Endodontic Practice US - July/August 2014 Issue - Vol7.4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews July/August 2014 – Vol 7 No 4

PROMOTING

EXCELLENCE

Clinical applications of bioceramic materials in endodontics Drs. Marga Ree and Richard Schwartz

ENDODONTICS

Treatment of mandibular first molars with five root canals

Drs. Yuriy Riznyk and Maxim Zhovtukha

Practice profile Dr. Scott A. Norton

Combining technology and endodontics Dr. Mark Colonna

Corporate profile

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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 NATIONAL ACCOUNT MANAGER | Michelle Manning Email: michelle@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORD. | Jacqueline Baker Email: jbaker@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.endopracticeus.com www.medmarkaz.com

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© FMC 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 Orthodontic Practice US or the publisher.

Volume 7 Number 4

It’s all about restorative!

t’s frequently said that implant dentistry is a restorative treatment with a surgical component, meaning that it is restorative driven. But, endodontics is also a restorative-driven treatment when the tooth needs restorative treatment with an endodontic component. It does not matter if we are able to locate the canal orifices, negotiate the canals, instrument them, and obturate the canal system, if we are unable to predictably restore the tooth. Prior to initiating endodontic therapy, the tooth needs to be evaluated not only from a periodontal standpoint but also structurally. How much Dr. Gregori M. Kurtzman unrestored and undecayed tooth is present? Can the remaining tooth support and retain the crown? Will a post be needed to help retain the core? Restoration of endodontically treated teeth should be approached from an engineering standpoint. Reconstruction of the tooth needs to follow principles taking into consideration the repetitive loads that will be placed in the tooth in function. Endodontists need to overengineer how the tooth is rebuilt to ensure better long-term survival. Ferrule is often overlooked in today’s age of adhesive dentistry, but it is as critical today as it was in the past. The common philosophy is with adhesive materials; we don’t need much tooth on which to hang the crown since the bonding will hold it all together. Unfortunately, this is not evidence based but opinion based, and at the undergraduate level, ferrule is no longer emphasized. Yet lack of ferrule has been shown to affect survival of the tooth, and the literature supports use of 2.0 mm of ferrule. This is more critical in maxillary anterior teeth due to the direction of loading during mastication, but it is also important in all teeth being restored. When ferrule is not achievable, we need to determine if osseous crown lengthening is needed to create the needed tooth to achieve the desired ferrule. As osseous crown lengthening will require crestal bone removal also from at least one tooth mesial and distal to the tooth being restored, will that procedure compromise the adjacent teeth periodontally? If yes is the answer, then extraction and placement of an implant may provide a better prognosis without compromise to other teeth. These clinical determinations need to be made prior to initiating endodontics. There is nothing more discouraging to the patient than having the endodontic treatment, only to be told when restoration is initiated that the tooth is not restorable, or the long-term prognosis isn’t good. When we have determined that the tooth is restorable, how we restore the remaining tooth plays a role in potential issues in the long term. The use of cast post and cores has diminished to the point that they are rarely used today. Prefabricated metal posts are being used less frequently due to vertical root fractures that can occur when the tooth is overloaded. Metal posts that have a higher modulus of elasticity are stiffer then the tooth’s root and have shown a higher incidence of vertical root fracture when they fail than when fiber posts are used. Frequently, when this type of failure does occur, the tooth is non-salvagable, and extraction is indicated. Fiber posts are being used more frequently, replacing sales of metal posts. The benefit of fiber posts is they mimic the root’s modulus of elasticity. When teeth restored with a fiber post are overloaded, fracture typically occurs in the coronal (supragingival) portion leaving sufficient tooth remaining to re-restore the tooth. Often I hear from practitioners, “We don’t need to use posts anymore, as I am bonding the core in.” But we need to remember the purpose of the post is to retain the core, and over-engineering the reconstruction of the tooth is always best. Because, teeth rarely fail when they are over-engineered, but many fail due to under-engineering. Dr. Gregori M. Kurtzman Gregori M. Kurtzman, DDS, MAGD, FAAIP, FPFA, FACD, FADI, DICOI, DADIA, is in private general practice in Silver Spring, Maryland, and is a former Assistant Clinical Professor at the University of Maryland, Baltimore College of Dentistry, Department of Endodontics, Prosthetics and Operative Dentistry. He has lectured both nationally and internationally on the topics of restorative dentistry, endodontics and implant surgery and prosthetics, removable and fixed prosthetics, and periodontics and has over 350 published articles. He is privileged to be on the editorial board of numerous dental publications, a consultant for multiple dental companies, and a former Assistant Program Director for a University-based implant maxi-course. He has earned Fellowship in the AGD, AAIP, ACD, ICOI; Pierre Fauchard; Academy of Dentistry International; Mastership in the AGD and ICOI; and Diplomate status in the ICOI and American Dental Implant Association (ADIA). Dr. Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006. He can be contacted at dr_kurtzman@maryland-implants.com.

Endodontic practice 1

INTRODUCTION

July/August 2014 - Volume 7 Number 4

TABLE OF CONTENTS

Practice profile Scott A. Norton, DMD, MSD

Focus on family, patients, friends, growth, and community

Clinical

GuttaCore® system: a step forward in the evolution of endodontics Dr. Andrei Zoryan dispels some of the common myths surrounding carrierbased obturation............................. 17

Case study

Combining technology and endodontics Dr. Mark Colonna blends technologies for more effective treatment ....................................................... 24

Corporate profile COLTENE

The company strives to exemplify its motto, “The Brands You Trust”

ON THE COVER Cover photo courtesy of Dr. Marga Ree. Article begins on page 32.

2 Endodontic practice

Volume 7 Number 4

simple, adaptable

endodontic solutions

Irrigation amplification

All grown up Ultradent now offers Consepsis (2% chlorhexidine), ChlorCid (3% sodium hypochlorite), and EDTA 18% in 480ml bottles* to give you the best value on the irrigants you use with every endodontic procedure.

Don’t change your technique. Make it easier—and more economical—with Ultradent’s economy-size irrigants.

And with Ultradent’s economically priced irrigants, you do not have to sacrifice ease of use. Designed with a unique flip-top cap, Ultradent’s economy-size irrigants are easy to dispense into a container or even backfill a syringe—so easy, in fact, you can do it with one hand.

800.552.5512 ultradent.com Use NaviTip to easily deliver Ultradent irrigants just short of the apex. Available with regular and sideport delivery. *Smaller-volume syringes still available. © 2014 Ultradent Products, Inc. All Rights Reserved.

Irrigants

Unique flip-top cap makes backfilling syringes easy.

Scan to watch a short video about Ultradent irrigants.

TABLE OF CONTENTS

Office matters

Hard-piped filtered water system vs. self-contained bottled water system John Bednar helps avert problems coming down the pipe.....................28

Industry news ..............29 Case report/ Young Dentist Endodontic Award

Treatment of symptomatic apical periodontitis Dr. Lydia Harris, the third-place winner in the 2013 Young Endodontist competition in the UK, develops her endodontic skills for S-shaped root canals..............................................30

Continuing education

Clinical applications of bioceramic materials in endodontics

Drs. Marga Ree and Richard Schwartz explore current premixed bioceramic materials

Abstracts

The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-todate with the most relevant research ...................................................... 48

Product Profile

Continuing education

Treatment of mandibular first molars with five root canals Drs. Yuriy Riznyk and Maxim Zhovtukha present two case reports demonstrating treatment of mandibular first molars with five root canals .......................................................42 4 Endodontic practice

ESX® Rotary Files from Brasseler USA® So Sophisticated It’s Simple™: Designed to safely and efficiently navigate the most challenging canals ...................................................... 50

Materials & equipment ........................53 Endospective

Optimizing irrigation — consider the possibilities Dr. Rich Mounce discusses trends for creating cleaner canals....................54

Diary.........................................56

Practice management Superior customer service Dr. Roger Levin presents the 10 top ways to help create a perfect dental team...............................................52

Volume 7 Number 4

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

Implantologists

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

Scott A. Norton, DMD, MSD Focus on family, patients, friends, growth, and community What can you tell us about your background? For as long as I can remember, I wanted to make people smile. I always loved getting the class laughing in grade school. Looking back, I am sure this was so I could “study” my classmates’ teeth and get a jump-start on dental anatomy. My story starts in 1971 in Evansville, Indiana (home of the Donut Bank — the best doughnuts anywhere). For historical reference, 1971 is the year the Pirates won the World Series and the Colts took home the Super Bowl V trophy. One of my favorite childhood memories was getting my friend, Josh, in my dad’s dental chair (at around 4 years of age) and attempting to “perform a dental procedure.” I was fascinated with teeth from the very beginning. After attending Indiana University for my undergraduate studies, I was accepted to University of Louisville School of Dentistry. I graduated dental school with honors in 1996, completed a general practice residency (GPR) at the University of Louisville, and then went into private practice. Next, I

Scott Norton with childhood friend Josh in his father’s dental chair (at around 4 years of age) 6 Endodontic practice

Volume 7 Number 4

Sharpen Your Root Canal Visibility Introducing the new Detect™ Apex Locator from Maillefer. Detect™ Apex Locator is innovative, aesthetically pleasing, and delivers successful root canal therapy. Other features include: • Large color display to facilitate file tracking • Progressive sound control for dual control • Fully automatic device • Powered by rechargeable battery • Latest multi-frequency technology enables location of the apex in most types of canal conditions Check out our website for a short technique and product educational video perfect for customer demonstrations:

maillefer.com

The cursor on the tooth icon indicates the progresion of the file in the canal

Extended apical zone from 0.9 to 0.0

a solid tone will emit when the apex is reached

The oVEr icon indicates when the file passes the apex

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PRACTICE PROFILE attended the endodontic residency program at Indiana University, earning a master’s degree and graduating in 2000. My master’s thesis was on electronic apex locators (EAL), and I still have a passion for the EALs and dental technology.

Is your practice endodontics?

limited

Yes, and I love every minute of it!

during my GPR and became even more fascinated with endodontics. After 2 months in private practice, I knew in my heart that endodontics was my calling.

How long have you been practicing? I have been a dentist since 1996, and I opened my endodontic private practice in 2000 in Louisville, Kentucky.

Why did you decide to focus on endodontics?

What training have you undertaken (beyond your formal dental education)?

Dentistry has always felt natural to me, and I have been passionate about endodontics from the get-go. I still remember the first root canal that I performed; it was on a mandibular canine of a fellow dental student. I enjoyed the satisfaction of relieving discomfort and improving my colleague’s well-being. Minutia is very important to me; therefore, I like the detail required by endodontics and the technology involved. While attending dental school, I was naturally drawn to the field’s growing innovative technologies and had the opportunity to assist Oral and Maxillofacial Radiologist, Dr. William Scarfe, with digital radiography research. The technology intrigued me. I used my first apex locator

The best advice I received when I graduated dental school was “never stop learning.” My license to learn has inspired me to participate in multiple dental study clubs and to take a broad range of continuing education. I also enjoy speaking to study clubs and sharing the knowledge that I have gained. I feel very lucky to have a great organization like the AAE that supports our specialty and enjoy attending our annual sessions. I am currently a member and past president of the Louisville chapter of the Alpha Omega International Dental Fraternity. I also serve on the Louisville Dental Society executive board and see a vital importance of participating with organized dentistry.

Who has inspired you? We stand on the shoulders of those who came before us. My father, Dr. Glenn Norton, is a great inspiration and still practices comprehensive dentistry in Evansville, Indiana. He has the same passion for the dental profession. Using his “license to learn” advice, he performs dentistry at a high level and continues to take an abundance of CE. My uncle, Dr. Lyle Siegel, was also an inspiration to me. He was an anesthesiologist who headed to the hospital each day at the break of dawn. Uncle Lyle was very entertaining and taught me that the recipe for success includes the perfect blend of professionalism, high performance, and fun. Dr. Cathy Binkley was the head of my GPR, and at my request, purchased the first apex locator that I ever used. I’m forever grateful for her believing in me, which further fueled my desire to succeed. So many endodontic mentors contributed to my journey. My program director, Dr. Cecil Brown, nurtured my early endodontic skills and taught me what was necessary to be an endodontic specialist. Dr. Brown’s amazing ability to tell a story and simultaneously teach an important lesson is a quality that I admire and try to emulate in

Dr. Norton setting the patient parameters for a Planmeca CBCT image 8 Endodontic practice

Volume 7 Number 4

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 • Mac OS and PC compatible

For a free in-office consultation, please call

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

PRACTICE PROFILE my life. Also, Dr. Joseph Legan at the Indiana University School of Dentistry taught me to think, listen, be patient, and gave me the gift of a general life philosophy. My endodontic study club (E.S.C.A.P.E.) continually inspires me. Each year, we meet up in the hosting member’s city for a weekend of sharing and fun. The exciting topics that we address are ever-evolving and usually take many twists and turns (like canal anatomy). I believe when it comes down to it, the true strength of the group is the friendship we share. The group includes Dr. Ken Denardo (Pittsburgh, Pennsylvania); Dr. Mike Griffey (Grand Rapids, Michigan); Dr. Larry Johns (Phoenix, Arizona); Dr. Ed Kaminsky (Las Cruces, New Mexico); Dr. Ken Spolnik (Indianapolis, Indiana); and Dr. Randy Yee (Wailuku, Hawaii). I’m thankful for and inspired daily by my referring doctors and their staff. Their obvious commitment to our patients and dedication to the dental profession are remarkable.

What is the most satisfying aspect of your practice? This question is easy — improving the quality of my patients’ lives. My staff and I are here to help our patients feel better and relieve their anxieties. When a patient comes to our office, the goal is to provide a welcoming, comfortable, relaxed, and painfree endodontic experience.

Professionally, what are you most proud of? At the end of the day, navigating complex canal anatomy with success gives me great satisfaction. My team is top-notch,

Dr. Norton and his staff

and together we create a pleasant experience using a gentle touch and state-of-theart endodontic technologies. Every patient expects and deserves the highest quality care.

What do you think is unique about your practice? Our exceptional personal touch! As an extrovert, I enjoy getting to know each and every patient.

What has been your biggest challenge? Balancing work and family. It is my top priority to provide ample time for individualized patient care while also carving out

quality time with my family. Juggling family events while making sure our practice flows smoothly can be a challenge. Many times an important activity, like “Dad’s day” at school, occurs during office hours. I wouldn’t miss these moments for anything, but they definitely present scheduling challenges!

What would you have become if you had not become a dentist? An ophthalmologist — I was determined to use a microscope in my chosen profession.

What is the future of endodontics and dentistry? Technology is changing at the speed of light — our future is so dynamic and bright. I am very excited about the rest of my career, and what we can share with the next generation of endodontists. It is thrilling to view the groundbreaking information received from my CBCT unit. This technological advancement is becoming an integral tool for our endodontic arsenal. Finally, our future in regenerative endodontics is something that continues to intrigue me.

What are your top tips for maintaining a successful practice?

Dr. Norton’s lobby 10 Endodontic practice

As the great New York Yankees’ Joe DiMaggio said, “There is always some kid who may be seeing me for the first or last time; I owe him my best.” I want to give every patient 110% every day! When it comes down to it, fostering relationships, providing the best patient care, and staying on the cutting edge of endodontic treatment and technology are our primary goals. Volume 7 Number 4

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PRACTICE PROFILE What advice would you give to budding endodontists? Do not forget, this is a journey — get better every day! It is very important to learn from our mistakes (or better yet from a mentor who has already made the mistake). Take time to listen to each patient and answer every question. Consistently perform endodontic therapy at the highest level on every case.

What are your hobbies, and what do you do in your spare time? In my spare time, I spend as much time with my family as possible. I feel fortunate to have such a wonderful wife (she completes me) and our two boys who keep me going 24/7. I also love playing tennis and try to take a tennis lesson at least once a week.

