrigants. • Realize some of the negative effects of the various irrigants. • Compare the antimicrobial action against Enterococcus faecalis of NaOCl, Optident Sterilox Electrolyte Solution (Optident Dental), and Sterilox’s Aquatine Alpha Electrolyte.

Electrolyte Solution, and Sterilox’s Aquatine Alpha Electrolyte) and subsequently sampled by grinding dentin using drills. The debris was placed in BHI broth, and dilutions were plated onto fresh agar plates to quantify growth. Results: Sodium hypochlorite was the only irrigant to eliminate all bacteria. When the dilutions were made, although NaOCl was still statistically superior, Sterilox’s Aquatine Alpha Electrolyte solution was superior to Optident Sterilox Electrolyte Solution. Conclusions: Under the conditions of this study, Sterilox’s Aquatine Alpha Electrolyte appeared to have significantly more antimicrobial action compared to the Optident Sterilox Electrolyte Solution alone; however, NaOCl was the only solution able to consistently eradicate E. faecalis in the model.

Introduction Endodontic irrigants should have, among other properties, a broad antimicrobial spectrum of activity against anaerobic and facultative microorganisms growing in biofilms and a relative absence of toxicity against periapical tissues and oral mucosa.25 Sodium hypochlorite (NaOCl) is recommended as the main root canal irrigant because of its broad antimicrobial activity, the capacity to prevent formation of and to dissolve the smear layer, in association with chelating agents, and

its ability to dissolve tissue remnants.25 However, NaOCl has been shown to have a cytotoxic effect on vital tissue and can therefore elicit inflammatory reactions if it reaches the periapex.13 Furthermore, NaOCl has been shown to cause a change in the force required to fracture dentin,24 and a reduction of the elastic modulus and flexural strength of dentin.5,21 Furthermore NaOCl corrodes ProTaper NiTi Rotary1 (Dentsply/Maillefer, Baillagues, Switzerland) and carbon steel instruments,3 cause early fractures of ProTaper (Dentsply/Maillefer) instruments1 and, when heated, reduce resistance to cyclic fatigue of nickeltitanium files.16 Sterilox’s Aquatine Alpha Electrolyte® (Optident Dental, Ilkley, West Yorkshire, UK) is a super-oxidized water that consists of a mixture of oxidizing substances, including hypochlorous acid (HOCl) at a concentration of 144 mg/L, with a pH of 5.0-6.5 and a redox potential of > 950 mV20. The manufacturer suggests that the production of HOCl in the Sterilox Dental System (Optident Dental) does not produce free radical Cl and that the available free chlorine in the solution is 200 PPM; that is larger than the concentration reported in literature. Super-oxidized water has been suggested as an alternative to NaOCl, as it provides efficient cleaning of root canal walls,22 and has been recommended for the disinfection of endoscopes,19 dental Volume 7 Number 3

CONTINUING EDUCATION Table 1: Colony-forming units (CFUs) in serial dilution plates. Each group contained five roots, and serial dilutions and plating were carried out in duplicate. While NaOCl (Group 2) was the only irrigant to eradicate the E. faecalis, a significant difference was seen between the Optident Sterilox Electrolyte Solution® (Group 1) and the Sterilox’s Aquatine Alpha Electrolyte® irrigation (Group 3)

unit water lines,10 and dental impression materials.11 The aim of this study was to compare the antimicrobial action against Enterococcus faecalis of NaOCl, Optident Sterilox Electrolyte Solution (Optident Dental) and Sterilox’s Aquatine Alpha Electrolyte when used as irrigating solutions in an E. faecalis infected bovine root canal model.

Material and methods Bovine incisors were used throughout this study. The study exerted no influence on the animal’s fate at any stage as they were previously slaughtered in an Italian slaughterhouse for commercial purposes. The apical 5 mm and the crown of each incisor were dissected, and the remaining root was cut into 1 cm slices with a diamond disc (Abrasive Technology Inc, Westerville, Ohio, United States). Subsequently the canal lumen was widened to a minimal diameter of 1.4 mm using the ParaPost® XP™ Endodontic post system drills (Coltene/Whaledent, Konstanz, Germany). Finally, the smear layer was removed via copious irrigation in an EDTA solution (SmearClear®, SybronEndo, Scafati, Italy) (4 min) and NaOCl (Teepol Bleach, Teepol, Orpington, UK) (4 min) in an ultrasonic bath. Fifteen roots were placed individually in 10 ml of Brain Heart Infusion (BHI) broth (Oxoid, Basingstoke, UK) and autoclaved. These were left to cool to room Volume 7 Number 3

temperature and then incubated overnight at 37°C to verify the sterility of the samples. The BHI broths containing the roots were inoculated with 100 IJL of an overnight culture of E. faecalis JH2-27 and incubated for 10 days at 37°C to allow for bacterial growth, infiltration of the dentin tubules, and E. faecalis JH2-2 biofilm formation. The roots were divided into three groups, according to the irrigant used: Group 1 was irrigated with the Optident Sterilox Electrolyte Solution (this is essentially saline and was used as our negative control); group 2 was irrigated with 4% NaOCl (Teepol Bleach); and group 3 was irrigated with freshly prepared Sterilox’s Aquatine Alpha Electrolyte solution. The concentration of the NaOCl solution was tested by iodometric titration. The obtained value amounted to 3.9. After sealing the apical portion with autoclaved physiowax (RA Lamb Ltd, Eastbourne, UK), 5 cc of the selected irrigant was dispensed using a 27-gauge Monoject® syringe (Kendall, Tyco, Mansfield, Massachusets, United States) in an up-and-down motion, and left in situ for 3 min. Following the removal of the apical seal to allow for the irrigation solution to drain, the coronal 5-mm portion of the specimen was sampled by grinding dentin and canal contents using ParaPost® XP™ Endodontic post system drill (Coltene/Whaledent) with a diameter of 1.5 mm. Debris collected in the flutes of each

drill was placed in a 1.5 ml microcentrifuge tube containing 1 ml BHI broth. After vortexing for 10 seconds, a serial dilution of the debris containing BHI broth was made and 100 IJL of neat, 10-2, 10-4, and 10-6 dilutions were plated in duplicate onto fresh BHI agar plates and incubated overnight at 37°C. To confirm the morphology and Gram group of the bacterial cells, Gram staining was performed. In order to determine if the carry-over of NaOCl could prevent the growth of cells in the broths, an additional experiment was carried out on sterile bovine teeth. These had been treated the same as the teeth used above except that they had not been inoculated with E. faecalis. After irrigation with NaOCl, the debris from the drill flutes were put into 900 IJL of BHI and 100 IJL of stationary phase E. faecalis culture was added. This was serially diluted as above and dilutions plated out as before. In addition, one group of teeth was irrigated with sterile water to provide a negative control. All data were compared stratified by dilutions. Colony-forming units (CFUs) with too many to count (TMTC) (defined here as > B00 CFU per agar plate) were attributed the highest rank in a nonparametric approach with ANOVA on ranks with a Duncan post-hoc. Differences were considered significant at p < 0.05. To double-check the results, an additional non-parametric approach was conducted. All data were compared stratified by Endodontic practice 33

CONTINUING EDUCATION

Figures 1A and 1B: Mean number of colony-forming units recovered from debris after dentin grinding and root canal irrigation with NaOCl (A) Sterilox’s Aquatine Alpha Electrolyte® (B) or Optident Sterilox Electrolyte Solution® (C) 1A: Neat broth (no dilution). 1B: 10-2 dilution. The vertical dashed line shows significant difference between the groups on either side (P < 0.05)

dilutions. The Kruskal-Wallis test was used to compare the three groups involved followed by Mann-Whitney’s test as a posthoc procedure adjusted with Bonferroni correction for multiple comparisons. Significance level was set at a = 0.05. Data were analyzed using SPSS software v. 15.0 for Windows (SPSS Inc., Chicago, Illinois, United States).

Results The overnight incubation of the sectioned bovine root canals resulted in no growth in any of the samples. This indicates that all the root sections were sterile at the start of the experiment. Gram staining of a number of the resulting colonies showed the presence of Gram-positive cocci, consistent with the E. faecalis inoculum. The bacteria were morphologically identical to the E. faecalis used in the inoculum. Results of the dilution series are presented in Table 1, while statistical analysis of the raw data for neat and 10-2 dilution is presented in Figure 1. Results for statistical analysis coincided for both approaches. NaOCl was the only irrigant to eliminate all bacteria and was significantly better at killing E. faecalis than both the Optident Sterilox Electrolyte Solution (saline) and Sterilox’s Aquatine Alpha Electrolyte. Additionally, Sterilox’s Aquatine Alpha Electrolyte solution was superior to Optident Sterilox Electrolyte Solution. The experiment to determine the effect 34 Endodontic practice

of carry-over of NaOCl resulted in similar colony counts for the samples from teeth irrigated with NaOCl and water (results not shown) indicating that carry over of NaOCl had no noticeable effect in our experiment.

Discussion This study evaluated the antimicrobial action of Sterilox’s Aquatine Alpha Electrolyte, a commercially available superoxidized water in the United Kingdom, in bovine root canals. E. faecalis was selected as the test species because it is commonly detected in asymptomatic, persistent root canal infections.12,15 The bovine root model was chosen as it is clinically relevant, although the large root canal preparation size allows for more favorable dynamics of irrigation for the solution tested than is likely to occur in vivo. Additionally, the number of bacteria present is likely to be artificially high compared to the in vivo situation. Despite these limitations, the ex vivo model has been successfully used previously to test the ability of E. faecalis to survive diverse root canal irrigations.17 Our study suggested that the protocol followed was either able to prevent carryover of the antimicrobial effect of NaOCl onto the BHI plates, possibly due to drainage of the solutions after irrigation or any carry over had no effect on the viability of the organisms, possibly due to the immediate dilution of the samples in the BHI broth. Furthermore, based on pilot studies, it was decided to collect

samples at a single depth as no difference was found between different depths of sampling when NaOCl was used as irrigant; this is consistent with the results from other investigators on a similar bovine tooth model.8 Sterilox’s Aquatine Alpha Electrolyte is obtained by passing a sodium chloride solution (Optident Sterilox Electrolyte Solution) over coated titanium electrodes at 9 amps in a specifically made device (Optident Sterilox Dental Generator®; Optident Dental). Optident Sterilox Electrolyte Solution (non-activated) was used as the negative control as we did not expect any antimicrobial action from this irrigant. NaOCl was tested because it is largely recommended as the main root canal irrigant.25 Endodontic literature suggests that infection of the root canal at the time of obturation has a negative influence on the prognosis of endodontic treatment23; NaOCl was the only irrigant tested that was consistently associated with negative cultures in our study. However, Sterilox’s Aquatine Alpha Electrolyte might be able to reduce the bacterial load to levels that could influence treatment outcome. These results are not consistent with those of a previous study where different irrigants, including NaOCl, were tested against E. faecalis in a bovine tooth model. In fact, Krause, et al.,8 (2007) suggest that 5.25% NaOCl was not able to render the dentinal shavings obtained sterile; it was, however, significantly more Volume 7 Number 3

References 1. Berutti E, Angelini E, Rigolone M, Migliaretti G, Pasqualini D. Influence of sodium hypochlorite on fracture properties and corrosion of ProTaper Rotary instruments. Int Endod J. 2006;39(9):693-699. 2. Davis JM, Maki J, Bahcall JK. An in vitro comparison of the antimicrobial effects of various endodontic medicaments on Enterococcus faecalis. J Endod. 2007;33(5):567-569. 3. Gallegos AG, Bertolotti RL. Effect of sodium hypochlorite on the strength of carbon steel endodontic instruments. J Endod. 1981;7(9):423-425. 4. González-Espinosa D, Pérez-Romano L, GuzmánSoriano B, Arias E, Bongiovanni CM, Gutiérrez AA. Effects of pH-neutral, super-oxidised solution on human dermal fibroblasts in vitro. Int Wound J. 2007;4(3):241-250.

a reduced bacterial load, as a result of a chemo-mechanical preparation, superoxidized water irrigation might have the ability to eradicate a more clinically relevant root canal infection. The result of a previous study2 showed that super-oxidized water had no ability to prevent the growth of E. faecalis using paper disks as the delivery method on Petri dishes, a protocol more favorable to the irrigant when compared to the bovine root model due to long time of contact with the microorganisms, absence of interaction with dentin and cells in a metabolically active phase, therefore more susceptible to antimicrobials.9 Nonetheless, a different irrigation source was tested (Dermacyn, Oculus Innovative Sciences, Petaluma, California, United States). Different superoxidized waters are produced by a similar electrolysis process, but due to a difference in the active concentration and the pH of the final solution, the product can have a different antimicrobial activity.18 One of the suggested advantages of super-oxidized water, when compared to NaOCl, is the level of toxicity of NaOCl.20 It is worth noting that the mechanism of action of super-oxidized water involves

9. Mah TF, O’Toole GA. Mechanisms of biofilm resistance to antimicrobial agents. Trends Microbiol. 2001;9(1):34-39. 10. Martin MV, Gallagher MA. An investigation of the efficacy of super-oxidised (Optident/Sterilox) water for the disinfection of dental unit water lines. Br Dent J. 2005;198(6):353-354. 11. Martin N, Martin MV, Jedynakiewicz NM. The dimensional stability of dental impression materials following immersion in disinfecting solutions. Dent Mater. 2007;23(6):760-768. 12. Molander A, Reit C, Dahlén G, Kvist T. Microbiological status of root-filled teeth with apical periodontitis. Int Endod J. 1988;31(1):1-7.

oxidative damage that might cause aging and irreversible dysfunctions, which eventually produce cellular death.4 A pHneutral super-oxidized solution (Microcyn; Dermacyn, Oculus Innovative Sciences, Petaluma, California, United States) has been tested. It was found to be significantly less cytotoxic than antiseptic hydrogen peroxide concentrations (used as a positive control for oxidative damage) because it does not induce genotoxicity or accelerated aging in vitro.4 However, Microcyn has a different pH than Sterilox’s Aquatine Alpha Electrolyte, and this needs to be taken into account when comparing the two irrigants.

Conclusions Under the conditions of this study, Sterilox’s Aquatine Alpha Electrolyte appeared to have significantly more antimicrobial action when used as an irrigant in the root canal system compared to the non-activated Optident Sterilox Electrolyte Solution®, but NaOCl was the only irrigant able to eliminate all bacteria in our experiments. Sterilox’s Aquatine Alpha Electrolyte caused a bacterial load decrease although it is less effective than NaOCl. EP

18. Sampson MN, Muir AV. Not all super-oxidized waters are the same. J Hosp Infect. 2002;52(3):228229. 19. Selkon JB, Babb JR, Morris R. Evaluation of the antimicrobial activity of a new super-oxidized water, Sterilox®, for the disinfection of endoscopes. J Hosp Infect. 1999;41(1):59-70. 20. Shetty N, Srinivasan S, Holton J, Ridgway GL. Evaluation of microbicidal activity of a new disinfectant: Sterilox® 2500 against Clostridium difficile spores, Helicobacter pylori, vancomycin resistant Enterococcus species, Candida albicans and several Mycobacterium species. J Hosp Infect. 1999;41(2):101-105.

13. Pashley EL, Birdsong NL, Bowman K, Pashley DH. Cytotoxic effects of NaOCl on vital tissue. J Endod. 1985;11(12):525-528.

21. Sim TP, Knowles JC, Ng YL, Shelton J, Gulabivala K. Effect of sodium hypochlorite on mechanical properties of dentine and tooth surface strain. Int Endod J. 2001;34(2):120-132.

5. Grigoratos D, Knowles J, Ng YL, Gulabivala K. Effect of exposing dentine to sodium hypochlorite and calcium hydroxide on its flexural strength and elastic modulus. Int Endod J. 2001;34(2):113-119.

14. Pataky L, Iványi I, Grigár A, Fazekas A. Antimicrobial efficacy of various root canal preparation techniques: an in vitro comparative study. J Endod. 2002;28(8):603-605.

22. Solovyeva AM, Dummer PM. Cleaning effectiveness of root canal irrigation with electrochemically activated anolyte and catholyte solutions; a pilot study. Int Endod J. 2000;33(6):494-504.

6. Huang TY, Gulabivala K, Ng YL. A bio-molecular film ex-vivo model to evaluate the influence of canal dimensions and irrigation variables on the efficacy of irrigation. Int Endod J. 2008;41(1):60-71.

15. Peciuliene V, Balciuniene I, Eriksen HM, Haapasalo M. Isolation of Enterococcus faecalis in previously root-filled canals in a Lithuanian population. J Endod. 2000;26(10):593-595.

23. Sundqvist G, Figdor D, Persson S, Sjögren U. Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative retreatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1988;85(1):86-93.

7. Jacob AE, Hobbs SJ. Conjugal transfer of plasmidborne multiple antibiotic resistance in Streptococcus faecalis var. zymogenes. J Bacteriol. 1974:117(2):360372.

16. Peters OA, Roehlike JO, Baumann MA. Effect of immersion in sodium hypochlorite on torque and fatigue resistance of nickel-titanium instruments. J Endod. 2007;33(5):589-593.

8. Krause TA, Liewehr FR, Hahn CL. The antimicrobial effect of MTAD, sodium hypochlorite, doxycycline, and citric acid on Enterococcus faecalis. J Endod. 2007;33(1):28-30.

17. Rossi-Fedele G, Roberts AP. A preliminary study investigating the survival of tetracycline resistant Enterococcus faecalis after root canal irrigation with high concentrations of tetracycline. Int Endod J. 2007;40(10):772-777.

Volume 7 Number 3

24. White JD, Lacefield WR, Chavers LS, Eleazer PD. The effect of three commonly used endodontic materials on the strength and hardness of root dentin. J Endod. 2002;28(12):828-830. 25. Zehnder M. Root canal irrigants. J Endod. 2006;32(5):389-98.