Tell us about a place that you have visited because of your involvement in endodontics. In 2012, I had the unique opportunity to visit DENTSPLY Maillefer in Ballaigues, Switzerland. The once-in-a-lifetime experience was a career highlight. I participated in a “Train the Trainer” class and was amazed at the sprawling college-like campus of the facility. The engineering and technology that go into making our instruments are remarkable. Watching our rotary and hand files crafted from start to finish is truly an eyeopening experience. We are endodontists at a fantastic time, where globally, the profession grows by leaps and bounds! I made many international friends on this trip, and it was a top 10 experience in my quest for more knowledge. EP

Top 10 Favorites 1. My wonderful wife and children (Kim, Alex, and Ben) 2. My awesome dental team 3. The Indianapolis Colts (I still miss Peyton Manning) 4. Giordano’s pizza (a must stop at the Chicago Midwinter dental meeting) 5. DEXIS® digital radiography 6. DENTSPLY Maillefer - Detect electronic apex locator - Transmetal burs 7. Planmeca ProMax® 3Ds CBCT (with Endo module) 8. Global microscopes 9. Designs for vision dental loupes (with Q-Optics dental headlight — very bright!) 10. Dentsply Tulsa Dental Specialties - ProTaper Next® rotary files - ProGlider™ rotary glide path files

Dr. Norton with his wife, Kim, and children, Alex and Ben 12 Endodontic practice

Volume 7 Number 4

TDO IS ENDOPRENEURIAL This year, hundreds of endodontic postgraduate students will venture forth into the world as enterprising young clinicians. Many had the advantage of using TDO for Postgrads as part of their university training. Still others purchased it on their own for a one-time fee of $50. Either way, they will avoid the costly mistakes commonly made by new clinicians, and so can you. If you are a postgraduate student in your final semester, it’s not too late to take advantage of our special student pricing. Find out how TDO for Postgrads can save you countless headaches, thousands of dollars, and ensure a seamless transition into private practice—call today for a free demo.

“Initially, I thought setting up an office while in residency would be virtually impossible. However through each phase of the process, TDO has been there for me with advice, support and encouragement. Amazingly, my office will be open for business just a few weeks after graduation.” — Dr. Steven Binkley, University of Indiana

TDO FOR POSTGRADS Call 1-877-435-7836 or visit www.tdo4endo.com/ep for details

WWW.TDO4ENDO.COM/EP TDO for Postgrads is identical to our professional version but with a 500-patient limit. Upon graduation, students can upgrade to the professional version for an unlimited patient database.

CORPORATE PROFILE

COLTENE® The company strives to exemplify its motto, “The Brands You Trust” History of Coltene Since merging the Swiss company, Coltène, with the North American company, Whaledent, in 1990, the blended company, COLTENE® has grown significantly throughout the years by acquiring brands and companies like Hygenic®, Roeko®, Diatech®, Cutting Edge Instruments, and Vigodent. Since 2012, the combined Coltène/Whaledent brand unified under the COLTENE brand logo has brought polymer chemistry-based impression and filling materials, a broad range of high-precision mechanical instruments, dental pins and posts, carbide and diamond burs, and other rotary instruments, as well as a comprehensive offering in the area of hygiene and patient safety to international markets through sales partners. COLTENE’s overarching brand is now recognized worldwide with a fresh new flag design introduced in 2014. COLTENE has its world headquarters in Altstatten, Switzerland, and maintains production facilities in Germany, Hungary, and Brazil, and an American headquarters in Cuyahoga Falls, Ohio. The Cuyahoga Falls location is home to 325 employees, including a field sales team based throughout North America. Products produced in Cuyahoga Falls include ParaPost®, TMS Link® parapulpal pins, BioSonic® Cleaners and Solutions, HyFlex® File systems, Alpen® Rotary Instruments, PerFect® TCS Tissue Contouring System, Pindex® Modeling System, Hygenic® Wax and Acrylics, and many other products used by dental professionals and held in high esteem by them for many years. The company tagline, “The Brands You Trust,” has become synonymous with the COLTENE suite of products.

COLTENE’s American headquarters in Cuyahoga Falls, Ohio

file separation. HyFlex® CM™ NiTi files are manufactured utilizing a unique process that controls the material’s memory, making the files extremely flexible but without the shape memory of other NiTi files. This gives the file the ability to follow the anatomy of the canal very closely, reducing the risk of ledging, transportation, or perforation. COLTENE offers 4-hour workshops nationwide led by an Endodontist focused on helping General Practitioners improve their endodontic skills. The Endodontist has a full complement of products from COLTENE that provide everything necessary for a complete Root Canal

Therapy treatment. Starting with Endo-Ice® for diagnosis and Hygenic Dental Dam and Dental Dam Clamps for isolation, the clinician is ready to begin shaping the canal with Alpen® Rotary Instruments, BioSonic® Piezo Tips, HyFlex® Hand Files and Rotary Files, and CanalPro™ Irrigation System. Once the canal is shaped and cleaned, the dentist can choose Hygenic® SpectraPoint®* for drying, and Greater Taper GuttaPercha Points or GuttaFlow® 2 for obturation. If needed, he/ she can place ParaPost with ParaCore® cement and Core Buildup. The patient can then be sent to his/her personal dentist for the crown placement.

Comprehensive Endo Product Line

Coltene endodontic focus Endodontics is one of the major focuses for the company during the past 3 years. COLTENE has a complete line of endodontic products that aid the endodontic professional and general practitioner alike. The Hyflex® CM™ NiTi files offer clinicians up to 300% more resistance to cyclical fatigue, helping reduce the incidence of 14 Endodontic practice

Volume 7 Number 4

In addition to Endo, COLTENE is dedicated to two other product lines, Hygiene and Restorative. In 2013, the company introduced the BioSonic SUVI® piezoelectric scaler, with multiple units in the line as well as a large assortment of tips. SUVI can be used just for hygiene, but with tips for Perio and Endo; just about every practitioner in the office can use this machine. Four models are available, two with air polishing capabilities. SUVI has a unique handpiece that has a soft grip (removable for autoclaving) and a band of LED lights at the tip that brightly illuminates even the darkest posterior areas of the patient’s mouth. Other unique features of SUVI include a foot pedal that controls the unit without interruption, and water control on the handpiece itself. To support the continuing education of the practitioner, COLTENE offers Hygiene courses worth 3 CE credits.

In 2011, COLTENE launched COMPONEER™, an exciting and unique product that serves as the first anterior composite bonding system with veneer “shells” that help even the newest dentist in the office complete a beautiful smile for his/ her patients. Hands-on demonstrations by COLTENE reps at Lunch and Learns, plus 4-hour CE courses in the United States and Canada by AACD-accredited lecturers, help clinicians learn how to offer their patients who cannot afford porcelain veneers this option for an anterior mouth restoration. At about half the cost of porcelain, dentists have the opportunity to call back those patients who couldn’t afford the porcelain option, and grow their practice with revenue that would otherwise have been lost. COMPONEER® complements the rest of the Restorative line of products offered by COLTENE, including Synergy D6 composite, One Coat Bond adhesive, and another

BioSonic SUVI® Elite piezoelectric scaler

Before COMPONEER® Volume 7 Number 4

product launched in 2012, the S.P.E.C. 3®LED light. Both dentists and dental assistants find the S.P.E.C. 3 lightweight and easy to use, with a powerful Lithium Polymer battery that has capacity to perform 300 10-second cures between charges. Multiple curing modes provide maximum functionality in any clinical situation: standard is designed to cure 2 mm of composite in 5 seconds; 3K mode allows for a more rapid curing time of 1 second for 2 mm of composite. A third option – Orthodontics mode – cures a full arch of brackets with two 3-second intervals per bracket.

S.P.E.C. 3®LED light

After COMPONEER® Endodontic practice 15

CORPORATE PROFILE

Additional corporate focus products

CORPORATE PROFILE Additional Coltene North America focus items Michael Nordahl, a 30-year COLTENE veteran, is General Manager of the North American Headquarters and is also in charge of Global Business Development. A large amount of COLTENE’s assets are invested in development activities, and it is up to Nordahl to help target products of the future. Development is planned far in advance by COLTENE’s R&D and marketing teams, with validation through research and customer interaction to ensure that COLTENE releases new products that provide improved clinical results, such as the ones previously shown. Nordahl says, “We have competent people who understand the needs of the end-user. Every new product undergoes extensive field-testing by dentists and opinion leaders. “The evolving dental consumer is another facet of the product development equation. There now exists a group of patients who not only seek dental health but also extend that desire to highly cosmetic transformations. Some patients now visit the dental office, not only to have certain things fixed but with a list of demands and questions about how to change other aspects of their smile,” Nordahl continues. COLTENE offers education materials for dentists who do COMPONEERs, which dentists can use in their offices (brochures and posters) and promote in their statement mailings (stuffers) that cater to that patient. “Another group that cannot be ignored is the ‘baby boomers’ who were born between 1946 and 1964, that are entering retirement. This group shares characteristics that include a great concentration of wealth, they are prolific consumers, they are well-educated, and they are living longer because they are not only very conscious about their health but also their beauty,” says Nordahl.

Michael Nordahl 16 Endodontic practice

Community-minded COLTENE believes in shared responsibility. “The dental industry can be described as a community and we can all grow — professionally and personally — by giving back to this community. Two issues that immediately come to mind are education and the underserved,” says Nordahl. “Education, through dental schools, hygiene and assisting programs, lab training, and so on, is fundamental to the future of dentistry. A pool of well-educated people entering the profession is necessary for the stability and development of the dental community.” Through its grants program, COLTENE supplies a

substantial amount of products globally to dental and hygiene schools every year. Nordahl says another issue of national importance is access to care for the underserved populations in this country. COLTENE has a wide range of initiatives that help give back to these struggling populations. “We have a long list of dental professionals who engage in mission work inside and outside of the U.S. and others who volunteer in clinics in our own cities.” COLTENE’s donations program shares dental supplies with many 501 (c) (3) organizations and views this as a principal responsibility to the marketplace. EP

Dr. Bob Koff doing a root canal in Antarctica Volume 7 Number 4

Dr. Andrei Zoryan dispels some of the common myths surrounding carrier-based obturation Carrier-based gutta percha Carrier-based obturation (such as Thermafil®, GT® obturator, ProTaper® obturator [Dentsply Tulsa Dental Specialties]) is one of the most popular techniques of root canal filling worldwide, which enjoys deserved recognition from leading authorities in the field of endodontics, including Drs. L. Stephen Buchanan, Giuseppe Cantatore, Julian Webber, Pierre Machtou, James L. Gutmann, and others. This simple and effective procedure significantly reduces dentists’ working time while ensuring high-quality obturation, especially in narrow root canals and anatomically complex canals (Buchanan, 2009; Christensen, 1991; Dummer, et al., 1994; Cantatore, 2001) (Figures 1 and 2). However, many dentists are still prejudiced against the use of obturators, preferring lateral or vertical condensation instead. The main reason for this is the existence of various myths about carrier-based obturation, which often contradict each other.

Myth one: Application of obturators causes periodontal tissue damage, manifested by postoperative sensitivity. Therefore, endodontic treatment will inevitably end in failure In fact, research suggests that temperature rise on the external surface of the root in the use of obturators is an average of 3.87°C, whereas for periodontal tissue damage, it is necessary to increase the temperature at least 10°C (Lipski, 2004). The postoperative pain that can occur in some cases is caused by extrusion of the air from the root canal space into the periapical tissues during insertion of the obturator. Such sensitivity resolves spontaneously, without subsequent development of any complications.

Andrei V. Zoryan, DDS, PhD, (medical science), is a member of the endodontics section of the Russian Dental Association and is director of the Garmoniya Dental Training Centre in Russia.

Volume 7 Number 4

Figures 1 and 2: Root canals with an evident curve, filled with carrier-based gutta percha

Myth two: When obturators are used, there is a high risk of guttapercha extrusion beyond the apex Despite its simplicity, the carrier-based gutta percha obturation technique requires strict adherence to the rules of root canal preparation. An important stage is the gauging of the apical foramen, since using an obturator of a smaller diameter than that of the apical foramen may indeed lead to guttapercha extrusion into the periapical tissues. Yet when the root canal is prepared correctly, and the instructions for carrier-based root canal obturation are followed accurately, the probability of extrusion is virtually ruled out.

Myth three: Only the obturator’s carrier reaches the apex. The gutta percha and sealer stay in the coronal and middle thirds of the canal This is actually a real possibility if the canal preparation, irrigation, and carrier-based obturation guidelines are not observed. There are several key factors to avoid this problem: 1. The root canal orifice must be sufficiently widened (“funnel shape”) for the obturator to enter freely, without losing gutta percha at the canal entrance. 2. The root canal must be properly disinfected. A vital condition for high-quality irrigation is the use of sodium hypochlorite and chemicals

removing smear layer created during canal preparation, such as a 15% to 17% EDTA (aqueous solution) or citric acid. This approach allows highquality obturation of the main canal to be achieved, as well as enabling the practitioner to fill its ramifications (lateral canals, apical delta system, anastomoses between canals). 3. The coronal and middle thirds of the canal should be filled with sealer, ensuring that the obturator slides smoothly along its walls. At the same time, the sealer’s consistency should not be too dense. Epoxy-resin-based sealers are the ideal option, such as AH Plus® (Dentsply), Adseal (Meta Biomed), etc. 4. The obturator must be inserted into the root canal slowly and smoothly. Thermafil® obturators, with .04 taper, are inserted into the canal over 3 to 4 seconds. Obturators with a larger taper (such as GT, ProTaper, and WaveOne®) are inserted during 6 to 8 seconds. Using carrier-based gutta percha allows predictable, successful results in root canal obturation to be achieved, as confirmed by numerous studies (Beatty, et al., 1989; Dummer, et al., 1993; Gençoglu, et al., 1993; Gençoglu, et al., 2002; Xu, et al., 2007; Inan, et al., 2007; Gençoglu, et al., 2007; Saunders, et al., 1994; Gutmann, et al., 1993; Endodontic practice 17

CLINICAL

GuttaCore® system: a step forward in the evolution of endodontics

CLINICAL

Figure 3: ProTaper Universal D series instruments

Dalat, et al., 1994; Pathomvanich, et al., 1996; Abarca, et al., 2001; Kontakiotis, et al., 2007).

Myth four: It is hard to remove obturators from the canal for retreatment Many clinicians encounter certain problems when a carrier-based gutta-percha obturation needs to be removed. These problems are most often caused by the dentist lacking the appropriate tools. The relevant literature attests that removing an obturator filling from a canal takes even less time than retreatment of a canal filled with gutta percha (Frajlich, 1998; Royzenblat, Goodell, 2007). The optimum solution for these purposes is using nickel-titanium rotary instruments (ProFile®, GT, etc.). In my own practice, I use ProTaper Retreatment files (D series) (Figure 3). Using these instruments, it is possible to extract the obturator’s plastic carrier within 1 minute, after which removing gutta-percha residue from the canal walls becomes a fairly easy task.

Myth five: A plastic obturator carrier impedes proper preparation of the post space When preparing the canal for a post, it is essential, before using the appropriately sized post preparation bur, to remove the obturator’s carrier to the necessary depth. To this end, practitioners often use diamond burs (which is not really a very safe approach),

Figure 6: GuttaCore obturator structure 18 Endodontic practice

Figure 5: GuttaCore obturators

Figure 4: Post space bur

ultrasonic tips, and electrically heated pluggers (System B™ [SybronEndo], Calamus® DUAL [Dentsply Tulsa Dental Specialties], Beefill® [VDW Dental], etc). However, in my opinion, the most predictable option is application of dedicated Post Space Burs (Dentsply Maillefer) (Figure 4). This bur is used in a turbine handpiece without water cooling; it allows removal of the plastic carrier from the root canal to the full length of the post planned in one movement.

Features and usage of the GuttaCore® (Dentsply Tulsa Dental Specialties) system Based on the prejudices set out previously, the main claim of dentists against obturators, one way or another, is the presence of the plastic carrier in them. The GuttaCore system demonstrates an all-new application in the concept of carrier-based gutta percha (Figure 5). The GuttaCore obturator carriers are not made from plastic, but from a guttapercha elastomer with intermolecular cross links (cross-linked gutta percha). Thus, the obturator is made entirely of gutta percha in two different forms (Figure 6). This makes for not only rapid and high-quality threedimensional root canal obturation, but also for an easy post space preparation and root filling removal, in case retreatment is required. The carrier can be removed from the root canal just as easily as gutta percha, since it also is gutta percha. Consequently, for these purposes, we can use the same

instruments as in canals filled using lateral or vertical condensation. Working with the GuttaCore system is very easy, but there are a series of key factors that should be considered to avoid procedural errors. Here is a stage-bystage sequence for the use of GuttaCore obturators: 1. The root canal must be properly shaped and disinfected. The GuttaCore system is universal, meaning it can be used regardless of which instruments were used to prepare the root canal. However, according to research, root canals should have either no less than .06 taper or a large apical diameter after preparation. This is essential in order to ensure high-quality irrigation and three-dimensional obturation (Boutsioukis, et al., 2010). When using the GuttaCore system, the root canal must be widened to at least size 20.06 or 25.04. 2. Select the right GuttaCore obturator diameter. If .06 or larger instruments were used to prepare the root canal, then select an obturator of the same size as the final nickel-titanium file. If .04 instruments were employed, then select obturator one size smaller. Under no circumstances should any gutta percha be cut off from the obturator, as this may damage the carrier. 3. Gauging the root canal is a very important stage in ensuring predictable, high-quality, three-dimensional obturation.

Figure 7: Blister pack with obturators and verifier Volume 7 Number 4

CLINICAL To this end, each GuttaCore blister pack, besides five obturators, has a verifier of corresponding size and taper (Figures 7 and 8). This is a manual instrument that is passively inserted to the working length of the root canal. If the verifier does not passively fit to working length, it can be used as a finishing file for apical enlargement. 4. When using GuttaCore obturators, a thin layer of sealer is applied to the coronal or, in case of long root canals, the coronal and middle thirds of the canal. To apply the sealer, a paper point, a probe, or in case of using AH Plus Jet sealant, a special mixing tip can be employed (Figure 9). The preheated obturator, in the process of insertion into the root canal, evenly distributes the sealer along its walls. If there is excess sealer, or it was applied to the full working length, there is a very high risk of sealer extrusion into the periapical tissues. 5. The working length is set on the oburator, after which it is placed into a holder of one of the ThermaPrepÂŽ 2 (Dentsply Tulsa Dental Specialties) ovenâ&#x20AC;&#x2122;s heating elements (Figures 10 and 11). The distinguishing characteristics of the ThermaPrep 2 oven are rapid three-dimensional heating of obturators, while maintaining the properties of the gutta percha carrier, as well as the option of having both heating elements operating simultaneously. When working with the GuttaCore system, unlike obturators with a plastic carrier, a minimum heating level of 20-25 is set on the operating panel of the oven, regardless of the obturator size (Figure 12). The obturator is placed into the ThermaPrep 2 heating element by gently pressing down the holder. Immediately, the operating cycle is automatically activated, and an indicator light is switched on. The option of having both heating elements operating simultaneously makes it possible to heat up two obturators at the same time, if necessary. When the heating is complete, the oven makes a sound signal, and the indicator

light starts blinking. Pressing on the holder releases it; the obturator is removed (Figure 13), and slowly, without rotation, inserted into the root canal to the working length. With cases that have difficult access to root canals, especially in posterior teeth in a patient with limited oral opening, the GuttaCore obturator carrier may be inserted with pliers (Figure 14), after the obturator

handle has been removed by bending it from side to side (Figures 15 and 16). 6. After the obturator is inserted into the root canal, the heated gutta percha can be condensed with a plugger in the coronal part of the root canal. This generates additional hydrodynamic pressure, enabling the gutta percha to fill the ramifications of the main canal, such as

Figure 9: AH Plus Jet sealer with mixing tip for inserting material directly into root canals

Figure 8: Canal size verifier

Figure 10

Figures 11-13: Heating an obturator in a ThermaPrep 2 oven

Figures 12

Figures 13

Figures 14-16: Application of GuttaCore obturators in hard-to-access root canals 20 Endodontic practice

Volume 7 Number 4

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CLINICAL

Figures 17-19: Examples of GuttaCore obturators used in clinical situations with nonstandard anatomy of root canals

lateral canals, apical delta system, anastomoses between canals, etc., even better. During the condensation process, the obturator should be held firmly by the handle, preventing any displacement. 7. The final stage of obturation is the removal of the handle and the excess carrier above the orifice level. When using the GuttaCore system, there is no need to use special Thermacut® burs for this purpose. The carrier can be cut off at the orifice using a regular round bur or sharp hand excavator, or simply broken off using gentle lateral motions. To clean off the gutta percha and sealer residue from the access cavity, a cotton pellet soaked in chloroform or ethanol can be used.

Conclusion Endodontics is evolving with simplification of technical procedures, reducing the dentist’s work time needed to perform them. There are new instruments, materials, devices, and accessories being developed in order to reduce the number of working stages and make endodontic treatment less labor intensive. At the same time, great attention must certainly be paid to ensure a simultaneous increase in the predictability of results and overall treatment success. Development of the GuttaCore obturation system is indeed a step forward in the evolution of endodontics. This system allows optimal three-dimensional obturation to be achieved, quickly and without special effort, in situations where the dentist may encounter certain problems when applying other obturation techniques (Figures 17-19). EP 22 Endodontic practice

REFERENCES 1. Abarca AM, Bustos A, Navia M. A comparison of apical sealing and extrusion between Thermafil and lateral condensation techniques. J Endod. 2001;27(11):670-672. 2. Beatty RG, Baker PS, Haddix J, Hart F. The efficacy of four root canal obturation techniques in preventing apical dye penetration. J Am Dent Assoc. 1989;119(5):633-637. 3. Boutsioukis C, Gogos C, Verhaagen B, Versluis M, Kastrinakis E, Van der Sluis LW. The effect of root canal taper on the irrigant flow: evaluation using an unsteady Computational Fluid Dynamics model. Int Endod J. 2010;43(10):909-916. 4. Buchanan S. Common misconceptions about carrier-based obturation. Endod Pract. 2009;12(4):7-11. 5. Cantatore G. Thermafil versus System B. Endod Pract. 2001;4(5):30-39. 6. Christensen G. Improved Thermafil concept well accepted. CRA Newsletter. 1991;12:4. 7. Dalat DM, Spångberg LS. Comparison of apical leakage in root canals obturated with various gutta percha techniques using a dye vacuum tracing method. J Endod. 1994;20(7):315-319. 8. Dummer PM, Lyle L, Rawle J, Kennedy JK. A laboratory study of root fillings in teeth obturated by lateral condensation of gutta percha or Thermafil obturators. Int Endod J. 1994;27(1):32-38. 9. Dummer PMH, Kelly T, Meghji A, Sheikh I, Vanitchai JT. An in vitro study of the quality of root fillings in teeth obturated by lateral condensation of gutta percha or Thermafil obturators. Int Endod J. 1993;26(2):99-105. 10. Frajlich SR, Goldberg F, Massone EJ, Cantarini C, Artaza LP. Comparative study of retreatment of Thermafil and lateral condensation endodontic fillings. Int Endod J. 1998;31(5):354-357. 11. Gençoglu N, Garip Y, Bas M, Samani S. Comparison of different gutta percha root filling techniques: Thermafil, Quick Fill, System B and lateral condensation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(3):333-336. 12. Gençoglu N, Oruçoglu H, Helvacioglu D. Apical leakage of different gutta percha techniques: Thermafil, Js QuickFill, Soft Core, Microseal, System B and lateral condensation with a computerized fluid filtration meter. Eur J Dent. 2007;1(2):97-103.

15. Inan U, Aydemir H, Tasdemir T. Leakage evaluation of three different root canal obturation techniques using electrochemical evaluation and dye penetration evaluation methods. Aust Endod J. 2007;33(1):18-22. 16. Kontakiotis E, Chaniotis A, Georgopoulou M. Fluid filtration evaluation of three obturation techniques. Quintessence Int. 2007;38(7):e410-416. 17. Lipski M. Root surface temperature rises in vitro during root canal obturation with thermoplasticized gutta percha on a carrier or by injection. J Endod. 2004;30(6): 441-443.

13. Gençoglu N, Samani S, Gunday M. Evaluation of sealing properties of Thermafil and Ultrafil techniques in the absence or presence of smear layer. J Endod. 1993;19(12):599-603.

18. Pathomvanich S, Edmunds DH. The sealing ability of Thermafil obturators assessed by four different microleakage techniques. Int Endod J. 1996;29(5):327-334.

14. Gutmann JL, Saunders WP, Saunders EM, Nguyen L. An assessment of the plastic Thermafil obturation technique. Part I. Radiographic evaluation of adaptation and placement. Int Endod J. 1993;26(3):173-178.

19. Royzenblat A, Goodell GG. Comparison of removal times of Thermafil plastic obturators using ProFile rotary instruments at different rotational speeds in moderately curved canals. J Endod. 2007;33(3):256-258.

Volume 7 Number 4

CASE STUDY

Combining technology and endodontics Dr. Mark Colonna blends technologies for more effective treatment

ecent developments in endodontic technology give clinicians today a definite advantage when performing root canal therapies. In particular, I have found success with the Endo-Eze® TiLOS™ endodontic system (Ultradent) combined with magnification and cone beam technology. The following case study shows how these products and technologies work together to achieve a quality result using minimally invasive techniques. A female patient, age 46, with a nonremarkable health history, came into the office with a toothache. The upper right second molar had been bothering her for a few months prior to her coming to the office to have it checked. We took a digital periapical radiograph, which didn’t appear to have any pathology (Figure 1). The patient exhibited advanced wear due to bruxism and had been treated for TMD at another dental office earlier in her life. Some small fractures and wear facets were found on the teeth upon examination with the dental microscope, and the tooth had a composite restoration that appeared to be in acceptable condition. We decided to perform a cone beam computed tomography (CBCT) scan using our Galileos® ComfortPLUS CBCT

Mark Colonna, DDS, is a 1983 graduate of Loyola University School of Dentistry. He has been in private practice since 1983 and has held positions as an assistant clinical professor of radiology and assistant clinical professor of operative dentistry at Loyola University School of Dentistry from 1983–1992. In 1992, he moved to Whitefish, Montana, and opened a new practice. He established the Montana Center for Laser Dentistry (MCLD) in Whitefish in January 2001. Dr. Colonna lectures and teaches nationally and internationally on laser dentistry and has published articles in various well-known dental journals on this topic. He is a member of the American Dental Association, Montana Dental Association, Academy of General Dentistry, Academy of Laser Dentistry, a founding member of the World Clinical Laser Institute, and a lifetime member of the World Congress of Minimally Invasive Dentistry. He received the 2003–2004 Clinician of the Year Award from the World Congress of Minimally Invasive Dentistry. Dr. Colonna also received Diplomate status in the World Congress of Minimally Invasive Dentistry and Mastership Status Certification in the use of the Er,Cr:YSGG dental laser from the World Clinical Laser Institute in January 2004. He is an adjunct associate clinical professor in the newly formed Department of Laser Dentistry at the Arizona School of Dentistry and Oral Health, the first dental school in the world to require its dental students to complete laser-certification training prior to graduation.

scanner (Sirona Dental). With the triangulation of data — i.e., magnification during exam (visual), digital X-rays (DEXIS), and CBCT scan — we were able to decide that tooth No. 2 was in need of endodontic treatment. With the CBCT scan, we are able to see a number of issues that pointed to pathology (Figure 2). On the tangential and cross-sectional slices, we were able to see the enlargement of the periodontal ligament in the periapical region (dark areas). Noted also was some

Figure 1

Figure 2

Figure 3 24 Endodontic practice

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CASE STUDY tissue inflammation in the right sinus floor, which can be an indication of periapical pathology with irritation into the sinus. On the axial view, we saw the presence of four canals about mid-root. Views from the coronal and sagittal also helped confirm the diagnosis (Figure 3). In addition to the inflammation noted in the oblique view, we also noted sinus inflammation above tooth No. 2 and a clean sinus on the left side in the coronal view. These differing views in the CBCT scan — the ability to see the pathology in 3D — is, in this author’s opinion, a huge advantage over traditional means of diagnosis. We scheduled the patient for endodontic treatment on tooth No. 2. We anesthetized the patient’s tooth using lidocaine with 1:100,000 epinephrine buffered with sodium bicarbonate (Onset from Onpharma®). We placed the rubber dam, and proceeded to make access into the root canal chamber

under the dental operating microscope (Global) (Figures 4 and 5). Because of the road map that the CBCT scan gives the operator, it was fairly easy to find all four orifices quite quickly. Also, a minimally invasive access preparation was easy to facilitate because we knew where the anatomy was prior to access. We then used a No. 6-10 file and an electronic apex locator (EAL) to measure the length of all four canals (Figure 6). We filed each canal to a size No. 15 file using Endo-Eze TiLOS files (Ultradent). We then used a reciprocating Endo-Eze handpiece and shapers (Ultradent) with File-Eze® (Ultradent) as a lubricant during the complete enlargement phase of treatment (Figure 7). In between each file and shaper, we used the LightWalker® Er:YAG laser (Fotona) utilizing PIPS™ (Photon Induced Photoacoustic Streaming) technology, laser-assisted irrigation with NaOCl

(ChlorCid® from Ultradent), and sterile water1 (Figures 8, 9). By irrigating in between each TiLOS file and shaper, we are assured that the dentinal debris and biofilm are removed with copious amounts of irrigants. This allows for better three-dimensional obturation with a flowable sealer or even calcium hydroxide intracanal medicaments when needed. Once we were finished with the TiLOS reciprocating shaper files (started after enlarging canals to size 15 with TiLOS hand files), we then used the apical files to enlarge to a No. 25 final file size in all canals (Figure 10). We then finished irrigation with sterile water and PIPS™, followed by a final rinse with a syringe and the double sideport irrigator NaviTip® (Ultradent). We then used a capillary suction tip to remove excess fluid in the canals and paper points to dry prior to calcium hydroxide placement (Figures 11 and 12).

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8: PIPS™ tip placed into fluid in coronal access only — not in canal orifices

Figure 9: Note fluid movement with laser tip activation with PIPS™

Figure 10

Figure 11

Figure 12

26 Endodontic practice

Volume 7 Number 4

CASE STUDY

Figure 13

Figure 16: Final radiograph of minimally invasive endodontic treatment. Note anastomosis between MB1 and MB2 about mid-root

Figure 19

In this particular case, we dressed the canals with UltraCal® XS calcium hydroxide paste (Ultradent) as an interim dressing (Figure 13). As seen in Figure 14, placing UltraCal XS into the MB2 canal actually causes it to flow up the MB1 canal due to the combined three-dimensional cleansing of PIPS™ and TiLOS files and shapers. The anastomoses are clear and devoid of tissue and debris (Figure 15). We then temporized with Fuji II™ LC glass ionomer cement (GC America) bonded in with Peak® Universal Bond (Ultradent) (Figure 17). Two weeks later, the patient returned, and we placed the rubber dam again, but this time no anesthetic was used. We used PIPS™ and Skini syringes (Ultradent) with NaviTip FX tips (Ultradent) to irrigate and remove excess calcium hydroxide. We then Volume 7 Number 4

Figure 14

Figure 15: UltraCal CaOH placement

Figure 17

Figure 18

Figure 20

checked each canal for any excess fluid weeping or drainage under high magnification with the microscope. With each canal dry and patent, we then used EndoREZ endodontic sealer (Ultradent) to obturate each canal. Placing resin-coated gutta percha cones specially formulated to bond with EndoREZ in each canal to working length ensures that the cones are completely bonded to the resin sealer (Figure 16). After obturation, we then needed to seal the orifice completely. We placed Peak Universal Bond (Ultradent) into the orifice and then covered with PermaFlo® Purple flowable sealer (Ultradent). We used Fuji II LC as a final orifice filling material and cured with VALO® Cordless LED curing light (Ultradent) (Figures 17–20). In conclusion, using the Ultradent system for mechanical debridement of the root canal system allows for minimal filing

and shaping. We have found that including PIPS™ along with the TiLOS file and shaping system helps us achieve threedimensional debridement with minimal, if any, transportation or changing of the canal morphology. This allows us to maintain more of the original tooth integrity and strength as well. By using all the chemistries that are designed to work together in a synergistic fashion during canal preparation and obturation, the outcome becomes very predictable. The method we used is time efficient and cost efficient. Predictable patient treatment outcomes make performing endodontics both enjoyable and profitable. EP

REFERENCES 1. Jarmillo DE, Aprecio AM, Agnelov N, DiVito E, McClammy TV. Efficacy of photon induced photoacoustic streaming (PIPS) on root canals infected with Enterococcus faecalis: A pilot study. Endodontic Practice US. 2012;5(3):28-32.