Endodontic practice 35

CONTINUING EDUCATION

effective than the other solutions tested.8 The major difference between the models is the difference in volumes of irrigation used — 60 IJL twice against 5 cc in our study, therefore suggesting a role for the amount of irrigant used on the ability to eliminate root canal infection in the bovine root model; in the same way a previous investigation indicates that the volume of irrigation has a significant influence in removing a bio-molecular film from root canal walls.6 The disinfecting actions of superoxidized water are heavily reduced in the presence of organic contamination.11,20 The model used in our study allows for a greater bacterial growth than one might expect in an in vivo situation. It further excludes the mechanical aspect of root canal preparation, so that the bacterial biomass present in the root canal is likely to be greater than in normal clinical conditions. Consequently, its elimination will depend exclusively on the flushing and chemical effects of the irrigation solution tested. The importance of instrumentation in obtaining a significant reduction in bacterial content has been shown.14 Therefore, we hypothesize that, in the presence of

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Antimicrobial effect of super-oxidized water and sodium hypochlorite against Enterococcus faecalis 1. Endodontic irrigants should have, among other properties, ________. a. a broad antimicrobial spectrum of activity against anaerobic and facultative microorganisms growing in biofilms b. a relative absence of toxicity against periapical tissues and oral mucosa. c. capability to encourage the smear layer d. both a and b 2. ______ is recommended as the main root canal irrigant because of its broad antimicrobial activity, the capacity to prevent formation of and to dissolve the smear layer, in association with chelating agents, and its ability to dissolve tissue remnants. a. Sterile saline b. Chlorhexidine (CHX) c. Sodium hypochlorite (NaOCl) d. Iodine potassium iodide (IKI) 3. Super-oxidized water has been suggested as an alternative to NaOCl, as it provides efficient cleaning of root canal walls, and has been recommended for the disinfection of ____. a. endoscopes b. dental unit water lines c. dental impression materials d. all of the above

36 Endodontic practice

4. E. faecalis was selected as the test species because it ______. a. is less costly than other bacteria b. is commonly detected in asymptomatic, persistent root canal infections c. affects only the bovine species d. grows more quickly than other bacteria 5. Endodontic literature suggests that infection of the root canal _____ the prognosis of endodontic treatment. a. encourages the more experienced clinician regarding b. has a negative influence on c. has no influence on d. none of the above 6. The disinfecting actions of _____are heavily reduced in the presence of organic contamination. a. sodium hypochlorite (NaOCl) b. non-oxidized water c. super-oxidized water d. chlorhexidine (DHX) 7. Consequently, its (the bacterial biomass) elimination will depend exclusively on the _____ of the irrigation solution tested. a. age b. flushing c. chemical effects d. both b and c

8. Different super-oxidized waters are produced by a similar electrolysis process, but due to a difference in the ______, the product can have a different antimicrobial activity. a. active concentration b. pH of the final solution c. delivery method d. both a and b 9. One of the suggested advantages of superoxidized water, when compared to NaOCl, is the level of ______ of NaOCl. a. toxicity b. alkalinity c. electrolysis d. bio-molecular film 10. Under the conditions of this study, Steriloxâ&#x20AC;&#x2122;s Aquatine Alpha Electrolyte appeared to have _____ when used as an irrigant in the root canal system compared to the non-activated Optident Sterilox Electrolyte SolutionÂŽ, but NaOCl was the only irrigant able to eliminate all bacteria in our experiments. a. not much more antimicrobial action b. the same antimicrobial action c. significantly more antimicrobial action d. negligible antimicrobial action

Volume 7 Number 3

TECHNOLOGY

Endodontics in 3D Dr. Richard Kahan discusses case studies using cone beam computed tomography (CBCT)

or a patient and the treating endodontist, a vertical root fracture (VRF) is a fairly catastrophic event. Bacteria from the canal spaces or from the gingival crevice will contaminate the crack surface with effective decontamination being impossible. Prognosis for the affected tooth will be hopeless. A VRF can be “crown up” (in the maxilla), which will be the extension of a vertical crown fracture through the root, or possibly less commonly, “apex down,” as a result of high forces of root canal obturation or rarely trauma. Early diagnosis of a VRF is critical to avoid the consequences of further fracture propagation, extensive related periradicular bone loss, and expensive and unsuccessful endodontic treatment. Recognition of the fracture though can often be impossible, particularly in the case of the “apex up” fracture. If the position of a fracture is favorable for direct vision, a “crown down” VRF can sometimes be seen on the outside of the root if the gingivae are not covering it. It will also be visible within a pulp chamber and at canal orifice level with magnification and maybe staining, but the extent of a fracture line running up along the canal wall can rarely be objectively assessed. This visual clarification can often only be done following extensive deconstruction of the tooth and effective debridement of the pulp chamber and canal orifices, which can take time. Another option can be surgical investigation taking back a gingival flap, which is invasive and also costly. A further clinical sign of a “crown up” VRF is the presence of an isolated narrow periodontal pocket. Bacteria from the gingival crevice will grow along the root

Richard Kahan is a specialist endodontist working in Harley Street, London, and the former Director of Endodontic Courses at UCL Eastman CPD. He has lectured widely on endodontics and technology and has recently set up the Academy of Advanced Endodontics to teach the fundamentals of endodontics to VTs and GDPs, more advanced techniques for GDPs and GDPwSI Endo, and CBCT reporting for Specialists and GDPwSI Endo, through practical hands-on courses. For more information, visit www.endoacademy.co.uk.

Volume 7 Number 3

Figure 1: Classical signs of vertical root fracture with mesial and distal periodontal ligament widening associated with the coronal third of the distal root of a LL6

fracture and cause adjacent bone loss, creating a fine vertical pocket to the level of fracture termination. This sign will be pathognomonic for a root fracture, but the narrowness of early pocket formation can make it difficult to find and effectively track. This is particularly so if the fracture is positioned interdentally, which it frequently is. This classical sign of pocketing can be radiographically recognized as increased widening of the periradicular periodontal ligament space on one or both sides of the root wall (Figure 1). These signs will be present as long as the fracture is relatively perpendicular to the X-ray beam. In more advanced cases where the fracture reaches the apex, it can be seen as a rather classic, J-shaped lesion as it loops around the root apex. Whereas picking up a root fracture from a standard periapical radiographic image can therefore be a matter of luck, CBCT could be the diagnostic answer. The ability for CBCT to visualize tooth and root fractures is a controversial area, and the subject of a number of frankly ridiculous invitro investigations. Clinically, the contrast level of even the highest resolution CBCT scan is only likely to be able to visualize open crown and root fractures. The vast majority of the VRFs are closed, and the fracture line itself will not be visible.

Furthermore, as root fractures are often associated with root filling materials, pins and posts, metallic and beam hardening artifacts will superimpose upon the root structure, rendering any image of the fracture unreadable. However, the main change that provides the diagnostic sign of VRF is within the periradicular bone, and CBCT offers an accurate circumferential view of the bone surrounding the root which can often be separated out from artifacts generated from internal materials. This ability to diagnose VRFs using CBCT before invasive and expensive investigations, or even endodontic treatment, offers significant advantages to both operator and patients. If a fracture can be quickly and accurately confirmed, the tooth can be removed before money is wasted on unsuccessful treatment, and the tooth replaced without the problems associated with severe alveolar bone loss. The case below describes how the consequences of misdiagnosis can be avoided with the use of a limited-volume CBCT scan.

Clinical details A 32-year-old female was referred by her general dental practitioner for re-root canal treatment of her upper left second premolar (UL5). She had been complaining of a sore Endodontic practice 37

TECHNOLOGY lump on the side of the gum adjacent to the UL5 that had appeared a few months before consultation. The lump would be variable in size, but the related teeth were comfortable in function with no significant discomfort. An onlay had been placed on the tooth a year earlier, and it had been root treated 13 years previously. Clinical examination revealed a good quality ceramic onlay present on the UL5. The tooth was slightly tender to percussion, and a small hard buccal swelling was present over the root apex which was tender to palpation. The gingival tissues were pink and healthy with no signs of bleeding on probing or deep pocketing. The general dental practitioner supplied a periapical radiograph (Figure 2), which showed a small coronal radiolucency (void) with a substantial centrally placed root filling terminating 1-2 mm from the radiographic apex. The root filling followed the slight distal curve in the apical third of the root with filaments of radiopacity extending from the termination of the fill suggesting some sealer spread into the apical deltas. Tracing the periodontal ligament spaces around the root showed some thickening of the ligament space along the distal root surface, and a second ligament space at mid-root level indicated either a second root or a groove along the primary root, which could be indicative of two root canals. The main periapical lesion was present at the mesial root apex with a smaller Iesion present at the distal apex. A provisional diagnosis of chronic periapical periodontitis was due to either apical recontamination or the presence of an untreated second canal. To further assess the cause of the problem, a limited volume (4 cm x 4 cm) CBCT scan was taken. Without access to this technology, a second angled periapical would have been taken. Scan analysis showed a single root with a cross-sectional figure-eight shape. A single canal was present and intra- and extraradicular symmetrical radiolucencies surrounding the root filling were present and due to beam hardening artifacts. There were no suggestions of voids within the canal system where untreated contaminants could have been present. Of particular significance was the presence of buccal and lingual vertical bone defects extending the full length of the root which culminated in a large lingually placed periapical lesion (Figures 3 and 4, vertical bone defects arrowed). A smaller buccal 38 Endodontic practice

Figure 2: Preoperative periapical radiograph from the referring general dental practitioner

Figures 3 and 4: Axial views of the upper left quadrant showing buccal and lingual vertical bone defects running along the root walls of the UL5 (arrowed)

lesion had perforated the buccal cortical plate, resulting in the clinical symptoms of a lump (Figure 5). The appearance of vertical defects along the root surfaces were pathonomonic of VRF and present due to bacteria sitting along the fracture line causing adjacent bone loss. Despite the coronal extension of the vertical defects, no pocketing could be found using a fine gutta-percha cone; this was due to the fracture being â&#x20AC;&#x153;apexup.â&#x20AC;? The lack of any disturbance to the mesial and distal PDL spaces was due to the fracture being bucco-lingual and in line with the beam of the periapical X-ray. The patient was advised that any treatment would be futile, and that the

tooth should be extracted. She returned to her dentist for the extraction, and the diagnosis was confirmed on inspection (Figure 6).

Discussion It would be useful to consider how the diagnosis and treatment plan would have turned out using purely conventional radiography as I would have done 6 years ago. A second angled radiograph would have been taken by a competent specialist endodontist, and this has been created virtually using a thick slice technique and angled from the mesial aspect, whereas the original periapical was angled a little from the distal aspect (Figure 7). Using Volume 7 Number 3

TECHNOLOGY

Figure 5: Coronal view of the UL5 showing buccal and lingual vertical bone defects running all the way around the root (arrowed) with lingual apical lesion expansion and a buccal plate perforation

this technique does show the reduced resolution of a CBCT thick slice, but no significant difference can be detected from this secondary angle. The diagnosis would therefore firmly be chronic periapical periodontitis with the likely causes possibly listed as coronal leakage, apical leakage, or missed/untreated canal anatomy. Treatment recommendation for the patient keen to save her tooth would have been conventional endodontic retreatment, likely to have a fair to good prognosis if treatment aims of full canal decontamination and sealing could be achieved. Access through the porcelain onlay and entrance into the canal system would have been uneventful with no signs of fracture along the buccal and lingual canal walls observed within the coronal third. The buccal apical swelling would have been unlikely to have receded following the first clean and dressing visit, and further disinfection may have been necessary a second time. Occasionally, the presence of heavy disinfection can reduce the bacterial load enough to reduce acute symptoms; however, in this case, this effect would not be long lasting; and at some point, either after completion or before, it would become obvious that treatment had not been successful or was not being successful. At this juncture, etiological theories may change to contamination of apical delta canals, extraradicular infection, or possibly cystic transformation; and apical surgery would be suggested; and it would only be at the stage of flap retraction and removal of some buccal bone that a 40 Endodontic practice

Figure 6: Extracted UL5 showing a buccal “apex down” vertical root fracture

Figure 7: A virtual periapical radiograph constructed from a CBCT scan using thick slice technique angled from a mesial aspect

vertical root fracture would be recognized and prognosis understood to be hopeless. By this time, the patient would have invested significant amounts of time, money, and aggravation in a futile attempt to save her tooth, further resulting in more bone loss and possibly a reduced prognosis for successful implant placement. Although the practitioners involved would be blameless, the whole episode would not reflect particularly well on them from the patient’s point of view. If it were me, I would be frustrated by my inability to effectively diagnose a hopeless situation. In reality though, early recognition through a simple 9-second scan identified the problem, and early extraction saved time, money, aggravation, and

the unnecessary loss of bone vital for successful implant therapy. As a postscript, it is interesting to note that this case would not fulfill the current guidelines for CBCT scan justification. It would seem to be a fairly routine periapical lesion as a result of primary endodontic treatment failure, which is the daily bread and butter for the specialist endodontist. This prompts the question of when one should scan and when one should not. A tricky question for future discussion. My thanks to Dr. Piotr Strojek, BDS, MSc, for the referral and the use of his radiograph and clinical picture. EP

Volume 7 Number 3

PRODUCT PROFILE

Planmeca® ProMax® 3Ds and 3D: New imaging mode for endodontics offers perfect visualization of the finest details

he Planmeca® ProMax® 3Ds and 3D units are designed for capturing the smallest anatomical details with precision. High-resolution images with a 75 μm voxel size and efficient artifact removal make these units an ideal choice for versatile endodontic case planning and precise diagnostic capabilities. The Planmeca AINO™ removes noise from CBCT images without compromising diagnostic quality

Artifact removal Planmeca ARA™ artifact removal algorithm removes shadows and streaks from the 3D image, such as those caused by metal and root fillings.

The Planmeca AINO™ (Adaptive Image Noise Optimizer) is an intelligent 3D noise filter that removes noise from CBCT images without losing valuable details. The result is a crystal clear, highly diagnostic image.

Volume 7 Number 3

All ProMax units include Planmeca Romexis open-architecture software with versatile tools for endodontic diagnostic and treatment planning needs, such as true measurements and 3D visualization of root canals. CBCT applications in endodontics: • Assessment of endodontic treatment complications • Diagnosis of periapical pathosis • Root canal system anomalies • Determination of root curvature • Trauma diagnosis, such as root fractures, luxation, displacement of teeth, and alveolar fractures • Localization of root resorption • Determination of exact root apex location in pre-surgical planning

Noise-free images

• Analyzes the reconstruction exposure data during reconstruction and adaptively differentiates noise and fine details • AINO filter is enabled in Planmeca Romexis® 3D capturing dialog, while the original image is also stored and accessible • Improves image quality in endodontic mode where noise is inherent due to small voxel sizes • Also useful in ultra low-dose images

Comprehensive Planmeca Romexis® software

Planmeca ARA™ artifact removal algorithm

Ideal patient support The adjustable patient support keeps the patient’s head firmly and comfortably in place, providing high-quality images without artifacts caused by movement.

Planmeca ProMax 3Ds and 3D: true allin-one units • CBCT, panoramic, anatomically accurate extraoral bitewings, and optional cephalometric imaging • Optional 2D SmartPan™ allows 2D and 3D images to be taken with the same sensor • Optional Planmeca ProFace™ 3D facial photo for advanced case presentation, operation pre-planning, and treatment follow-up EP This information Planmeca.

was

provided

Endodontic practice 41

PRODUCT PROFILE

ChlorCid® and ChlorCid® V

here remains a growing belief among clinicians that obturation is to blame for endodontic failures. This notion has more recently fallen under scrutiny as researchers have discovered that the most thorough obturation can only reflect the quality of the cleaning and shaping of the canal. In fact, a number of researchers point to the thorough use of irrigants — making sure that the debris and irrigant itself are lifted completely out of the canal, not forced out the apex — as the most important determinant in the long-term success of an endodontic procedure. The right irrigants, when used properly, eliminate harmful microorganisms and bacteria in the root and tubules, and prevent recontamination, even long after the RCT is complete. The recently acknowledged vital role of irrigants stands to reason, as RCT itself was born out of the necessity to treat the infected, and very often painful, dentinal tubules and roots that traditional restorative dentistry couldn’t address. One of these vital irrigants includes ChlorCid®, a 3% sodium hypochlorite solution, and its more viscous formula, ChlorCid® V.

ChlorCid and ChlorCid V 3% sodium hypochlorite (NaOCl) Dating back to World War I, NaOCl solutions have been used in health care because of the antibacterial effects they provide. Studies have shown that irrigants containing antibacterial properties exhibit superior ability to reduce and eliminate bacteria when compared to a commonly used generic saline solution. NaOCl is both relatively inexpensive, and when used as an endodontic irrigant, exhibits antiseptic and lubricating properties. When in the canal, ChlorCid dissolves soft tissue/ organic matter and acts as a file lubricant. When the solution comes into contact with the before-mentioned organic tissue, ChlorCid also releases chlorine, whose strong antimicrobial properties kill bacteria and prevent bacterial rebound by oxidizing the enzymes essential to its regrowth. One of the concerns with NaOCl is the possibility of extrusion of the solution to periapical tissues past the apex. Depending on the level of patient sensitivity, this can produce everything from mild discomfort to large amounts of swelling and bruising.

However, irrigating the canal with NaOCl with Ultradent’s NaviTip® greatly reduces this risk. This tip is unsurpassed in its small diameter and technologically advanced preparation of the different areas of the cannula, as well as its rounded tip, designed to eliminate as much ledging as possible. For endodontic cases requiring enhanced flow control and/or enhanced lubrication, ChlorCid V provides the same antibacterial properties as ChlorCid, in a slightly more viscous formula.

A NaviTip 31ga tip with Double Sideport Irrigator is recommended for use with the ChlorCid IndiSpense syringe, while the NaviTip 29ga tip is recommended for the ChlorCid V IndiSpense syringe, although several other tip options are compatible. To learn more about ChlorCid, ChlorCid V, and the other Ultradent products mentioned, please visit ultradent. com, or call 800-552-5512. EP This information was provided by Ultradent.

42 Endodontic practice

Volume 7 Number 3

simple, adaptable

endodontic solutions

Adaptable delivery for your irrigation protocol

NaviTips® deliver any irrigant Your endo procedures, your protocols, your techniques. They’re personal. They’re tested. And they work. So why would you change them? You wouldn’t. But you would make them easier. NaviTips are designed to deliver any manufacturer’s irrigant directly where and when you need it. And they adapt to your technique. Use NaviTip to deliver these and many other irrigants: ChlorCid · EDTA 18% · File-Eze · Consepsis

Don’t change your technique. Make it easier with NaviTip. Scan to watch a short video showing NaviTip’s side port delivery in action

800.552.5512 ultradent.com NaviTips are available with side port delivery for safe delivery of sodium hypochlorite

NaviTip delivers any irrigant just short of the apex—right where you need it

NaviTip

PRACTICE MANAGEMENT

Secrets to financial and personal freedom for endodontists In part 1 of his series, Dr. Ace Goerig offers the first steps to becoming debt-free

was presenting at a recent AAE national meeting with over 200 endodontists in the room, and I asked the question, “How many of you are completely debt-free?” Only about 12 people raised their hand. I did not ask the question, “How many are financially free?” Personal and financial freedom begins first with becoming debtfree. In this first of a three-part series, I want to show you how you can be completely debt-free within 2 to 10 years and where to invest to make over a 100% return your money guaranteed, without risk or tax consequence. In part 2, I want to introduce you to the concept of effortless endodontics and how to modify your business systems in your practice so that you only work 3 days a week, take 8 to 12 weeks off a year, and produce more than you are now. And in part 3, I will help you understand how to obtain total personal freedom by shifting your “deserve level” to a point where abundance and peace can easily flow into your life. I am not a financial advisor or a broker, but an endodontist who eventually realized that the American financial system was designed to keep us broke and always in debt. Working with a few great mentors, I was shown the secrets of financial and personal freedom that work for everyone. It does not matter how much you make or what age you are; this simple program will help you find the elusive goal of financial freedom and personal peace that you are always searching for in your life.