Endodontic practice 27

OFFICE MATTERS

Hard-piped filtered water system vs. self-contained bottled water system John Bednar helps avert problems coming down the pipe

f your office currently has a hard-piped filtered water system, now is a good time to consider if and when you should change to a self-contained bottled water system. A hard-piped filtered water system is a system that has a copper water line connected to a water filter that is usually located within the equipment room. The copper water line is typically installed under the concrete floor and either runs towards the front of the office, and then branch lines run to each treatment room, or individual lines run from the equipment room to each treatment room. There are a few issues in having the hard-piped filtered water system. One issue is where the hard-piped filtered copper water line terminates within the treatment area. It usually requires a 3/8” compression fitting to be installed on the line so that the DCI water handpiece hose can be connected. The point of this connection often fails, and if an equipment control panel is not being utilized, then the water is constantly running. If the failure occurs after hours, then the doctor and staff arrive the following morning to find that the office has flooded. Another issue that is standard practice is that building departments and/or city inspectors are requiring that a backflow preventer be installed on every line where a handpiece or another piece of equipment is connected. So, a backflow preventer is beginning to be a requirement in the individual treatment areas, in addition to within the equipment room or wherever the main water source enters the suite. A backflow preventer will cost anywhere from $800 to $1,000 and will require annual testing.

John Bednar currently serves as the construction project manager at OrthoSynetics and has been with the company since 2002. Mr. Bednar works with the entire project team from the initial space-planning, concept through the architectural and engineering phase, ultimately working with and overseeing the construction of the office until the office is open. He also helps in expansions and remodels and assists in facility management. John has over 17 years of experience in the construction of dental facilities.

28 Endodontic practice

If your office did not to have to meet these requirements at the time it was built, then you can expect for these requirements to be imposed on you some time in the near future as more local jurisdictions are starting to perform inspections to check on items such as these. Keep in mind that after the backflow preventer installation is complete, it then must be tested on an annual basis by a company that is certified to do so. The reason for this requirement is to prevent any contaminated water from backing up and finding its way back into the city’s main domestic water supply. If your office currently has this hard-piped filtered water system, then you may want to make sure you have an equipment control panel or another way to shut off this water line when you leave for the day or for an extended period of time. The equipment control panel has switches and/or buttons to control the turning on and off of the hard-piped filtered water system, the vacuum pump, and the air compressor. This equipment control panel should be conveniently located so that staff can easily turn the filtered water, air compressor, and vacuum pump on upon arrival and then turn if off before leaving for the day. Turning the filtered water off at the end of the day will prevent the office from flooding if a failure should occur since the only water that will leak from the system will be the minimal amount of water still within the line. As an alternative, you could install a self-contained bottled water system. This system comes with different-sized bottles depending on your needs. The cost of these bottles ranges between $200 and $400 per bottle. The bottle can mount inside a cabinet if rear delivery is used or inside a chairside mobile or stationary cart. The bottle can also attach directly to the chair or to the pivot arm if an over-the-patient delivery is desired. The bottle is pressurized directly off of the air line. The 3/8” compression fitting installed on the air line may possibly need to be replaced with a double 3/8” compression fitting depending on the exact system to be used. Filling the bottles with domestic water has become

more of the norm, although an independent countertop filtering system can be utilized to fill the bottles without the worries of backflow prevention. The old hard-piped filtered water line in the treatment areas would simply be capped since it would no longer be in use, and the same would apply within the equipment room or wherever the main water source may be. When you consider updating your hard-piped water system, it is important to evaluate the cost of the modifications that need to be made and implemented in an effort to prevent failure, as well as the cost of the inspections to meet your city’s building requirements. While doing so, you should also evaluate the potential costs for a self-contained water system considering the versatility, and if such system meets your needs. It is important to address this issue as we are coming across more cities and jurisdictions that are changing their requirements. You will also be making an effort to protect yourself against the potential of a flooded office. Please keep in mind that different cities and jurisdictions will have different building requirements, and it is important to educate yourself on these, as well as surround yourself with people who understand the issues and requirements associated with such projects. EP Volume 7 Number 4

Sonendo® receives clearance from FDA for Multisonic Ultracleaning System Sonendo®, Inc., the developer of a revolutionary technology for the endodontic marketplace has received 510(k) clearance from the U.S. Food and Drug Administration (FDA) for the second generation of its Multisonic Ultracleaning System for root canal therapy. The system is designed to be a minimally invasive, disruptive technology that utilizes multiple wavelengths of sound to clean the entire root canal system simultaneously. The FDA clearance gives Sonendo the right to market the system within the United States. Sonendo plans a limited launch in 2014, noted Leo Pranitis, Vice President, Sales and Marketing. “This 510(k) clearance is another important milestone for Sonendo and puts us on a path for a commercial launch of the GentleWave System this year,” Pranitis said. “Given the tremendous level of interest we experienced at the American Association of Endodontists meeting in May, it’s exciting that we are one step closer to our goal of transforming endodontics.” For more information, visit www.sonendo.com.

The Sirona DAC UNIVERSAL cleans, lubricates, and sterilizes turbines and straight and contra-angle handpieces fully automatically at the push of a button — in just 16 minutes. Manual tasks such as external cleaning, disinfecting, and lubricating of instruments are a thing of the past with the DAC UNIVERSAL. Only the instrument clamping system still needs to be lubricated separately (weekly). The DAC UNIVERSAL processes instruments fully automatically and in just one cycle. Simply push a button, and the special cover closes, and the reprocessing program starts. The first step is internal cleaning in which the internal channels are rinsed with water. In the second step, the drive channels are lubricated. Then the third step begins, an external cleaning, in which the instruments are cleaned in a multi-cyclical process using a pulse wash procedure and then cleaned with hot steam. In the fourth step, the instruments are sterilized and dried. All steps take place in a closed hygiene cycle. The result is that users have clean instruments in a completely safe and reliable way. The DAC UNIVERSAL supports workflows in the practice, reduces the workload for personnel, and avoids the possibility of human error, for example, through manual cleaning before or after the process. For more information, visit www.sirona.com

Acquisition strengthens dental portfolio Kerr Corporation, a global manufacturer of dental products has acquired DUX Dental and Vettec Inc. to further expand its product portfolio and to better serve dental professionals and healthcare providers globally. DUX Dental is a manufacturer and distributor of high-quality dental products, including Zone Temporary Cement, Identic™ alginate, and Bib-Eze disposable bib holders, as well as its award-winning PeelVue sterilization pouches. Vettec Inc. is a worldwide provider of animal healthcare products. DUX Dental and Vettec Inc. will proudly join Kerr and the KaVo Kerr Group global platform of brands that include KaVo, Kerr, Kerr Total Care, Pentron, Axis|SybronEndo, Orascoptic, Pelton & Crane, Marus, DCI Equipment, Gendex, DEXIS, Instrumentarium, SOREDEX, i-CAT, NOMAD, Implant Direct, and Ormco. For more information, visit www.kerrdental.com or www.kavokerrgroup.com.

Volume 7 Number 4

Endodontic practice 29

INDUSTRY NEWS

Fast and safe instrument processing supports workflows in the practice

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

Treatment of symptomatic apical periodontitis Dr. Lydia Harris, the third-place winner in the 2013 Young Endodontist competition in the UK, develops her endodontic skills for S-shaped root canals

his patient attended in pain from the UL5, and a diagnosis was made of symptomatic apical periodontitis. I was aware that the presence of an apical radiolucency, curved roots, and a heavily restored crown meant that the tooth had a guarded prognosis, but since the patient was keen to keep the tooth, we began root canal treatment. I placed the rubber dam, accessed the tooth, located the canals, patency filed, and irrigated. At the university, I had trained by using the step-back technique with K-files, and ProTaperÂŽ hand files. I had starting using rotary instruments in my DF1 placement, and I attempted to use the rotary files to my corrected working length, but struggled to do so due to the canal curvature. I had struggled to get to grips with using rotary instruments in more curved canals, and I therefore returned to using the step-back technique and K-files. Upon obturation, I noted that something was awry, as the ThermafilÂŽ (Dentsply Tulsa Dental Specialties) would not seat to length. I was aware that the GP was unable to negotiate the canal curvature, and a radiograph showed that the gutta percha (GP) was not at length, and some had entered the second canal. In order to achieve a satisfactory result, I needed to remove GP using DMZ-IV and ProTaper retreatment files. This was my first experience of removing GP, and I was careful to ensure complete removal of the GP before re-preparing the canals chemomechanically. As I had evidently failed to sufficiently prepare the canals for GP the first time round, I spent some time enlarging the orifice using hand files and using EDTA to ensure that I could use the ProTaper files to length prior to obturation. I then obturated using Thermafil and have subsequently restored the tooth using a porcelain onlay. An S-shaped curvature or double curvature can make a canal very challenging to negotiate. I learned that using hand files

At the time of this case, Dr. Lydia Harris was working in a Bristol dental practice as a foundation dentist, in her second year of vocational training.

30 Endodontic practice

initially can help prepare the canal sufficiently prior to using rotary files. I now know to approach curved canals like these with more caution and to take time preparing the canals ensuring adequate mechanical preparation. I had never used retreatment files before, and I learned to use a pecking motion and ensure visualization of GP on the files. I now feel more confident in doing

this and, therefore, am more able to attempt re-root treatment in the future. I chose a porcelain onlay to restore the tooth as it provided excellent esthetics and cuspal coverage, and also helped preserve more of the buccal and lingual tooth present, which would have been destroyed had I chosen to perform a crown preparation. The tooth was in the patientâ&#x20AC;&#x2122;s smile line, and she

Figure 1: Preoperative radiograph taken 4/15/2013

Figure 2: Working length radiograph taken 4/29/2013 Volume 7 Number 4

was very pleased with the esthetic result. Overall, I was pleased with the end result of this root canal treatment and hope that the patient is able to retain this tooth for many years as a result. I feel that this case helped me develop my endodontic skills overall as it involved improving upon a myriad of skills. First, my assessment of a case: I had not previously spent a long time analyzing the curvature of the roots, and the effect this would have on my method of root filling the tooth. Since this case, I have become acutely aware of the need to tailor my technique to the type of roots present, including ensuring adequate access, the need for anti-curvature filing, and the advantages and disadvantages of using rotary instrumentation in these cases. Second, it made me realize the importance of establishing the etiology of any problems encountered. I realized that, as my GP had not seated to length, I had evidently not prepared the canals adequately; and by establishing this etiology, I could therefore improve the outcome by rectifying this problem. I have also realized that acknowledging my own limitations and competency is key in endodontics; I was aware that the initial treatment I provided was poor, but that rectifying it may be difficult. I therefore ensured I informed the patient that I would try my best to improve on the root treatment, but that should it be beyond my competency, we would have to consider alternative pathways. This case helped me improve upon my endodontic planning and also, the techniques involved in S-shaped root canals. It has encouraged me to realize that if an ideal result is not achieved initially, things can be improved upon and should not just be accepted. EP

Figure 4: Post-op radiograph taken 5/20/2013

THE FUTURE HAS RETURNED.

THE ORIGINAL PLASTIC ENDODONTIC ROTARY FINISHING FILE IS BACK. MANUFACTURER DIRECT.

MADE IN THE U.S.A.

eďŹ&#x20AC;ective is the most cost The Finishing File nal! ca a an cle to y and simplest wa

REFERENCES 1. Bergenholtz G, Horsted-Bindslev, P, Reit C. Textbook of Endodontology, Second Edition. Oxford: Wiley Blackwell; 2010. 2. Chong, BS. Hartyâ&#x20AC;&#x2122;s Endodontics in Clinical Practice, Sixth Edition. London: Saunders Elsevier; 2010.

Volume 7 Number 4

orders@engineeredendo.com

www.engineeredendo.com

Endodontic practice 31

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

Figure 3: Mid-obturation radiograph taken 5/20/2013

CONTINUING EDUCATION

Clinical applications of bioceramic materials in endodontics Drs. Marga Ree and Richard Schwartz explore current premixed bioceramic materials Abstract

Introduction: Bioceramic materials are currently available in three forms: sealer, paste, and putty, and have a variety of clinical applications. Some are premixed, and some require manual mixing. They are fairly new to endodontics and not well understood by most clinicians. The purpose of this article is to discuss the current premixed bioceramic materials, give an overview of the literature, and present five clinical cases in which they were used successfully. Methods: Five cases were selected in which bioceramic materials were used for retreatment, perforation repair, and periapical surgery. Recalls up to 2 years are presented. Conclusions: This case series shows that bioceramic materials can be used successfully to manage a variety of clinical scenarios and offer some potential advantages over other materials. In each case, treatment resulted in elimination of clinical symptoms and bone healing.

Introduction Root canal filling (obturation) is performed after the microbial control phase of treatment with the goal of entombing the remaining bacteria inside the root canal system, preventing the influx of apical fluids and preventing reinfection from the oral cavity.1 A variety of core and sealer combinations have been used, including silver cones, gutta-percha, and resin-based materials in conjunction with a variety of root canal sealers, mineral trioxide aggregate (MTA) products, and recently, bioceramic (BC) materials. Traditional obturating methods do not provide an effective seal. They shrink on setting, have little or no adhesion to dentin, and are not dimensionally stable when they come in contact with moisture, leading to

Marga Ree, DDS, MSc, is in private practice, limited to endodontics, Purmerend, The Netherlands. Richard Schwartz, DDS, is in private practice, limited to endodontics, San Antonio, Texas.

32 Endodontic practice

Educational aims and objectives

The aim of this article is to give an overview of current premixed bioceramic materials and how they can be used successfully in endodontic treatment.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 41 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the drawbacks of traditional obturating methods. • Realize several advantages of bioceramic materials over MTA. • Identify certain benefits of bioceramic materials to endodontic treatment. • See some information on studies regarding endodontic premixed bioceramic materials. • Realize various treatment options involving bioceramic materials through clinical cases.

dissolution and leakage over time. In recent years, new materials have been developed that overcome some of these shortcomings. MTA is a cement that is not sensitive to moisture and blood contamination.2 It is dimensionally stable, expands slightly as it sets, and is insoluble over time.2 It has antibacterial properties, due to its high pH during setting, and is biocompatible.2,3 It is considered the material of choice for perforation repair, root-end fillings, pulp caps, pulpotomies, and obturation of immature teeth with open apices.4 These are all situations where the presence of moisture may affect the quality of the root canal filling. When MTA comes in contact with tissue fluids, it releases calcium hydroxide that can interact with phosphates in the tissue fluids to form hydroxyapatite. This property may explain some of the tissue-inductive properties of MTA and may contribute, along with slight setting expansion, to its good sealing properties.5-8 MTA is described as a first-generation bioactive material. It has many advantages, but also some disadvantages .2,3 The initial setting time is at least 3 hours. It is not easy to manipulate, resulting in considerable wasted material, and is hard to remove. Clinically, both gray and white MTA stain dentin, presumably due to the heavy metal content of the material or the inclusion of blood pigment while setting.9,10 Finally, MTA is hard to apply in narrow canals, making the material poorly suited for use as a sealer. Efforts have been made to overcome these

shortcomings with new compositions of MTA11-13 or with additives.14,15 However, these formulations affect MTA’s physical and mechanical characteristics.