Dr. Ace Goerig cofounded Endo Mastery in 1996, a coaching company designed specifically for endodontists. He has worked with 20% of all endodontists in the country to understand the business of dentistry, become debt free, and learn how to love their practice. He graduated from Case Western Reserve University Dental School in 1971, entered the Army, and retired as a colonel in 1991. He is a Diplomate of the American Board of endodontists and owns one of the most successful endodontic practices in the country. Dr. Goerig co-authored a book with Kendrick Mercer entitled Time and Money, Your Guide to Economic Freedom to teach doctors and their teams the secrets of becoming personally and financially free. He and his wife, Nancy have five children and were married in 1969.

44 Endodontic practice

Every endodontist I talk to says they would want to have financial and personal freedom, but 95% of all of them still are slaves to their monthly payments. The real problem is that they think always being in debt is normal. The big banks, credit card companies along with the mortgage companies have trained them in this belief. And they have developed a proven profit system that keeps you in debt for a lifetime so they can steal half of your life’s income. You become their cash cow. Getting out of debt is very easy especially for endodontists. In the next few minutes, you will read about how to make over 100% guaranteed return on your money while watching ALL of your debts disappear (even your mortgage, school loans, and practice debt) in 2-10 years — no debt payments of any kind. You will no longer worry about paying off student loans, a slowdown in your practice, or having enough money for your retirement. Once you are debt-free, the two-thirds of your income that was going to debt payments will be yours to live the life of your dreams. One endodontist that I personally coached was able to double his net income in 1 year and, over the next 18 months, became completely debt-free

and paid off $705,000 in debt using this system. The secret to getting out of debt and becoming financially free is to use your debt to make over a 100% return on your money, guaranteed, without risk or tax consequences. Most people think they have a 3%-6% interest rate on their home mortgage, but in reality, they are paying over 100% interest for the first 18 to 20 years of the loan. Here is an example from Karl’s mortgage calculator found at www.drcalculator.com. Go there and put in your own numbers. In this calculation, we have a $300,000 loan for 30 years with a 5.61% interest rate. The monthly payment is $1,724.13 of which $321 goes to principal and $1,400 goes to interest. This may be a 5.61% loan, but the first month of the loan is really a 400% interest loan. Most people do not know that they are paying 400% interest on their loan. Instead, pay an additional principal payment of $321 and eliminate the $1,400 interest payment that you gave to the bank; thereby, you will make 400% return on your money, guaranteed, without risk and without tax consequence. With this type of return on your money, you can get completely out of debt between 2 to 10 Volume 7 Number 3

You need to realize that two-thirds of your lifetime income is lost to monthly payments. Credit card and mortgage companies take the best 2/3 of your life.

Yearly Income

years depending on your situation. “A penny saved is a penny earned” – Ben Franklin As Table 1 shows, by paying an additional $3,960, you could eliminate $16,729 in interest. This is like earning an additional $16,729 a year, for which you would have to pay an extra $5,855.15 in taxes. If you paid off this loan in 7 years, you will have saved $257,244 in interest payments.

Multiply by 40 years

Monthly payments (banks keep)

You keep

$100,000

$4,000,000

$2,680,000

$1,320,000

$200,000

$8,000,000

$5,360,000

$2,640,000

$400,000

$16,000,000

$10,720,000

$5,280,000

$700,000

$28,000,000

$18,760,000

$9,240,000

The mortgage hoax Most financial advisors and accountants recommend that you keep your home mortgage so that you can reduce your taxes by writing off the interest. This is pure stupidity. The problem is that most accountants are taught to save you taxes and not make you money. In the preceding example, when you write off interest, you lose your yearly standard deduction of $12,400. In the first year, you paid $16,729 in interest, and because you lose your standard deduction, you are able to deduct

$4,329. But because you are in a 30% tax bracket, you are only able to write off 30% of that, which is a total of $1,299. ($16,729 - $12,400 = $4,329 x 30% tax bracket = your real tax savings is only $1,299, not the $16,729 in interest you paid.) In other words, you paid $16,729 to save $1,299 in interest. Not the wisest return on your money. This even gets worse. To pay back the original $300,000 loan, you will need to earn $912,733 (3 times what was borrowed). Because the $620,686 is

November 8-9, 2014 Annenberg Center

ENDODONTIC RETREATMENT SURGICAL/NON-SURGICAL M A N A G E M E N T

Join us in Philadelphia for this two day program featuring Penn Dental Medicine faculty, alumni and colleagues from around the world on topics ranging from endodontic pathology to endodontic surgical and non-surgical techniques. SYMPOSI UM PR ESENTERS AN D MOD ERATORS Seungho Baek KOREA Gunnar Bergenholtz SWEDEN Ian Chen TAIWAN Noah Chivian Spyridon Floratos GREECE Garrett Guess Bekir Karabucak Raed Kasem Denis F. Kinane Euiseong Kim KOREA Anil Kishen CANADA Meetu Kohli Samuel Kratchman Brian Lee Jung Lim Frank Setzer Songtao Shi Sujung Shin KOREA Martin Trope Yoshi Terauchi JAPAN Helmut Walsch GERMANY

HAN DS-ON WO R KS HO PS Friday, November 7, 2014 “Microscopic Non-Surgical Retreatment” Samuel Kratchman, Helmut Walsch and Yoshi Terauchi “Advanced Microendodontics – From Theory to Practice” Martin Trope and Bekir Karabucak “Microsurgical Endodontics” Syngcuk Kim, Meetu Kohli and Frank Setzer Penn Dental Medicine gratefully acknowledges support of this event from Carl Zeiss.

www.dental.upenn.edu/endoretreat2014

Volume Ad 7 8x5.35.indd Number 3 1 PD Endodontics

Endodontic practice 4/15/14 45 4:10 PM

PRACTICE MANAGEMENT

Table 1: If you paid an additional $3,960.35 this year toward the principal, you would save (earn) $16,729.20.

PRACTICE MANAGEMENT

aftertax money, the true amount you would have earn before taxes is determined by dividing the total house payments by 132% tax bracket (national and state taxes) — $620,686/0.68 equals $912,733. If you live in a high-income tax state (California, Oregon, New York, Hawaii, Vermont, Washington D.C.), you may be paying over 45% in taxes. You would have to earn $1,128,520 (3.7 times) to pay off the $300,000 loan. The average American moves every 7 years. By then, only 11% of the home is paid off. Then a new mortgage starts all over again at 100%. By then, you have paid $144,918.00 toward your mortgage, but only $33,087.00 went to principal (home equity). You also lost an additional 7% to the agent in sales commission ($21,000), $20,000 in home improvements, plus $5,000 in closing costs — an overall loss of $12,913.00. If most Americans understood this system, they could have paid their entire house off in the 7 years and then paid cash for every other house after that.

How to eliminate dental school loans within 5 years Dental school loans are misunderstood by most new endodontists, and this limits their possible career choices. With the current administration, interest rates on school loans have gone up from 2% to 3% to over 8%. Here is a true example of an endodontic student with a 30-year $300,000 loan at a 7.9% interest rate where she will pay $485,000 in interest and would have to produce $1.5 million to pay that interest. In the first year of the loan, $23,600 goes to interest and only $2,500 goes to principal, which is over a 900% interest rate. If she 46 Endodontic practice

would pay $6,000 toward principal each month instead of the $2,180.41, the loan would be paid off in 5 years, and she would save $420,000 in interest.

Recommendations for quickly getting rid of student loans • Just because they will lend it, does not mean you have to take all of it. • Try to refinance your loan at a lower interest rate. • Live like a student when you are a student. • Live like a student until all school loans are paid off. • Buy a cheap practice. • Buy used equipment. • Look for office space (800 to 1,200 sq. ft.) where a dentist is moving out. • Take advantage of minority loans. • Commit to paying your loans off in 5 years. • Get a practice coach to show you how to double your net profit. Until their school debt is paid off, it would be very smart to live more simply as if they were residents because the benefits are enormous. Now that you understand the value of paying off debt first, I would recommend that all excess money should be focused on paying debt. Many people want to put money away for retirement in 401(k)s, emergency funds, or children’s education funds. Before you put your money anywhere else, ask yourself this question: Am I getting 100% return on my money, guaranteed without risk, or tax consequences? Some people may like to tell you that there is good and bad debt, but all debt is bad.

When you are debt-free, you will have the freedom, time, and money to… • You can live a life of your own design. (No one owns you.) • Retire in practice. • Live and work where you want. • Go to work because you want to, not because you have to. • Be with the people you love and want to be with. • Do only what you want to do in your life. • Truly live the life of your dreams. To learn more on the specific step-bystep game plan to pay off all your debts, and to find out the 12 financial myths and mistakes that almost all endodontists do not understand, go to my free endodontic website www.endomastery.com and watch the entire video series on becoming financially free while downloading the handouts and audios. In part 2, we will talk about understanding the business systems of endodontics to help you become more profitable, have more time off, and practice true effortless endodontics. Change is terrifying for most people. Robert Frost once wrote, “Two roads diverged in a wood, and I, I took the one less traveled by, and that has made all the difference.” The only way this program works is by your making an intentional change and to committing to becoming debt-free in the next few years. Personal and financial freedom is just around the corner. EP

Volume 7 Number 3

TDO IS THE ENDOADVANTAGE It is more important than ever to be strategic in todayâ&#x20AC;&#x2122;s competitive environment. Give yourself the advantage and demonstrate your excellence with TDO Software. Make TDO your next move! TDO Evaluations facilitate excellent patient communication and provide feedback on many important aspects of your practice. TDO Web allows patients to complete medical history, pain history and prescriptions online. Referring doctors enjoy viewing case reports and referring new patients via the web. TDO CBCT allows you to easily adopt the latest technology. Only TDO offers seamless integration to Carestream and Morita Conebeam units.

ENDOSPECTIVE

Good times in the endo space or the end of reamin’ and dreamin’ as we know it? Dr. Rich Mounce shares his optimism on the specialty of endodontics

re we going forward as a specialty to better times, or are we headed toward extinction? My viewpoint on the endodontic space is somewhat unique in that I am a full-time clinician who earns his living treating patients and also the owner of an endodontic supply company (my second full-time job). From my vantage point from the chairside, podium, and trade show floor, I am overwhelmingly optimistic on the future of endodontics. Unquestionably, a number of forces propel our specialty into stiff headwinds. Such headwinds are manifested by thirdparty-owned corporate dental offices (often without adequate endodontic specialty care), wholesale extraction of teeth that could be retreated in favor of implants, an uneven economic recovery, and possibly too many endodontists in metro areas all competing for the same pie, among many factors. These are all challenges to our specialty. The above notwithstanding, our specialty will survive, evolve, and ultimately continue to prosper. At the end of the day, water finds its level. In an endodontic context, such thirdparty-owned clinics will ultimately fail and/ or evolve, depending upon the appropriate care for patients. The same can be said of the implant versus endodontics debate. The economic viability, convenience, and clinical success of microscopic retreatment relative to implant therapy will cause the pendulum to swing back to natural tooth retention where appropriate. Eventually, the dispersion of endodontists will find its equilibrium between the metro areas and

Richard (Rich) Mounce, DDS, is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, an endodontic supply company also based in Rapid City, South Dakota. Dr. Mounce has no commercial interest in Sonendo. He can be reached by phone at 605-791-7000 or by email at RichardMounce@MounceEndo.com, MounceEndo.com. Twitter: @MounceEndo

48 Endodontic practice

less populated areas; how can it not? In time, a change in national leadership is inevitable and will realistically set us on a course to pursue responsible and sustainable pro-growth policies instead of continuing on the current regulatory expansion and debt-laden trajectory draining our economy and diminishing the outlook for upward mobility for our children and grandchildren. I am optimistic because the American Association of Endodontists (AAE) has been proactive, responsive, and acting in our collective best interest. They deserve our thanks for what is a thankless job done

to train general dentists on how to save teeth through endodontic therapy, and companies like Aseptico donating supplies to support his efforts. Hats off to Glenn Kazen at Aseptico for doing so. While I am sure that there are many such examples of our collective willingness to share (far more than I can possibly list here), as a group, both the endodontists and our general dental colleagues are clearly trying to improve the level of endodontic care, education, and oral health around the world. This is good for us all. I am optimistic because I see companies like Sonendo raising endodontic

While I am sure that there are many such examples of our collective willingness to share (far more than I can possibly list here), as a group, both the endodontists and our general dental colleagues are clearly trying to improve the level of endodontic care, education, and oral health around the world. This is good for us all.

without credit and often in the background, balancing a wide range of interests. I am optimistic because my role with MounceEndo takes me around the country to visit endodontic programs and see the future of our specialists while in training. It’s exciting to see the infectious enthusiasm and desire to learn from the residents and their program directors that I encounter. Makes me wish I could go back to residency and/or to teach! I am optimistic because I see people like Dr. Ken Serota in Canada trying to bring global endodontic education online. I see Dr. Blake McKinley Sr. of Spokane, Washington, (now retired) donating his time and experience going to Ethiopia

technology to the next level and making our specialty all it can be, and creating solutions to vexing problems (how to truly clean a canal and dissolve tissue, bacteria, and biofilm, including the dentinal tubules). Say what you want about the major commercial forces present in the endodontic space, it’s companies like Sonendo that are truly innovating and providing the quantum leap forward for endodontics to the next level. My optimism on the future of endodontics led me to start MounceEndo and put my money where my mouth is. Like my colleagues, I want to see my specialty improve, grow, and prosper. It’s a privilege to do so. I welcome your feedback. EP Volume 7 Number 3

THE NEW STANDARD

I N E N D O D O N T I C I N S T R U M E N TAT I O N ™

Standard NiTi $25* Controlled Memory NiTi $35*

D Finders

Mani D Finders are stiff hand files used for the negotiation of calcified canals— available in sizes 8-15 in 21 and 25 mm lengths—highly efficient and economical when a “stiff” file is needed. $5.95/box of 6 files.

*Pack of 6 instruments, limited time offer, minimum purchase quantities apply, please call for this pricing and details.

Aseptico

The AEU-27A-ME Electric endodontic motor is customized with rpm and torque pre-sets for the MounceFiles in Controlled Memory and Standard Nickel Titanium. Alternatively, the rpm and torque can easily be adjusted for any rotary nickel titanium file on the market. Solid performance at a great price. $1595.

Stropko Irrigators

The Stropko irrigator can be used in every dental procedure to assure a gentle and effective stream of water and/or air for superior and efficient cleaning and drying of any surface or working area. The Stropko easily adapts to old or new air/water dental syringes. Priced at $75

EFFICIENT, SAFE, ECONOMICAL

MounceFiles are proudly manufactured in America MounceEndo, LLC | Rapid City, SD, USA 57701 | 605.791.7000 | info@MounceEndo.com | www.MounceEndo.com

LEGAL MATTERS

2014 employment law updates every dentist should know Ali Oromchian examines some changes that can affect practices

s we welcome another new year, there are many changes and updates to employment laws across the United States that are important and relevant to your practice. 2013 saw a reduction of more than 30% in the number of labor and employment bills enacted as compared to 2012, but new legislation in 2014 provides for changes that are just as important as ever for both large and small employers. Changes to employment law this year run the gamut, spanning health care, Health

Ali Oromchian, JD, LLM, is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Mr. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clientsâ&#x20AC;&#x2122; businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States.

50 Endodontic practice

Insurance Portability and Accountability Act (HIPAA), social media policy, minimum wage, and arbitration agreements.

The Patient Protection Affordable Care Act

and

The Patient Protection and Affordable Care Act (Affordable Care Act) includes measures meant specifically for small employers that help lower premium cost growth and increase access to affordable, high-quality health insurance. Currently, small businesses (up to 50 full-time employees) pay on average 18% more than big businesses (more than 50 full-time employees) for health insurance because of administrative costs. The small business Health Care Tax Credit, offered as part of the Affordable Care Act, helps small employers afford the cost of health care coverage for their employees. The credit is designed to encourage small employers to offer health insurance coverage for the first time or maintain coverage they already have for

employees. Beginning in 2014, there will be a tax credit of 50% to help offset the costs of insurance. It is available to qualified small employers of up to 50 employees that participate in the Small Business Health Options Program (SHOP). SHOP offers small employers increased purchasing power to obtain a better choice of high-quality coverage at a lower cost. To enroll, eligible employers must have an office within the service area of the SHOP and offer SHOP coverage to all full-time employees. Enrollment for SHOP is open now. The Affordable Care Act creates incentives to promote employer wellness programs and encourage employers to promote and support healthier workplaces. Health-contingent wellness programs generally require employees to meet a specific standard related to their health to obtain a reward, such as programs rewarding employees who donâ&#x20AC;&#x2122;t use tobacco and programs rewarding employees who achieve lowered Volume 7 Number 3

Health Insurance Portability and Accountability Act (HIPAA) Effective September 23, 2013, and through 2014 into the future, the new HIPAA rules are important for medical professionals to know and understand. They are part of sweeping changes made to the HIPAA Privacy and Security Rules through enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The new rules expand the obligations of physicians and other health care providers to protect patients’ protected health information (PHI), extend these obligations to a host of other individuals and companies who have access to PHI, and increase the penalties for violations of any of these obligations. There are several areas to focus on when implementing these changes: • Breach notification requirements – The obligation to notify patients if there is a breach of their protected health information (PHI) is expanded and clarified under the new rules. There is now a rebuttable presumption of a breach, and breaches must be reported unless, after completing a risk assessment using four factors, it is determined that there is a low probability of PHI compromise. • Disclosures to health plans – At the patient’s request, physicians and other health care providers may not disclose information about care the patient has paid for out-of-pocket to health plans, unless for treatment purposes or in the rare event the disclosure is required by law. • Marketing communications – The new rules further limit the circumstances when physicians and other health care providers may provide marketing communications to their patients in the absence of the patients’ written authorization. • Notice of Privacy Practices (NPP) – Physicians and other health care providers must amend their NPPs to reflect the changes set forth above, Volume 7 Number 3

including those related to breach notification, disclosures to health plans, and marketing of PHI.