Bioceramics Bioceramics are inorganic, non-metallic, biocompatible materials that have similar mechanical properties as the hard tissues they are replacing or repairing. They are chemically stable, non-corrosive, and interact well with organic tissue. During the 1960s and 1970s, the materials were developed for use in the human body. They are used in many medical applications, such as joint replacement, bone plates, bone cement, artificial ligaments and tendons, blood vessel prostheses, heart valves, skin repair devices (artificial tissue), cochlear replacements, and contact lenses. Bioceramics in endodontics Bioceramic materials used in endodontics can be categorized by composition, setting mechanism, and consistency. There are sealers and pastes, developed for use with gutta-percha, and putties, designed for use as the sole material, comparable to MTA. Some are powder/liquid systems that require manual mixing. The authors have found the mixing and handling characteristics of the powder/liquid systems to be very technique sensitive, and a deterrent to their use. Premixed bioceramics require moisture from the surrounding tissues to set. The premixed sealer, paste, and putty have the Volume 7 Number 4

is recommended for use with gutta percha. The primary difference between RRM paste and BC sealer is that RRM paste is more viscous.

defects,32 and EndoSequence Paste, Putty, and MTA had similar antibacterial efficacy against clinical strains of E. faecalis.33

Biocompatibility and cytotoxicity Several in vitro studies report that BC materials display biocompatibility and cytotoxicity that is similar to MTA.16-26 Cells required for wound healing attach to the BC materials and produce replacement tissue.17 In comparison to AH Plus® (Dentsply) and Tubli-Seal™ (SybronEndo), BC sealer showed a lower cytotoxicity.16,17 On the other hand, one study concluded that BC Sealer remained moderately cytotoxic over the 6-week period,27 and osteoblastlike cells had reduced bioactivity and alkaline phosphatase activity compared to MTA and Geristore® (DenMat).28

Bioactivity Several studies evaluated bioactivity. An in vitro study on the effects of iRoot SP root canal sealer suggested that iRoot SP is a favorable material for cellular interaction.34 Exposure of MTA and EndoSequence Putty to phosphate-buffered saline (PBS) resulted in precipitation of apatite crystalline structures that increased over time, suggesting that the materials are bioactive.35 Human dental pulp cells exhibited optimal proliferation and mineralization on the surface of iRoot BP Plus.36 iRoot SP exhibited significantly lower cytotoxicity and a higher level of cell attachment than MTA Fillapex, a salicylate resin-based, MTA particles containing root canal sealer.37 EndoSequence Sealer had higher pH and greater Ca2+ release than AH Plus30 and was shown to release fewer calcium ions than BioDentine® (Septodont) and White MTA.38 It was reported that MTA may provide more inductive potential and hard tissue deposition than iRoot SP.39 The clinical significance of these findings is uncertain, however.

pH and antibacterial properties BC materials have a pH of 12.7 while setting, similar to calcium hydroxide, resulting in antibacterial effects.29 BC Sealer was shown to exhibit a significantly higher pH than AH Plus30 for a longer duration.31 Alkaline pH promotes elimination of bacteria such as E. faecalis. In vitro studies reported EndoSequence Paste produced a lower pH than white MTA in simulated root resorption

Bond strength A number of studies evaluated bond strength. One study reported that iRoot SP and AH Plus performed similarly, and better than EndoREZ® (Ultradent) and Sealapex™ (SybronEndo).40 Another study found that iRoot SP displayed the highest bond strength to root dentin compared to AH Plus, Epiphany®, and MTA Fillapex, irrespective of moisture conditions.41 In a push-out test,

Studies on endodontic premixed bioceramic materials To date, approximately 50 studies have been published on premixed bioceramic materials in endodontics. The vast majority have shown that the properties conform to those expected of a bioceramic material and are similar to MTA.

Material

Brand

Abbreviation

Composition

Manufacturer

Bioceramic Sealer

iRoot SP Injectable Root Canal Sealer

iRoot SP

-----------------------------EndoSequence BC Sealer

EndoSequence Sealer

Innovative Bioceramix Inc. (IBC) Vancouver, British Colombia, Canada -----------------------------Brasseler USA Dental LLC, Savannah, GA

TotalFill BC Sealer

TotalFill Sealer

Tricalcium silicate, dicalcium silicate, calcium hydroxide, zirconium oxide, phosphate monobasic, filler and thickening agents

iRoot BP Injectable Root Repair Filling Material

iRoot BP

-----------------------------EndoSequence Root Repair Material (RRM) Paste

EndoSequence Paste

Innovative Bioceramix Inc. (IBC) Vancouver, British Colombia, Canada -----------------------------Brasseler USA Dental LLC, Savannah, GA

TotalFill BC RRM Paste

TotalFill Paste

Tricalcium silicate, dicalcium silicate, zirconium oxide, tantalum pentoxide, calcium phosphate monobasic and filler agents

iRoot BP Plus Injectable Root Repair Filling Material -----------------------------EndoSequence Root Repair Material (RRM) Putty

iRoot BP Plus EndoSequence Putty

Innovative Bioceramix Inc. (IBC) Vancouver, British Colombia, Canada -----------------------------Brasseler USA Dental LLC, Savannah, GA

TotalFill BC RRM Putty

TotalFill Putty

Tricalcium silicate, dicalcium silicate, zirconium oxide, tantalum pentoxide, calcium phosphate monobasic and filler agents

Bioceramic Root Repair Material Paste

Bioceramic Root Repair Material Putty

Table 1 Volume 7 Number 4

Endodontic practice 33

CONTINUING EDUCATION

advantage of uniform consistency and lack of waste. They are all hydrophilic. In 2007, a Canadian research and product development company (Innovative BioCeramix, Inc., Vancouver, Canada), developed a premixed, ready-to-use calcium silicate based material, iRoot® SP injectable root canal sealer (iRoot® SP). Some time later, they developed two other products with similar compositions, but different consistencies: iRoot® BP injectable root repair filling material (iRoot® BP) and iRoot® BP Plus injectable root repair filling material putty (iRoot® BP Plus). Since 2008, these products have also been available as EndoSequence® BC Sealer™, EndoSequence® Root Repair Material (RRM) Paste™, and EndoSequence® Root Repair Material (RRM) Putty™ (Brasseler, USA Dental LLC). Recently, these materials have also been marketed as Totalfill® BC Sealer™, TotalFill® BC RRM Paste™, and TotalFill® BC RRM Putty™ (Brasseler USA Dental LLC) (Table 1). The manufacturer states that the three forms of bioceramics are similar in chemical composition (calcium silicates, zirconium oxide, tantalum oxide, calcium phosphate monobasic, and fillers), have excellent mechanical and biological properties, and good handling properties. They are hydrophilic, insoluble, radiopaque, aluminumfree, and high pH, and require moisture to harden. The working time is more than 30 minutes, and the setting time is 4 hours in normal conditions, depending of the amount of moisture available. RRM putty and RRM paste are recommended for perforation repair, apical surgery, apical plug, and direct pulp caps. BC sealer

CONTINUING EDUCATION the bond strength of EndoSequence Sealer was similar to AH Plus and greater than MTA Fillapex.42 When iRoot SP was used with a self-adhesive resin cement, the bond strength of fiber posts were not adversely affected.43 Smear layer removal had no effect on bond strengths of EndoSequence Sealer and AH Plus, which had similar values.44 The presence of phosphate-buffered saline (PBS) within the root canals increased the bond strength of EndoSequence Sealer/gutta percha at 1 week, but no difference was found at 2 months.45 Because of the low bond values in these studies, it is doubtful that any of these findings are clinically significant. Resistance to fracture iRoot SP was shown in vitro to increase resistance to the fracture of endodontically treated roots, particularly when accompanied with bioceramic impregnated and coated gutta-percha cones.46 Fracture resistance was increased in simulated immature roots in teeth with iRoot SP,47 and in mature roots with AH Plus, EndoSequence Sealer, and MTA Fillapex.48 Similar results were reported for EndoSequence Sealer and AH Plus Jet sealer in root-filled single-rooted premolar teeth.49 Microleakage Microleakage was reported to be equivalent in canals obturated with iRoot SP with a single cone technique or continuous wave condensation, and in canals filled with AH Plus sealer with continuous wave condensation.50 Similar microleakage values were reported for sealers that contained calcium hydroxide, methacrylate resin and epoxy resin, as well as iRoot SP and AH Plus.51 EndoSequence paste was similar to white MTA in preventing bacterial leakage of

Figure 1A: Radiograph of three root canal treated lower incisors and associated radiolucency

34 Endodontic practice

E. faecalis52 or preventing glucose leakage53 in vitro. In contrast, EndoSequence Putty was found to leak significantly more than ProRoot MTA in a study using a bacterial leakage model.54 Solubility High levels of Ca2+ release were reported from in a solubility from iRoot SP, MTA Fillapex, Sealapex, and MTA-Angelus, but not AH Plus. Release of Ca2+ ions is thought to result in higher solubility and surface changes.55 However, the study tested the materials following ANSI/ADA spec. No. 57, which is not designed for premixed materials that require only the presence of moisture to set. This could be the reason for the difference in findings in this study and in vivo observations. Retreatment Removal of EndoSequence Sealer and AH Plus were comparable in a study comparing hand instruments and ProTaper Universal retreatment instruments.56 None of the filling materials could be removed completely from the root canals, however.57 Micro-computed tomography showed that none of the retreatment techniques completely removed the gutta-percha/iRoot SP sealer from oval canals.58 Clinical studies A randomized clinical trial evaluated iRoot BP and white ProRoot MTA as direct pulp-capping materials. The study evaluated clinical signs/symptoms and histological pulp reactions, such as inflammation and mineralized bridge formation. No significant differences were found in pulpal inflammation, or in the formation or appearance of a hard tissue bridge. However, clinical sensitivity to cold was significantly less for teeth treated

Figure 1B: Eight years later, the radiolucency has increased in size

Figure 1C: Radiograph at 12 years showing the radiolucency was unchanged. Endodontic treatment was carried out in the mandibular left canine for unknown reasons

with MTA (P < 0.05). All teeth formed a hard tissue bridge, and none of the specimens in either group had pulpal necrosis.59

Clinical cases Patient No. 1 was a 47-year-old white male who was referred for a second opinion on a radiolucency in the lower anterior area. It had been present since 2000 (Figure 1A), but had increased in size since 2008 (Figure 1B). He presented with swelling and severe pain. His medical history was noncontributory. Clinical examination revealed that teeth Nos. 24, 25, and 26 were restored with large composite restorations, and were all tender to pressure and percussion. Tooth No. 23 was non-tender and responded normally to pulp tests. There were no significant probing depths. A radiographic examination revealed a large periapical radiolucency associated with teeth Nos. 23, 24, 25, and 26 (Figure 1C). In addition, the teeth were structurally compromised. The endodontic diagnosis was previous root canal treatment with acute apical periodontitis in teeth Nos. 24, 25, and 26. The existing endodontic treatment in teeth Nos. 24, 25, and 26 was 12 years old. Because there was reason to suspect the presence of one or more untreated canals, a CBCT scan was performed (Kodak 9000 3D; Carestream Dental), which suggested the presence of lingual canals in all three endodontically treated teeth (Figures 1D-1F). The patient was presented with two treatment options: 1. Extraction of teeth Nos. 24, 25, and 26 and replacement by a 3-unit, implant supported bridge 2. Nonsurgical retreatment of teeth Nos. 24, 25, and 26 The patient chose the second option. Upon access, there was drainage of pus from tooth No. 25, and subsequent drainage of blood from teeth Nos. 24, 25, and 26 (Figures 1G-1H). It took two appointments to remove the root canal fillings and negotiate the untreated canals. After each appointment, the canals were dressed with calcium hydroxide (UltraCal® XS, Ultradent) (Figure 1I). At the third appointment, the patient was completely asymptomatic, and the swelling had resolved. There was still some moisture from the periapical tissues seeping into the canals. Therefore, it was decided to use a hydrophilic sealer (EndoSequence BC sealer, Brasseler, USA Dental LLC), since it is not sensitive to moisture,41 in conjunction with gutta percha to obturate all lower incisors (Figure 1J). After root canal treatment was completed, the teeth were Volume 7 Number 4

CONTINUING EDUCATION

Figures 1D-1F: Representative slices of a CBCT scan showing untreated lingual canals in all three lower incisors

Figure 1H: Clinical picture showing drainage of blood from teeth Nos. 24, 25, and 26

Figure 1I: The teeth were dressed with calcium hydroxide

Figures 1K-1L: Postoperative radiographs show the teeth restored with fiber posts and composite resin

Volume 7 Number 4

Figure 1G: Upon access, there was drainage of pus from tooth No. 25

Figure 1J: The root canals were filled with gutta percha and EndoSequence Sealer

Figure 1M: Recall radiograph after 1 year, showing the radiolucency has significantly decreased in size

restored with a fiber post (DT light post; RTD, Saint Egreve, France) and composite (LuxaCore速, DMG America) (Figures 1K-1L). The 1-year recall showed a significant reduction of the periapical radiolucency (Figure 1M). The patient was asymptomatic, and there was no evidence of endodontic disease or significant probing depths. Patient No. 2 was a 57-year-old white female who was referred for endodontic treatment of tooth No. 2. Her chief complaint was spontaneous pain and biting tenderness. Her general dentist diagnosed an Endodontic practice 35

CONTINUING EDUCATION acute apical periodontitis (Figure 2A), and started root canal treatment. During negotiation of the root canal system, a perforation was created in the apical portion of the mesiobuccal root (Figure 2B). Calcium hydroxide was placed, and the patient was referred for further treatment. Clinical testing confirmed that tooth No. 2 was tender to pressure and percussion. There were no significant probing depths. Radiographic examination revealed an apical radiolucency and extrusion of calcium hydroxide through the perforation (Figure 2C). The CBCT scan showed a very curved mesiobuccal root and extrusion of calcium hydroxide into the maxillary sinus (Figure 2D). She had no significant medical history. The preoperative diagnosis was incomplete endodontic treatment with lateral perforation and acute apical periodontitis. Two treatment options were discussed with the patient: 1. Extraction and replacement by an implant 2. Nonsurgical endodontic treatment with the possible need for surgery The patient chose the second option. At the first treatment session, the intracanal dressing of calcium hydroxide was removed, and the apical portion of the mesiobuccal canal was located and negotiated with prebent hand files (Figure 2E). All 3 canals were prepared to working length, and calcium hydroxide was placed. At the second appointment, approximately 1 month later, the biting tenderness

had subsided and the patient was asymptomatic. Two options were considered to repair the perforation: 1. Obturation of the entire mesiobuccal canal with MTA 2. Obturation of the entire mesiobuccal canal with gutta-percha and a bioceramic sealer MTA is a material with many benefits, but one of its disadvantages is that it is difficult to effectively obturate long narrow canals, so this approach was rejected. A concern with method No. 2 was extrusion of obturating materials into the perforation site and the maxillary sinus. EndoSequence BC Sealer was chosen because of its biocompatibility17, 18, 22, 24, 37 and lack of sensitivity to moisture.41 Once the cones were seated (Figure 2F), the downpack was performed using a System Bâ&#x201E;˘ heat source (SybronEndo), followed by backfilling with

an Obtura gun (Spartan Obtura Endodontics). The access opening was restored with a bonded composite core material (LuxaCore; DMG, Hamburg, Germany), which was covered with a layer of a hybrid composite (TetricÂŽ Ceram, Ivoclar Vivadent) (Figure 2G). At the 1-year recall, the patient was asymptomatic, and periapical radiographs showed no evidence of endodontic disease with normal tissue architecture (Figure 2H). Patient No. 3 was a 37-year-old white female who was referred for retreatment of tooth No. 18. The restorative treatment plan was for a crown. The patient was asymptomatic, and her medical history was noncontributory. Clinical examination revealed that tooth No. 18 was restored with a large composite restoration. The tooth was non-tender to pressure and percussion, and there were no significant probing depths. Radiographic examination revealed a periapical radiolucency