Social media privacy policy Legislation has been introduced or is pending in at least 36 states that governs social media and online privacy in the workplace. Ten states — Arkansas, Colorado, Illinois, Nevada, New Jersey, New Mexico, Oregon, Utah, Vermont, and Washington — enacted legislation in 2013. Fifteen states have 2014 legislation governing employee and applicant social media and online privacy — California, Florida, Georgia, Hawaii, Illinois, Iowa, Kansas, Massachusetts, Minnesota, New Hampshire, New York, North Carolina, Ohio, Rhode Island, and Wisconsin. Typical

2013 saw a reduction of more than 30% in the number of labor and employment bills enacted as compared to 2012, but new legislation in 2014 provides for changes that are just as important as ever for both large and small employers

of the social media privacy legislation is new legislation in Florida, which prohibits an employer from requesting or requiring access to a social media account of an employee or prospective employee and prohibits an employer from taking retaliatory personnel action for an employee’s failure to provide access to his or her social media account. Further, it prohibits an employer from failing or refusing to hire a prospective employee who does not provide access to his or her social media account.

Arbitration agreements Several cases in the last year shed light on what rules will govern employer arbitration agreements going forward. The United States Supreme Court ruled in 2013 that arbitration agreements containing class action waivers are enforceable, even if individual arbitration is economically

unfeasible, but employers must ensure the agreement contains an express waiver of class action arbitrations. The Ninth Circuit, applying California law, recently ruled that an employer cannot present an arbitration agreement on a “take it or leave it” basis when an employee submits an employment application. Recent California cases have held that an employer must choose a reputable arbitration forum whose rules are accessible and balanced, the employer must give the arbitration terms to the employee when he signs the agreement, and the arbitration clause must be readily identifiable.

Minimum wage Laws have been enacted in many states that raise the minimum wage effective in 2014. These states include the following: • Arizona ($7.90/hour effective 1/1/2014) • California ($9.00/hour effective 7/1/2014) • Colorado ($8.00/hour effective 1/1/2014) • Connecticut ($8.70 effective 1/1/2014) • Florida ($7.93/hour effective 1/1/2014) • Missouri ($7.50/hour effective 1/1/2014) • Montana ($7.90/hour effective 1/1/2014) • New Jersey ($8.25/hour effective 1/1/2014) • New York ($8.75/hour effective 12/31/2014) • Ohio ($7.95/hour effective 1/1/2014) • Oregon ($9.10/hour effective 1/1/2014) • Rhode Island ($8.00/hour effective 1/1/2014) • Vermont ($8.73/hour effective 1/1/2014) • Washington ($9.32/hour effective1/1/2014)

Employee handbooks With all of the changes to employment law in 2014, covering everything from health care to social media privacy and minimum wage, it is important that an employer’s employee handbook is updated to reflect these changes. To avoid mistakenly violating these and other important employment laws, we recommend using services such as HR for Health that ensure that you are compliant with all the necessary federal and state laws. EP

Endodontic practice 51

LEGAL MATTERS

cholesterol levels. Under final rules effective January 1, 2014, the maximum reward to employers using a health-contingent wellness program will increase to 30 percent of the cost of health coverage. The maximum reward for programs designed to prevent or reduce tobacco use will be as high as 50 percent.

ENDO INSIGHT

AAE promotes root canal awareness

he effectiveness of root canal treatment is well-established in dentistry; however, misinformation continues to circulate on the Internet that may cause patients to question the safety of endodontics. During Root Canal Awareness Week, March 30 – April 5, the American Association of Endodontists asked everyone in the dental industry to be an advocate for good dental health and share information about root canal safety. A new web page, www.aae.org/ rootcanalsafety, provides endodontists, general dentists, dental media, industry partners, and patients with authoritative and reliable information about the safety of endodontic treatment, while debunking myths that root canals cause cancer or other health problems. “As dental professionals, we know there is no evidence of a link between root canal treatment and cancer or other diseases,” said AAE President, Dr. Gary R. Hartwell. “Unfortunately, claims to the contrary, with sensational headlines, continue to make their way through social media and can be persuasive to a small portion of the public. It is in the best interest of patients to understand there is no valid, scientific evidence linking root canals to such health problems, and also to understand the advancements in modern dentistry that make endodontic treatment predictable, effective, and successful.” AAE resources to help support root canal safety include: Root Canal Safety Fact Sheet — explains the history of focal infection theory and research showing that there is no valid, scientific evidence linking endodontically treated teeth and systemic disease. Myths About Root Canals — patientfocused information explaining the safety and effectiveness of root canal treatment. Tooth Saving Tips — patient-focused resource explaining why saving a tooth is the preferred choice for optimal health. Endodontists Put Root Canal Patients at Ease — video educating patients about endodontic specialists and root canal procedures. 52 Endodontic practice

Endodontists: Partners in Patient Care — video explaining the relationship between general dentists and endodontic specialists. A recent study published in JAMA Otolaryngology — Head & Neck Surgery tested the association between dental caries and head and neck cancers. Results indicate that patients who have had one endodontic treatment had no change in their risk of cancer, while those who had two or more endodontic treatments actually had a 45 percent reduction in

their risk of cancer. The study could be a valuable talking point with patients and reinforces the fact that root canal treatment is both a safe and effective way to save the natural dentition. The AAE encourages the dental community to share these education resources via websites and social media channels to help get the facts to patients about root canal safety. You can also connect with AAE on Facebook at www. facebook.com/endodontists and Twitter @ savingyourteeth and @AAENews. EP

Volume 7 Number 3

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll CE COURSES Excellent and Effective Endodontics Dr. John Olmsted May 30, 2014 Raleigh, NC www.sybronendo.com/index/ sybronendo-events-02 Problem-Solving Essential in Endodontics Dr. Bernice KO May 30, 2014 Salt Lake City, UT www.sybronendo.com/index/ sybronendo-events-02 Hands-On Workshop: CS 3D Imaging Software Ryan Roosekrans June 6, 2014 Burlington, MA www.carestream.com/default. aspx?LangType=1033 Efficient and Effective Endodontics Dr. Michael J. Ribera June 6, 2014 Brooklyn, NY www.tulsadentalspecialties.com/default. aspx Efficient and Effective Endodontics Dr. Troy McGrew June 6, 2014 Knoxville, TN www.tulsadentalspecialties.com/default. aspx Efficient and Effective Endodontics Dr. Reid Pullen June 13, 2014 Claremont, CA /www.tulsadentalspecialties.com/default. aspx Efficient and Effective Endodontics Dr. Michael Ribera June 13, 2014 Allen, TX www.tulsadentalspecialties.com/default. aspx

Volume 7 Number 3

The Essentials of Endodontics Understand and Utilize EvidenceBased Concepts to Maximize Your Clinical Success Dr. Garry Bey June 13, 2014 San Antonio, TX www.sybronendo.com/index/sybronendoevents-02 Endodontic Solutions: Strategies for Performing Endodontic Treatment Predictably, Profitably, and Painlessly Dr. Gary Glassman June 13, 2014 Atlanta, GA www.sybronendo.com/index/sybronendoevents-02 Creating Endodontics Excellence Dr. Clifford Ruddle June 20, 2014 Phoenix, AZ www.tulsadentalspecialties.com/default/ education/calendar.aspx Troubleshooting in Endodontics — “Simplified …” Dr. Bernice Ko June 20-22, 2014 Anaheim, CA www.sybronendo.com/index/sybronendoevents-02 Everything Endo: A Live Clinical Experience Dr. Brett Gilbert June 27-28, 2014 Niles, IL www.sybronendo.com/index/sybronendoevents-02

EVENTS CBCT Technology Can Revolutionize Your Practice Dr. Bradley S. McAllister June 5, 2014 Rancho Cucamonga, CA www2.carestreamdental.com/events/ Views/Pages/SubSeminars.aspx

2014 Dental XP Global Symposium June 18-21, 2014 Hollywood, FL www.dentalxp.com/symposium

FREE WEBINARS A New Look at Filling Techniques Webinar Dr. Sergio Kuttler www.tulsadentalspecialties.com/default/ education/calendar.aspx Case Acceptance: Getting to “Yes” Dr. Kristin Pelletier www.tulsadentalspecialties.com/default/ education/calendar.aspx Changing the State of Obturation Webinar Dr. William Nudera www.tulsadentalspecialties.com/default/ education/calendar.aspx Endodontic Case Selection Webinar Dr. Diwakar Kinra www.tulsadentalspecialties.com/default/ education/calendar.aspx Endodontology: Diagnosis Webinar Dr. George Bruder www.tulsadentalspecialties.com/default/ education/calendar.aspx What’s New in Endo? Dr. Mike Horrocks www.dentsply.co.uk/Home.aspx Modern Canal Shaping Dr. Mike Horrocks www.dentsply.co.uk/Home.aspx Successful Endodontic Retreatment Dr. Carol Tait www.dentsply.co.uk/Home.aspx WaveOne: The New Single File System from Maillefer Dr. Justin Moody www.dentsply.co.uk/Home.aspx

Endodontic practice 53

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Instrumentarium Dental™ unveils the OP300 Maxio, delivering 3D scans up to 5 times lower dose than 2D pans

J. Morita announces TwinPower Turbine® 45 non-optic J. Morita, world leader in handpiece design, has expanded the TwinPower Turbine® 45 product line with a non-optic model. For clinicians using loops or a microscope, this handpiece offers a powerful, yet economical option. As with the original 45°, its compact head is smaller than competitive units and provides maximum access and visibility. Extremely powerful, it delivers up to 20 watts for smooth, efficient cutting. Rear-facing exhaust vents direct airflow away from the surgical site for patient protection. With zero suck back in the air line, TwinPower also provides excellent contamination control, especially important in surgical procedures such as sectioning of third molars. For more information, visit www.morita.com/usa/twinpower or call 1-888-JMORITA (566-7482).