Figure 2A: Preoperative radiograph of No. 2 shows a periapical radiolucency

Figure 2B: Radiograph showing a perforation in the apical portion of the mesiobuccal root

Figure 2C: Calcium hydroxide was placed in the canals with some extrusion into the periapical tissues

Figure 2D: CBCT slice showing extrusion of calcium hydroxide into the maxillary sinus

Figure 2E: Working length radiograph showing a file in the original mesiobuccal canal

Figure 2F: Cone-fit radiograph

Figure 2G: Postoperative radiograph showing the root-filled tooth restored with a composite core

Figure 2H: At 1 year, the radiolucency had decreased in size significantly, and the patient was asymptomatic

36 Endodontic practice

Volume 7 Number 4

the fragment in place. The extruded root filling material was retrieved from the periapical tissues using a Terauchi gutta-percha removal instrument (Hartzell and Son) (Figures 3C-3D). The distal and mesiobuccal canals were prepared to the working length, the mesiolingual canal was instrumented to the level of the fractured silver cone, and calcium hydroxide was placed in all canals (Figure 3E). At the second session, the mesial canals were obturated with Resilonâ&#x201E;˘ and Epiphany sealer (SybronEndo). The apical portion of the distal canal was filled with EndoSequence Root Repair Material Putty (Brasseler USA Dental LLC) using a Dovgan MTA carrier (Hartzell and Son) (Figure 3F) and a Dovgan endodontic condenser (Miltex) dipped in a small amount of EndoSequence BC Sealer to prevent sticking of the plugger to the putty. A moist cotton pellet was

Figure 3B: An apical fragment of one of the silver cones separated and was left behind in the mesiolingual canal

Figure 3C: The extruded part of the gutta percha in the distal canal has been retrieved from the periapical tissues using a Terauchi gutta-percha removal instrument

Figure 3D: Terauchi gutta-percha removal instruments

Figure 3E: Calcium hydroxide was applied to the canals

Figure 3F: A Dovgan MTA carrier

Figure 3G: The mesial canals were filled with Resilon and Epiphany sealer, and the distal canal was filled with EndoSequence Putty, leaving a space for a post in the distal canal

Figure 3H: The EndoSequence Putty was completely set

Figure 3I: Postoperative radiograph showing the obturated tooth, restored with a fiber post and composite resin core

Figure 3J: Two-year recall radiograph showing normal bony architecture

Volume 7 Number 4

inserted on top of the putty, and the tooth was temporized (Figure 3G). At the third appointment, it was verified that the apical plug of putty had fully set (Figure 3H). The tooth was restored with a fiber-reinforced composite post

Figure 3A: Preoperative radiograph showing a radiolucency associated with No. 18 with extrusion of root filling out the end of the distal root

Endodontic practice 37

CONTINUING EDUCATION

associated with the distal root and extrusion of root filling material (Figure 3A). The endodontic diagnosis was previous root canal treatment with chronic apical periodontitis. The patient was presented with three options: 1. No immediate treatment with eventual extraction of the tooth should it become symptomatic 2. Extraction and replacement with an implant 3. Nonsurgical endodontic retreatment followed by a crown The patient opted for retreatment. At the first treatment session, most of the existing root canal filling was removed. A small fragment of the silver cone remained in the mesiolingual canal (Figure 3B). Because there was no radiolucency associated with the mesial root, it was decided to leave

CONTINUING EDUCATION (DT Light-Post; RTD, Saint Egreve, France) and a bonded composite core material (LuxaCore) (Figure 3I). At the 2-year recall, the patient had remained asymptomatic, and periapical radiographs showed no evidence of endodontic disease and normal tissue architecture (Figure 3J). Patient No. 4 was a 41-year-old white male who was referred for retreatment of tooth No. 30 after the referring dentist had been unable to remove the existing root canal filling. His medical history was noncontributory. Clinical examination revealed tenderness at tooth No. 30 and no probings deeper than 3 mm with anesthesia. An endodontic access cavity had been prepared through the metal-ceramic crown and sealed with a temporary restoration. Radiographs showed a periapical radiolucency and removal of a significant amount of coronal tooth structure (Figure 4A). The diagnosis was previous root

canal treatment with chronic apical periodontitis of tooth No. 30. Two treatment options were discussed with the patient: 1. Extraction and replacement by an implant 2. Nonsurgical endodontic retreatment The patient opted for retreatment. Upon access, a perforation was visible in the pulp

floor, and there was drainage of blood from the perforation site (Figure 4B). In addition, two lateral perforations were identified in the apical one-third of the mesial canals (Figure 4C). The perforation in the pulp floor was repaired with EndoSequence RMM Putty (Brasseler USA) (Figure 4D). It took two appointments to remove the carrier-based

Figure 4A: Preoperative radiograph showing an endodontically treated mandibular first molar with substantial loss of coronal dentin and a radiolucency

Figure 4B: Upon access, there was bleeding from the perforation in the pulp floor

Figure 4C: Radiograph showing two lateral perforations in the mesial root

Figure 4D: Perforation in the furcation was sealed with EndoSequence Putty

Figure 4E: A Thermafill carrier was removed from the root canal system with a Hedstrom file

Figure 4F: The original mesiobuccal canal was negotiated

Figure 4G: Cone-fit radiograph

Figure 4H: The root canal system was filled with gutta percha and EndoSequence Sealer

Figures 4I-4J: Postoperative radiograph from different angles showing the endodontically retreated root canals and a composite core 38 Endodontic practice

Figure 4K: At 1 year, the periapical lesion had decreased in size significantly Volume 7 Number 4

incision was made, and a labial full-thickness flap was reflected. A root-end resection was performed followed by a root-end preparation (Figure 5B) with a diamond coated ultrasonic tip (KiS tip #3D, Spartan Obtura Endodontics). After obtaining a dry field, the apical preparation was filled with EndoSequence RRM Putty (Brasseler, USA Dental LLC) (Figures 5C-5D), utilizing a Lee block and corresponding Lee carver (Hartzell and Son)(Figures 5E-5I). The flap was repositioned and sutured.

Figure 5E: The Lee MTA block and Lee carver

Figures 5F-5G: The sharp blade of a Lee carver was used to pick up a pellet of the Root Repair Material Putty from the Lee block

Figure 5A: Preoperative radiograph of tooth No. 14 revealing a periapical radiolucency and apical transportation of the canals in the mesial root

Discussion The authors have presented five cases in which a premixed bioceramic material was used to manage clinical situations that are not uncommon in an endodontic practice. In each case, treatment resulted in elimination of clinical symptoms and bone healing. It was shown that bioceramic materials can be

Figure 5B: Photograph of the resected mesial root and a rootend preparation carried out with an ultrasonic tip

Figures 5C-5D: EndoSequence Putty was applied as a root-end filling

Figures 5H-5I: A RRM Putty pellet was applied in a root-end preparation with a Lee carver. The pellet is formed in a Lee MTA block (different case than depicted in Figures 5A-5D) Volume 7 Number 4

Healing was uneventful, and the 1-year recall showed resolution of the periapical lesion (Figure 5J).

Figure 5J: The 1-year recall radiograph showing a healthy tooth in full function Endodontic practice 39

CONTINUING EDUCATION

root canal fillings (Figure 4E) and to relocate and negotiate the original canals (Figure 4F). After each appointment, the canals were dressed with calcium hydroxide (UltraCal XS; Ultradent). At the third appointment, the gutta-percha cones were seated (Figure 4G), and the root canal system was obturated with gutta percha and EndoSequence BC Sealer (Brasseler, USA Dental LLC) (Figure 4H). A composite core material (LuxaCore) was placed in the access opening, with a top layer of a hybrid composite (Tetric Ceram, Ivoclar Vivadent) (Figures 4I-4J). At the 1-year recall, the tooth was asymptomatic, the radiolucency had decreased in size, and probing depths were within normal limits (Figure 4K). Patient No. 5 was a 47-year old white female with a noncontributory medical history. Her chief complaint was persisting discomfort after retreatment of tooth No. 14 1 year earlier. Clinical examination revealed tenderness to palpation and percussion. Radiographs revealed a periapical radiolucency and an apical transportation of the canals in the mesial root (Figure 5A). According to the endodontist who carried out the retreatment a year earlier, it was not possible to completely instrument MB2, and the apical portion was left untreated. The diagnosis was previous root canal treatment with acute apical periodontitis of tooth No. 14. Treatment options were discussed with the patient, including these three: 1. Extraction 2. A second retreatment 3. Apical surgery The patient chose a surgical approach. To obtain surgical access, an intrasulcular

CONTINUING EDUCATION used successfully in conjunction with guttapercha, or as stand-alone materials. In all cases, the presence of moisture could have affected the quality of the root canal filling and the clinical result. Bioceramic materials are also a good choice for cases in which extrusion into the periapical tissues may damage vital structures, such as the maxillary sinus or the inferior alveolar nerve. In the opinion of the authors, bioceramic materials have several advantages over MTA. Premixed bioceramic materials have better clinical handling properties. The difficulties in handling of MTA have been frequently reported by clinicians.4 Another drawback of MTA is the potential for staining dentin, which has been shown in several in vitro studies,10, 60, 61 clinical investigations ,62, 63 and case reports,9, 64 which have shown that both white and gray MTA cause discoloration. To date, there have been no reports of staining of dentin by bioceramic products, which has also been the experience of the authors. Several studies report that bismuth oxide, which acts as a radiopacifier in MTA as a radiopacifier,65, 67 may increase the cytotoxicity of MTA, because bismuth oxide does not encourage cell proliferation in cell culture.66 Bioceramics contain zirconium oxide and tantalum pentoxide as opacifiers.67 The presence of heavy metals may be another potential drawback of MTA. A recent study showed that MTA Angelus and Micro Mega MTA contained minor amounts of several metal oxides (aluminum, arsenic, beryllium, cadmium, chromium, and iron). Bioaggregate, from which bioceramic products are made (iRoot BP stands for “Injectable Root BioAggregate Paste”),59 contains only trace amounts of aluminum, approximately 1/1000 of the amount found in MTA Angelus or Micro Mega MTA.68 Innovative BioCeramix, Inc., Vancouver, Canada, also developed bioaggregate. There have been concerns about the retreatability of BC sealer, in particular when the gutta-percha cone is short of working length.56 The material sets very hard, and there are no solvents available to soft it. The majority of papers show favorable properties for bioceramic materials including biocompatibility, bioactivity, and antimicrobial properties. It has sealing properties similar to MTA, and some in vitro studies show that bioceramic materials increase resistance to fracture. While in vitro studies are promising, it is not clear if any of these results influence clinical success. Only well-designed, prospective outcome studies can answer this question. EP 40 Endodontic practice

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Clinical applications of bioceramic materials in endodontics 1. Root canal filling (obturation) is performed after the microbial control phase of treatment with the goal of ___________. a. entombing the remaining bacteria inside the root canal system b. preventing the influx of apical fluids c. preventing reinfection from the oral cavity d. all of the above 2. MTA is described as a(n) ___________ bioactive material. a. first-generation b. second-generation c. non-effective d. easily manipulated 3. The initial setting time (for MTA) is at least _________. a. 1 hour b. 2 hours c. 3 hours d. 4 hours 4. They (bioceramics) are ___________. a. chemically stable

Volume 7 Number 4

b. non-corrosive c. interact well with organic tissue d. all of the above 5. Several in vitro studies report that BC materials display biocompatibility and cytotoxicity that is ________ MTA a. very different from b. similar to c. equal to d. less stable than 6. BC materials have a pH of ____ while setting, similar to calcium hydroxide, resulting in antibacterial effects. a. 3.4 b. 6.7 c. 9.5 d. 12.7 7. ___________ is(are) also a good choice for cases in which extrusion into the periapical tissues may damage vital structures, such as the maxillary sinus or the inferior alveolar nerve. a. MTA

b. Silver cones c. Bioceramic materials d. Resin-based materials 8. Bioceramics contain zirconium oxide and tantalum pentoxide as ________. a. heavy metals b. opacifiers c. organic oxides d. antimicrobials 9. The presence of heavy metals may be another ________ of MTA. a. benefit b. potential drawback c. innovation d. inorganic aspect 10. It (bioceramic materials) has sealing properties similar to MTA, and some in vitro studies show that bioceramic materials ________ resistance to fracture. a. decrease b. increase c. ensure d. do not affect

Endodontic practice 41

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Treatment of mandibular first molars with five root canals Drs. Yuriy Riznyk and Maxim Zhovtukha present two case reports demonstrating treatment of mandibular first molars with five root canals

n dental practice, and for successful endodontic treatment, it is necessary to have thorough knowledge of the root canal system anatomy. The incomplete instrumentation, cleaning, and defective obturation of the root canal system are the main causes of endodontic failure (Leonardo, 1998). Mandibular first molars erupt earlier than all other teeth, which is why they are more often damaged by caries. Consequently, caries complications can lead to endodontic treatment. Different anatomical variations of the mandibular first molar root canal system can be challenging for a dentist, since only one missed and untreated root canal can result in endodontic failure. For the best clinical results, the dentist should be aware of normal and abnormal variability of the root canal system anatomy (Zattar, Al-Busairy, Behbehani, 1990). The purpose of this study is to justify the importance of knowledge about basic root canal morphology and its possible variations for successful endodontic outcomes. The authors also wanted to consider the possible treatment options of the mandibular first molar with five root canals and to analyze the frequency of occurrence of such number of canals in the literature.

Materials and methods The authors performed a literature review and presented two case reports of mandibular first molars with the five root canals. In the majority of cases, the mandibular first molar has two roots. According to de Pablo, et al.’s (2010) systematic review on root anatomy and canal configuration of the permanent mandibular first molars (with

Educational aims and objectives

This clinical article aims to justify the importance of knowledge about the anatomical diversity of the root canal system for successful endodontic therapy and presents case reports demonstrating treatment of mandibular first molars with five root canals.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 46 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Discuss the typical morphology of mandibular molars. • Recognize one way of treating a mandibular first molar with five root canals. • Realize the incidence of different numbers of canals in mandibular first molars. • Analyze the frequency of occurrence of certain numbers of canals. • Identify basic root canal morphology and its possible variations for successful endodontic outcomes.

reference to 41 studies and a total of 18,781 teeth), the third root was present in 13% of cases, and it was ethnically dependent. The researchers analyzed 4,745 teeth, which had three or more canals, and found that three root canals were found present in 61.3% of cases, four canals in 35.7% and five canals in only 0.8%. In the mesial root (4,535 roots), two canals were present in 94.4% and three canals in 2.3%. The most common canal system configurations were type IV (52.3%) and type II (35%), according to the Vertucci classification (Table 1). In the distal root (2,992 roots), type I was most often found (62.7%), followed by type II (14.5%) and then type IV (12.4%). Fabra-Campos (1985) researched 145 mandibular first molars and detected five root

canals in molars in 2.75% of all the cases, whereas Martinez-Berna, et al. (1983) found 29 molars with five canals from 2,362 teeth (1.2%) in the clinical research. Hess (1925) examined 512 mandibular first molars and found that: • 0.3% had one canal • 17.7% had two canals • 78% had three canals • 4% had four canals. Navarro, et al. (2007), examined 25 mandibular molars using an electron microscope and found three canals in the mesial root in three cases (12%). Middle mesial (MM) canal is found between the mesiobuccal (MB) and mesiolingual (ML) canals. The diameter of the MM canal is smaller compared to ML and MB

Dr. Yuriy Riznyk is assistant of the therapeutic dentistry department at Danylo Halytsky Lviv National Medical University, Lviv, Ukraine. He was co-winner of the Ukrainian Endodontic Association contest “Art of Endodontic Treatment” in 2012. Dr. Maxim Zhovtukha is an assistant in the therapeutic dentistry department at the Kyiv Medical Institute of the Ukrainian Association of Folk Medicine. He is also head doctor of the Avanto dental clinic in Kyiv, Ukraine, and winner of the Ukrainian Endodontic Association contest “Art of Endodontic Treatment” in 2011.

Table 1: Classification of the root canal morphology 42 Endodontic practice

Volume 7 Number 4

Clinical case one A 23-year-old female patient presented with persistent acute pain in the mandibular left first molar, increasing on biting. Her medical history was found to be noncontributory. Percussion test of tooth LL6 revealed intense and continuous pain, and the tooth was tender to palpation test. The tooth did not respond to the pulp thermal (cold) test or to the EPT. The adjacent teeth responded normally to pulp testing. Periodontal probing and mobility were within physiological limits. The periapical radiograph of tooth LL6 showed a periradicular lesion (Figure 1). Radiographic evaluation of the involved tooth indicated a normal canal configuration. It is difficult to evaluate the mandibular molars morphological structure due to the fact that radiographs provide a two-dimensional image, hiding the complexity of the root canal system (Figure 1). The preliminary diagnosis was pulp necrosis — symptomatic apical periodontitis

of tooth LL6. Based on the examination results, the patient was recommended to undertake conservative endodontic treatment. First visit Anesthesia of a 4% solution Ubistesin with adrenalin 1:200000 (3M™ ESPE™) was performed before placement of the rubber dam so that the tooth could be cleaned with antiseptic solution. While preparing the straight-line access to the root canal orifices, care was taken to save as much healthy tissue as possible, especially in coronal pre-cervical dentin area. Access was made using the long neck round-shaped drills, cone-shaped drills with non-aggressive tips, and ultrasonic tips (Figure 2). After removal of the pulp chamber roof, a continuous serous purulent exudate was observed. Examination of the pulp chamber floor was performed with a DG16 endodontic probe under optical magnification. After access preparation, two root canals were located — both in the mesial and distal roots — and the orifice of the MM was found after isthmus preparation with ultrasonic tips in the mesial root between the previously identified mesiolingual and mesiobuccal canals. The pulp chamber was rinsed with 5.25% sodium hypochlorite. The canals were negotiated with a slightly bent 08 K-file (Dentsply Maillefer) coated with Glyde™ (Dentsply Maillefer) lubricant using a watch-winding

motion and slow pushing movements toward the apical constriction. Patency was established at working length using iPex apex locator (NSK) and confirmed radiographically. The glide path was performed using size 08 and 10 K-files and rotary nickel-titanium PathFile™ instruments (Dentsply Maillefer). PathFile No. 1 was used to the working length with light up-and-down movements. The root canal system was irrigated with 5.25% sodium hypochlorite, and the patency was confirmed with a size 08 K-file. PathFiles No. 2 and No. 3 were used the same way. The root canals were prepared with rotary nickel-titanium ProTaper® Universal and Profile instruments (Dentsply Maillefer). The instrumentation of the coronal and the middle third of the root was performed using the ProTaper Universal instruments SX, S1, and S2, and the apical third with the ProFile® system (Dentsply Tulsa Dental Specialties) instruments, .04 taper. The MB, MM, and ML canals of the medial root merged in the apical third. The apical third of MB, ML, DB, and DL canals were shaped up to the size 35. The canals were irrigated between file insertions with 5.25% sodium hypochlorite solution. After the instrumentation and irrigation of the root canal system, it was not possible to achieve a dry canal with absorbing paper points, so it was decided to treat the patient in two visits. The root canals were irrigated with sterile saline, dried with absorbent paper points, and filled with calcium hydroxide paste. The glass ionomer cement Fuji IX GP® (GC) was used for the temporary restoration. Second visit The patient attended the clinic for obturation of the root canals 10 days later. The tooth was asymptomatic. After the antiseptic wash, local anesthesia was given, and the rubber dam was applied. The temporary restoration was removed. The access cavity and root canals were filled with citric acid, and the solution was activated by means of ultrasonic tip 3 times for 20 seconds with regular solution replacement for residual calcium hydroxide removal. While planning the irrigation protocol before root canal system obturation, the

Figure 1: Case one — initial radiograph of tooth LL6 Volume 7 Number 4

Figure 2: Start- X™ (Dentsply) ultrasonic tips were used for access cavity refinement Endodontic practice 43

CONTINUING EDUCATION

(Martinez-Berna, Badanelli, 1985). Mortman (2003) suggests that the third mesial canal is not an extra canal but rather the sequelae of instrumenting the isthmus between the mesiobuccal and mesiolingual canals. According to the literature analysis, the authors found that the anatomy of the root canal system of mandibular first molar needs a high level of attention, because the number of roots and canals often varies.

CONTINUING EDUCATION

Figures 3A and 3B: Postoperative radiographs

dilution effect of disinfectant (reduction of its initial concentration while moving through the dentinal tubules, which reduces the potential disinfecting ability) was taken into account. It was concluded that any irrigant alone cannot completely remove all organic and inorganic matter from the canal walls (Basrani, et al., 2007). That is why, for the final irrigation, the combination of several solutions was used in the correct sequence reinforced by ultrasonic activation for the effective removal of the residual dentinal debris (Jensen, et al., 1999). Irrigation protocol: • NaOCl 5.25% activated by ultrasonic tip 3 times for 20 seconds with regular replacement of solution • EDTA 17% activated by an ultrasonic tip 3 times for 20 seconds with regular replacement solution • Sterile saline • 2% solution of chlorhexidine for 3 to 5 minutes and activated by an ultrasonic tip 3 times for 20 seconds with regular replacement of solution • Sterile saline All master cones were cleaned with antiseptic, fitted and set to working length. Obturation was conducted by cold, lateral condensation of gutta percha and AH Plus® (Dentsply) sealer. After examination, the post-obturation radiographs (Figures 3A and 3B) and the CBCT results (Figures 4, 5, and 6) revealed the following: • Axial slice of CBCT of tooth LL6 confirmed three root canals in the mesial and two root canals in the distal roots (Figure 6). • In the medial system, three separate root canals with separate orifices and two separate apices (Figure 4), which 44 Endodontic practice

Figure 4: Cross-sectional slices of the mesial root of tooth LL6

Figure 5: Cross-sectional slices of the distal root of tooth LL6

Figure 7: CBCT sagittal projection of tooth LL6

are the XII (3-1) type, according to the Gulabivala (2001) classification of the root canal morphology (Table 1), that partially overlap on the postoperative radiograph (Figure 3). • A thin isthmus partially divides two distal root canals, which exit by two separate apices that corresponds to the type IV morphology of root canals, according to the Vertucci classification (Table 1). These canals also overlap on the postoperative radiograph (Figure 5).

Figure 6: Axial slice of tooth LL6 confirms three root canals in the mesial and two root canals in the distal roots

Figure 8: Checkup after 3 months

Cross-sectional and tangential sections (Figures 4, 5, and 7) confirm the presence of osteolytic changes in the area of the LL6 tooth roots, which are poorly visible on radiographs. Glass ionomer cement Fuji IX GP was used for temporary sealing. The patient was referred for the restorative treatment of tooth LL6. The patient was recalled after 3 months (Figure 8), and radiological evidence of the periapical healing was confirmed. Volume 7 Number 4

CONTINUING EDUCATION

Figure 10: Root canal orifices were not visible

Figure 11: Pulp chamber view after use of ultrasonic tip

Figure 9: Case two — initial radiograph

Clinical case two The patient contacted the practice complaining of aching pain in tooth LR6, which increased on biting. The temperature test was negative, while the percussion test was positive. The radiograph didn’t show any evidence of periapical radiolucencies (Figure 9). The diagnosis was acute apical periodontitis of tooth LR6, and conservative endodontic treatment was recommended. After the pulp chamber roof was removed, the root canal orifices were not visible (Figure 10). Figure 11 shows the pulp chamber view after the use of ultrasonic tips. After cleaning the access cavity, the root canals were shaped with ProTaper Universal instruments (Figure 12). Obturation of root canals was made by condensation of warm gutta percha using the continuous wave method (Figures 13A and 13B). The glass ionomer cement Fuji IX GP was used for the temporary restoration. The patient was referred for the permanent restoration of tooth LR6.

Discussion The typical morphology of mandibular molars is widely described in the literature, along with numerous case reports. Inability to locate, prepare, and obturate the entire root canal system usually leads to the failure of treatment (Leonardo, 1998).

Conclusion According to the literature, the third canal in the mesial root of the mandibular first molar is found in 0.8-12% of cases. This Volume 7 Number 4

Figure 12: After cleaning the access cavity, the canals were shaped with ProTaper® Universal instruments

canal can be separate, with separate apex, or can merge with either the mesiolingual or mesiobuccal canal. In daily practice, it is important to use methods such as preoperative periapical radiographs in three projections or, if necessary, CBCT. Optical magnification and special tools for root canal detection can significantly improve the quality of treatment. A detailed knowledge of root canal anatomy, the correct diagnosis, and appropriate shaping and cleaning of the root canal system usually leads to successful results (Schafer, Bossmann, 2001). EP

Figures 13A and 13B: Obturation of root canals was made by condensation of warm gutta percha using the continuous wave method

REFERENCES 1. Basrani BR, Manek S, Sodhi RN, Fillery E, Manzur A. Interaction between sodium hypochlorite and chlorhexidine gluconate. J Endod. 2007;33(8):966-969. 2. De Pablo OV, Estevez R, Péix Sánchez M, Heilborn C, Cohenca N. Root anatomy and canal configuration of the permanent mandibular first molar: a systematic review. J Endod. 2010;36(12):1919-1931. 3. Fabra-Campos H. Unusual root anatomy of mandibular first molars. J Endod. 1985;11(12): 568-572. 4. Hess W. The anatomy of the root canals of the teeth of the permanent dentition. Part 1. New York: Williams Wood & Co.; 1925. 5. Jensen SA, Walker TL, Hutter JW, Nicoll BK. Comparison of the cleaning efficacy of passive sonic activation and passive ultrasonic activation after hand instrumentation in molar root canals. J Endod. 1999;25(11):735-738. 6. Kim V, Mingazeeva Y, Novikov V. Variety of internal anatomy of the tooth. DentArt. 2011;4:18-22. 7. Leonardo MR. Aspectos anatomicos da cavidade pulpar: relacoes com o tratamento de canais radiculares. In: Leonardo MR, Leal JM, eds. Endodontia: tratamento de canais radiculares. 3rd ed. Sao Paulo: Panamericana. 1998:191. 8. Martinez-Berna A, Badanelli P (1983) Investigacion clinica de molars inferiors con cinco conductos. Boletin de information dental. 1983;43:27-41. 9. Martínez-Berná A, Badanelli P. Mandibular first molars with six root canals. J Endod.1985;11(8): 348-352. 10. Mortman RE, Ahn S (2003) Mandibular first molars with three mesial canals. Gen Dent. 2003;51(6):549-551. 11. Navarro LF, Luzi A, García AA, García AH. Third canal in the mesial root of permanent mandibular first molars: review of the literature and presentation of three clinical reports and two in vitro studies. Med Oral Patol Oral Cir Bucal. 2007;12(8): E605-609. 12. Schäfer E, Bossmann K. Antimicrobial efficacy of chloroxylenol and chlorhexidine in the treatment of infected root canals. Am J Dent. 2001;14(4): 233-237. 13. Weller RN, Niemczyk SP, Kim S. Incidence and position of the canal isthmus. Part 1. Mesiobuccal root of the maxillary first molar. J Endod. 1995;21(7):380-383. 14. Zattar EI, Al-Busairi MA, Behbahani MJ. Maxillary first premolars with three root canals: case report. Quintessence Int. 1990;21(12):1007-1011.

Endodontic practice 45

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Treatment of mandibular first molars with five root canals 1. The _________ of the root canal system is/are the main cause(s) of endodontic failure. a. incomplete instrumentation b. incomplete cleaning c. defective obturation d. all of the above 2. Mandibular first molars __________, which is why they are more often damaged by caries. a. erupt earlier than all other teeth b. are used more often c. have a greater biting force d. are often left untreated 3. In the majority of cases, the mandibular first molar has _____ root(s). a. one b. two c. three d. four 4. According to de Pablo, et al.â&#x20AC;&#x2122;s (2010) systematic review on root anatomy and canal configuration of the permanent mandibular first molars (with reference to 41 studies and a total of 18,781 teeth), the third root was present in ________ of cases, and it was ethnically dependent. a. 5% b. 13%

46 Endodontic practice

c. 23% d. 33% 5. The most common canal system configuration(s) was/were ____________, according to the Vertucci classification. a. type III (45.3%) b. type IV (52.3%) c. type II (35%) d. both b and c 6. The diameter of the MM canal is _________ compared to ML and MB. a. smaller b. larger c. equal d. undetectable 7. (In clinical case one)While planning the irrigation protocol before root canal system obturation, the dilution effect of disinfectant (reduction of its initial concentration while moving through the dentinal tubules, which reduces the potential disinfecting ability) was taken into account. It was concluded that any irrigant alone cannot completely remove _____________ from the canal walls. a. all organic matter b. all inorganic matter

c. the gutta percha d. both a and b 8. According to the literature, the third canal in the mesial root of the mandibular first molar is found in 0.8-12% of cases. This canal can be ___________. a. separate with separate apex b. can merge with either the mesiolingual or mesiobuccal canal c. can be easily damaged by using several irrigating solutions d. both a and b 9. In daily practice, it is important to use (a) method(s) such as preoperative periapical radiographs in _________ projection(s) or, if necessary, CBCT. a. one b. two c. three d. four 10. _________ can significantly improve the quality of treatment. a. Digital photographs b. Optical magnification c. Special tools for root canal detection d. Both b and c

Volume 7 Number 4

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ENDODONTIC PRACTICE CE

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. Endodontic0 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 implant 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 Volume 7 Number 4

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(Multiple) Doe JF, Roe JP

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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

Endodontic practice 47

ABSTRACTS

The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research Histological evaluation to study the effects of dental amalgam and composite restoration on human dental pulp: an in vivo study Chandwani ND, Pawar MG, Tupkari JV, Yuwanati M Medical Principles and Practice (2014) 23(1):40-4 Abstract Aim: To study and compare the effects of dental amalgam and composite restorations on human dental pulp. Methodology: One hundred sound premolars scheduled for orthodontic extraction were divided equally into two groups: group A, teeth restored with silver amalgam, and group B, teeth restored with composite resin. Each group was equally subdivided into two subgroups â&#x20AC;&#x201D; extracted after 24 hours (A-1 and B-1) or 7 days (A-2 and B-2) â&#x20AC;&#x201D; and the histological changes in the pulp related to the two different materials at the two different intervals were studied. Results: It was found that after 24 hours, the inflammatory response of the pulp in teeth restored with amalgam and composite was similar (p = 1.00). However, after 7 days, the severity of the inflammatory response of the pulp in teeth restored with amalgam was less compared to that in teeth restored with composite (p = 0.045). Conclusion: This study confirmed that amalgam continues to be the mechanically as well as the biologically more competent restorative material. Composite could be a promising restorative material to satisfy esthetic needs for a considerable period of time. However, its biological acceptance is still in doubt.

Long-term survival rate of teeth receiving multidisciplinary endodontic, periodontal, and prosthodontic treatments Moghaddam AS, Radafshar G, Taramsari M, Darabi F Journal of Oral Rehabilitation (2014) 41(3):236-42

Kishor Gulabivala, BDS, MSc, FDSRCS, PhD, FHEA, is professor and chairman of endodontology, and head of department of restorative dentistry at Eastman Dental Institute, University College London. He is also training program director for endodontics in London.