Instrumentarium Dental, a designer and manufacturer of advanced imaging solutions, extends its extraoral product line with the new, feature-rich OP300 Maxio Pan/Ceph/3D, its most advanced imaging system. The latest addition introduces new and larger fields-of-view for dental and maxillofacial imaging, and a revolutionary Low Dose Technology (LDT) delivering qualityoptimized cone beam 3D scans with very low radiation dose, up to 5 times lower than traditional 2D panoramic images. Low Dose Technology provides quality-optimized images with a very low radiation dose across all fields-of-view. As a result, Low Dose Technology is ideal for dose-sensitive applications such as pediatric patients, follow-up imaging, or implant planning. All of these cases may be assessed with particularly low radiation dosage while still maintaining the clinical value. For more information, visit www.instrumentariumdental.com.

Brasseler USA® introduces the ESX® Rotary File

New Flow 150® gutta percha delivers smooth consistency and control at a lower working temperature Obtura Spartan® Endodontics is expanding its comprehensive line of endodontic products with the addition of new Flow 150 gutta percha, a superior filling material infused with nano technology. Flow 150’s unique nano formula produces optimal consistency and smoothness at a lower working temperature for better clinical application. Designed to work best when heated between 145˚ C and 165˚ C, this latex-free material is easily manipulated for a longer period of time without cooling or shrinking.

Brasseler USA , a leading manufacturer of quality instrumentation, is pleased to introduce the ESX® Rotary File. Designed with several performance-enhancing patented features, ESX Rotary Files are designed for a powerful yet minimally invasive performance, maximizing the long-term success of the treated tooth. The ESX Rotary File is equipped with a patented ACP™ (alternating contact point) design that efficiently cleans three-dimensionally as its sharp cutting edges engage with the canal walls at opposing intervals. The asymmetrical flute design alternates between zero to three points of engagement while moving debris coronally in a wave-like motion. This mechanism allows the ESX to operate at a low torque setting yet at a higher speed, reducing stress on the file and root.

Because it requires a lower working temperature to produce a desirable flow, clinicians are able to bring a heating plugger deeper into the root canal space for a better three-dimensional fill. Flow 150 is designed for use with smaller-gauge needles, and its smoother flow character prevents the material from sticking to endodontic condenser instruments. Its flow rate is also more consistent, helping prevent post-dispensing runoff from extruding devices. Nano technology increases Flow 150’s density, resulting in less volumetric change — and therefore fewer air bubble voids — when heated. The denser formula and lower working temperature help reduce gutta-percha molecule crystalline phase changes, which in turn reduces material shrinkage during the heating and cooling cycles.

For more information about the ESX Rotary File, visit http:// brasselerusadental.com/index.cfm/esx/ or call 800-841-4522.

For more information or to request samples, call 800-344-1321 or visit www.obtura.com.

54 Endodontic practice

Volume 7 Number 3

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT DENTSPLY Tulsa Dental Specialties launches ProTaper Gold™ – the next generation of its ProTaper® legacy DENTSPLY Tulsa Dental Specialties has launched the next generation in its ProTaper® legacy – ProTaper Gold.™ They feature the same efficient, variable tapered shapes and predictable performance that clinicians have known and trusted from ProTaper Universal,® with increased flexibility. ProTaper Gold’s proprietary advanced metallurgy creates a difference clinicians can see and feel. That’s because ProTaper Gold rotary files feature the same geometry as ProTaper Universal, but offer an increase in flexibility. This is especially important in the finishing files, which must navigate challenging curves in the apical region of the canal. The files also feature a shorter 11-mm handle for improved accessibility to teeth. ProTaper Gold provides more than twice the resistance to cyclic fatigue than ProTaper Universal. ProTaper Gold’s durability comes from a patented, progressively tapered design, which serves to significantly improve cutting efficiency and safety. For more information, visit www.TulsaDentalSpecialties.com/ ProTaperGold.aspx.

Carestream Dental launches latest digital imaging products Carestream Dental has launched two new products, the CS 8100 3D and the RVG 6200, to expand endodontists’ diagnostic capabilities and streamline daily workflows. Building on the highquality, 2D panoramic images available with the CS 8100, the CS 8100 3D now also offers 3D imaging and 3D model scanning all in one unit. The system’s 3D imaging technology captures images with 1:1 accuracy without distortion or overlap of anatomy. Selectable 3D programs give endodontists control of the image size, resolution, and dose, providing an EndoHD mode (5 cm x 5 cm), for high-resolution scans with 75 μm precision to capture the smallest details of root and canal morphology. The RVG 6200, Carestream Dental’s newest digital intraoral sensor offers a streamlined, three-step acquisition process: position, expose, and view. Practitioners simply position the sensor in a patient’s mouth, capture the image, and the image appears within seconds, further streamlining workflow. Endodontists can optimize image contrast according to their diagnostic needs with the RVG 6200’s endodontic filter, which optimizes contrast values throughout the entire range of the image for faster, more accurate diagnoses. The system’s easy-to-use sharpness filter enables clinicians to customize the appearance of images to their preferred look and feel. The filter displays contrast changes in real time, and six different sharpness options on the dynamic slider bar ensure practitioners are able to find their ideal image cosmetic, including a high-sharpening filter for endodontic procedures. For more information on Carestream Dental’s innovative solutions or to request a product demonstration, call 800-944-6365 or visit http://www.carestreamdental.com/2014AAE.

INDUSTRY NEWS CLINICIAN’S CHOICE partners with Angelus, Brazil

SS White Burs announces name change — now SS White Dental

CLINICIAN’S CHOICE Dental Products, Inc., announces a new partnership with Angelus, Brazil, and the addition of both MTA Angelus and MTA Fillapex to the CLINICIAN’S CHOICE line of innovative endodontic products. Having been on the dental market since 2001, and with a proven scientific and clinical track record, MTA Reparative Cement from Angelus exhibits excellent handling, ideal radiopacity, low solubility, and incomparable biological healing properties. With a 10-15 minute setting time, compared with 2-plus hours for other MTA products on the market, MTA Angelus is the material of choice for pulp capping, perforation repair, root-end filling, apexification, and apexogenesis, as well as root resorption repair.

SS White is pleased to announce an exciting new step for the business. The firm has changed its name from SS White Burs to SS White Dental, effective May 15, 2014. This name change better reflects the company’s commitment to the broader dental industry. Its corporate roots are founded in the history of Samuel Stockton White, who began his career as an apprenticing dentist and ventured into his own business in 1844, manufacturing porcelain teeth, in Philadelphia, Pennsylvania. SS White Dental embraces these strong company roots, and this recent name change is the first step of a longer strategic journey. The company proudly bears the name of its founder and embraces his original objective: simply better dentistry. The naming convention change reflects the firm’s strategic vision of impacting dentistry for the better.

Both products can be ordered directly by calling CLINICIAN’S CHOICE at 1-800-265-3444 or online at www.clinicianschoice.com

Volume 7 Number 3

For more information, visit http://www.sswhitedental.com.

Endodontic practice 55

AUTHOR GUIDELINES

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

Submitting articles Endodontic Practice US requires original, unpublished article submissions on endodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Endodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to endodontic dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot 56 Endodontic practice

Pictures/images

Disclosure of financial interest

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

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

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

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year;vol(issue#):inclusive pages. URL. Accessed [date]. Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

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

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

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

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

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

Volume 7 Number 3

ø5 x 8 cm

Endodontic imaging mode is available on all ProMax 3D models

The ProMax 3Ds is a versatile and dynamic 2D/3D imaging system that brings new possibilities for diagnostics, treatment planning, and patient counseling. • Endodontic mode features an ultra-high resolution with a voxel size of 75 m- perfect for diagnostics requiring the finest anatomical details • Determining root curvature • Diagnosis of periapical pathosis • Diagnosis of trauma: root fractures, luxation, displacement of teeth, and alveolar fractures • Determining exact location of root apex in presurgical planning to mitigate endodontic treatment complications • Obtaining true anatomical measurements

For a free in-office consultation, please call

1-855-245-2908 or visit us on the web at www.planmecausa.com

THE WAIT IS OVER

CS 8100 3D 3D imaging is now available for everyone Many have waited for a redefined 2D/3D multi-functional system that was more relevant to their everyday work, that was plug-and-play and that was a strong yet affordable investment for their practice. With the CS 8100 3D, that wait is over. • • • •

Versatile programs and views (from 8 cm x 9 cm to 4 cm x 4 cm) New 4T CMOS sensor for detailed images with up to 75 μm resolution Intuitive patient placement, fast acquisition and low dose The new standard of care, now even more affordable

LET’S REDEFINE EXPERTISE The CS 8100 3D is just one way we redefine imaging. Discover more at carestreamdental.com © Carestream Health, Inc. 2014. 10667 EN CS 8100 3D AD 0414