48 Endodontic practice

Abstract Aim: Deciding whether to replace or preserve a compromised tooth, even with emerging trends in implant dentistry, is still a common dilemma for dental practitioners. This study sought to determine the 3- to more than 10-year survival rate of teeth that had undergone endodontic, periodontal, and prosthodontic treatments. Methodology: A total of 245 teeth in 87 patients were clinically and radiographically evaluated. All the teeth had received crown lengthening surgery by a single periodontist. Root canal therapy and prosthodontic procedures were rendered either by specialists or by experienced general dentists. Numbers of lost teeth were recorded, and the criteria for hopeless teeth were defined. Survival rate was determined using the Kaplan-Meier estimator. Clinical indices, including pocket depth (PD), bleeding index (BI), C/R ratio, position of the restoration margin relative to the gingival margin (RM-GM), and the presence of intra-canal post were compared between different survival groups (less than 3, 3 to 5, 5 to 10, and more than 10 years) using one-way analysis of variance (ANOVA). Potential predictors of failure were determined using the Cox regression model. Results: The mean + s.d. of 3-, 5-, 10-, and 13-year survival rates was 98 + 1%, 96 + 16%, 831 + 45% and 519 + 145%, respectively. The mean PD (P < 0013), as well as C/R ratio in the mesial (P = 0003) and distal (P = 0007) surfaces, was significantly higher in the more than 10-year-survived teeth. Bleeding index and RM-GM showed no significant differences between the groups. C/R ratio and RM-GM position appeared to be the major determinants of tooth loss. Conclusion: The long-term survival rate of multidisciplinary-treated teeth was 83%-98% in this specific sample.

Comparison of the bacterial composition and structure in symptomatic and asymptomatic endodontic infections associated with root-filled teeth using pyrosequencing Anderson AC, Al-Ahmad A, Elamin F, Jonas D, Mirghani Y, Schilhabel M, Karygianni L, Hellwig E, Rehman A PLoS ONE [Electronic Resource] (2013) 8(12):e84960

Abstract Aim: Residual microorganisms and/ or re-infections are a major cause for root canal therapy failure. Understanding of the bacterial content could improve treatment protocols. Methodology: Fifty samples from 25 symptomatic and 25 asymptomatic previously root-filled teeth were collected from Sudanese patients with periradicular lesions. Amplified 16S rRNA gene (V1-V2) variable regions were subjected to pyrosequencing (FLX 454) to determine the bacterial profile. Obtained quality-controlled sequences from 40 samples were classified into 741 operational taxonomic units (OTUs) at 3% dissimilarity, 525 at 5% dissimilarity, and 297 at 10% dissimilarity, approximately corresponding to species-, genus-, and class-levels. Results: The most abundant phyla were Firmicutes (29.9%), Proteobacteria (26.1%), Actinobacteria (22.72%), Bacteroidetes (13.31%), and Fusobacteria (4.55%). Symptomatic patients had more Firmicutes and Fusobacteria than asymptomatic patients, while asymptomatic patients showed more Proteobacteria and Actinobacteria. Interaction of disease status and age was observed by two-way ANOSIM. Canonical correspondence analysis for age, tooth restoration, and disease status showed a correlation of disease status with the composition and prevalence of different members of the microbial community. Conclusion: The pyrosequencing analysis revealed a distinctly higher diversity of the microbiota compared to earlier reports. The comparison of symptomatic and asymptomatic patients showed a clear association of the composition of the bacterial community with the presence and absence of symptoms in conjunction with the patientsâ&#x20AC;&#x2122; age.

What are the key endodontic factors associated with oral healthrelated quality of life?

Liu P, McGrath C, Cheung G International Endodontic Journal (2014) 47(3):238-45 Abstract Aim: To determine the associations between endodontic factors and oral healthrelated quality of life (OHQoL), controlling for socio-demographics, pain, and other oral health clinical factors. Volume 7 Number 4

Incidence and characteristics of acute referred orofacial pain caused by a posterior single tooth pulpitis in an Iranian population

Hashemipour MA, Borna R Pain Practice (2014) 14(2):151-7 Abstract Aim: This study was designed to evaluate incidence and characteristics of acute referred orofacial pain caused by a posterior single tooth pulpitis in an Iranian population. Methodology: In this cross-sectional study, 3,150 patients (1,400 males and 1,750 females) with pain in the orofacial Volume 7 Number 4

region were evaluated via clinical and radiographic examination to determine their pain source. Patients completed a standardized clinical questionnaire consisting of a numerical rating scale for pain intensity and chose verbal descriptors from the short form McGill questionnaire to describe the quality of their pain. Visual analog scale (VAS) was used to score pain intensity. In addition, patients indicated sites to which pain referred by drawing on an illustration of the head and neck. Data were analyzed using chi-squared, Fisherâ&#x20AC;&#x2122;s exact, and Mann-Whitney tests. Results: Two thousand, one hundred and twenty patients (67/3%) reported pain in sites that diagnostically differed from the pain source. According to statistical analysis, sex (P = 0.02), intensity of pain (0.04), and quality (P = 0.001) of pain influenced its referral nature, while age of patients and kind of stimulus had no considerable effect on pain referral (P > 0.05). Conclusion: The results of the present study show the prevalence of referred pain in the head, face, and neck region is moderately high. Therefore, in patients with orofacial pain, a careful examination is essential before carrying out treatment that could be inappropriate.

Comparison of clinical outcomes of endodontic microsurgery: 1-year versus long-term follow-up

Song M, Nam T, Shin SJ, Kim E Journal of Endodontics (2014) 40(4):490-4

Abstract Aim: The purpose of this study was to examine and compare the clinical outcome of endodontic microsurgery after 1 year of follow-up and over a period of 4 years. Methodology: The database of the department of conservative dentistry, Yonsei University, Seoul, South Korea, was searched for patients who had undergone endodontic microsurgery and had been evaluated 1 year after surgery and over a period of 4 years. Two examiners independently evaluated the postoperative radiographs taken 1 year after surgery and over a period of 4 years using Rudâ&#x20AC;&#x2122;s criteria. To analyze and compare the success rate based on the observation period, the McNemar test was performed with a significance level of 0.05. Results: The study included 115 cases. Using Rudâ&#x20AC;&#x2122;s criteria, the overall success rate of cases with 4 or more years of follow-up was 87.8% compared with 91.3% at 1 year

of follow-up. There was no significant difference between the follow-up periods (P = .344). Conclusion: There was no significant difference in the clinical outcome after endodontic microsurgery when comparing 1-year follow-up periods with longer followup periods.

Free available chlorine concentration in sodium hypochlorite solutions obtained from dental practices and intended for endodontic irrigation: are the expectations true? Waal Sv, Connert T, Laheij A, Soet Jd, Wesselink P Quintessence International (2014) 45(6):467-74 Abstract Aim: Sodium hypochlorite (NaOCl) is an important tool in root canal disinfection, although it is well-known that the shelf life of NaOCl is limited. In this study, NaOCl solutions that were collected from dental practices and were intended for endodontic irrigation were investigated to see whether they contained the expected concentration of free available chlorine. Methodology: NaOCl solutions were collected from dental practices. The concentration of available chlorine per sample was determined with iodometric titration and the pH was measured. Each participating dentist completed a questionnaire that requested data on a range of issues relating to the assumed concentration of NaOCl and handling of the sample. Results: Eighty-four samples with questionnaires were received. NaOCl was purchased from supermarkets and drugstores (36%), dental suppliers (48%), or pharmacies (16%). The median expected concentration was 2% (n = 36). On average, 27% less available chlorine was measured than the dentist assumed was in the sample (P < .001). Fifteen percent of samples contained less than 1% available chlorine, which is needed for tissue dissolution and disinfection. The average pH was 11.5. Conclusion: The greatest differences in concentrations were found in NaOCl sourced from supermarkets or drugstores. Future studies should elucidate the cause of this discrepancy. Clinical relevance: In the meantime it is recommended to purchase NaOCl from professional suppliers, because this group showed the most reliable content of free available chlorine. EP Endodontic practice 49

ABSTRACTS

Methodology: OHQoL assessments were conducted among a consecutive sample of 412 Chinese patients requiring endodontic treatment, employing the shortform Oral Heath Impact Profile (OHIP-14). Information on number of teeth requiring endodontic treatment; tooth type; retreatment requirements; periapical radiolucency assessment; and diagnostic classification was obtained. In addition, socio-demographic information (age, gender, educational attainment, and family income), pain ratings on a visual analogue scale (VAS) and other clinical oral health status information were collected. Results: Bivariate analyses identified association between number of teeth requiring endodontic treatment and summary OHIP-14 score (P < 0.01) and four of its seven domain scores (P < 0.05). Need for endodontic retreatment was associated with summary OHIP-14 score (P < 0.05) and two of its seven domain scores (P < 0.05). In regression analyses having controlled for socio-demographics, other clinical factors and pain rating among 15 confounding variables, patients requiring endodontic treatment for multiple teeth were more than twice as likely to have poor OHQoL (upper quintile OHIP-14 scores) compared to those requiring endodontic treatment for a single tooth (OR = 2.16, 95% CI 1.17, 3.98, P < 0.05). Pain VAS rating and age also emerged as significant factors associated with poor OHQoL in the regression analysis. Conclusion: OHQoL is compromised among patients requiring endodontic treatment. Number of teeth requiring endodontic treatment is associated with poor OHQoL, controlling for socio-demographic, and other oral health clinical and pain factors.

PRODUCT PROFILE

ESX® Rotary Files from Brasseler USA® So Sophisticated It’s Simple™: Designed to safely and efficiently navigate the most challenging canals

rasseler USA®, a leading manufacturer of quality instrumentation, has introduced the new ESX® Rotary File System. Designed with several performance-enhancing patented features, ESX is a two file shaping system with a minimally invasive protocol which seeks to maximize the longterm prognosis 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 wavelike 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. In addition, the triangular cross section of the ESX Rotary File supports sharper cutting edges and a larger chip space for more effective debris removal. As with all Brasseler USA rotary files, the ESX Rotary File surface is treated with Brasseler’s exclusive proprietary electropolished finish. The electropolished treatment greatly improves resistance to cyclic and torsional fatigue often associated with the long-term use of dental rotary files. Another significant feature of the new ESX Rotary File is its patented booster tip. The BT Tip™ maximizes safety and efficiency and provides the user stress-free apical progression and clearing of debris while respecting even the most challenging canal anatomy. The BT Tip features six cutting edges that smoothly transition to a true reamer design for increased cutting efficiency, and has an anti-ledging and anti-perfing centering mechanism that provides superior performance each and every time. For more information about the ESX Rotary File, please visit http://brasselerusa.com/go/esx, or call 800-841-4522.

About Brasseler USA® Brasseler USA® is a leading ISO Certified healthcare company, providing quality instrumentation to healthcare professionals for use in restorative dentistry, endodontics, oral surgery, and oral hygiene. For nearly 40 years, Brasseler USA has developed a reputation as an innovative market leader in diamonds, carbides, polishers, endodontics, hand instruments, and handpieces. Today, Brasseler USA offers the most comprehensive assortment of instruments and power systems under one brand in the world. For more information, please visit http://brasselerusa.com. EP 50 Endodontic practice

Volume 7 Number 4

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PRACTICE MANAGEMENT

Superior customer service Dr. Roger Levin presents the 10 top ways to help create a perfect dental team

ith the changes brought on by the economy, top companies are bringing in the best resources they can find to evaluate where their organizations stand. They want to know what and/or how they can improve. These executives want their organizations to perform better both now and in the future. Everyone in the dental field must do the same. It is more critical than ever to have a high-performance team to provide patients with a superior customer service experience. Here are 10 tips to help you and your team meet these demands and help maintain, or increase case acceptance.

Create a vision statement As the CEO of your practice, you are the leader. As a leader, you have to take people somewhere, which is why your vision statement is so important. It focuses on where you want to take your practice in the next 3 to 5 years. Your vision statement will provide focus and direction for the practice. It should contain clearly written information describing where the practice is going. The length of a vision statement can vary, but it is rarely longer than several paragraphs.

Share your vision To make the vision a reality, you need to share it with your team members — and not just once; they should be exposed to it on a regular basis. Make sure every staff member understands your vision, so reinforce it during monthly staff meetings. Individuals can’t support your vision if they don’t understand it. When your team has a clear understanding of where the practice is going, they have a better idea of their roles in the practice’s success. To do their jobs effectively, all team members must understand and also buy into the vision.

Roger P. Levin, DDS, is founder and CEO of Maryland-based Levin Group, a dental practice management consulting firm. Since the company’s inception in 1985, Dr. Levin has worked to bring the business world to dentistry. Dr. Levin addresses thousands of dentists and staff worldwide each year in seminars and dental meetings.

52 Endodontic practice

Communicate your goals You will only reach your vision by establishing and accomplishing specific and measurable goals along the way. However, these goals will never be fulfilled if they stay in your head. Communicate them daily to team members during meetings. Each goal brings you one step closer to making your vision a reality.

Hire the right people Only individuals with the right skills, talents, and attitude will move the practice forward. Hiring the right people will make your life easier. Communicate your vision during the interview, so potential employees know the type of practice you have.

Achieve great customer service Customer service affects every practice system. The level of your customer service determines how comfortable you make patients feel, which in turn determines how successful you are in presenting cases. Remember that patients won’t accept treatment in an environment that doesn’t meet their expectations. Your goal is to exceed their expectations. Your system for customer service must be one that can be repeated for every patient, every day. You should be able to outline this process so that all employees know what you want to have happen for every patient, every single time. Train your team to provide superior customer service during every patient interaction, and watch the positive impact it will have on your practice.

Educate your team Remember that many patients will seek a second opinion about your recommended treatment — before they even leave the practice. That means you want everyone up-to-date and knowledgeable about the services your practice provides. Team meetings provide an excellent opportunity to educate staff about new services. All team members must be able to educate and motivate patients during case presentation appointments.

Train with scripting Scripting provides the practice with a consistent method to train every team member. As in sports, working from the same “playbook” builds team unity. Scripts help your team communicate clear and consistent messages to patients. Create scripts for every aspect of patient interaction and maximize the capabilities of your team members.

Encourage success Team members want your appreciation, which can be shown in any number of ways. You could treat the team to lunch or breakfast after a stressful or trying week. Or you could take the entire team to an amusement park for a day. Whatever option you choose, socializing outside of the practice is an excellent way to motivate people and build team cohesiveness.

Give positive feedback Most people want to be recognized. This can be as simple as saying “thank you” or “well done” after a team member has completed a task or somehow gone above and beyond in his/her responsibilities. Compliment team members when you see them handle a difficult situation, praise them when their verbal skills persuade a patient to accept treatment, and thank them for helping the practice succeed.

Recognize that team building will be continuous Practices will always face challenges. Prepare your team for those challenges. Complacency will only create more challenges. Set time aside for specific training, out-of-office activities and performance discussions. A truly excellent team won’t shy away from challenges; they’ll want to tackle them head on! EP Volume 7 Number 4

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Brasseler USA® introduces EndoSequence® BC RRM-Fast Set Putty™ Fast set formula and improved Sanidose™ syringe delivery Brasseler USA®, a leading manufacturer of quality instrumentation, has introduced EndoSequence® BC RRM-Fast Set Putty™. Made with a fast set formula and equipped with improved Sanidose™ syringe delivery, BC RRM-Fast Set Putty provides users with superior handling and excellent healing properties. Formulated with superior healing properties, BC RRM-Fast Set Putty is highly biocompatible, has an extremely antibacterial pH balance of +12, and is osteogenic, making it the ideal solution for all pulp capping and root repair procedures. Moreover, BC RRM-Fast Set Putty provides users with superior handling. BC RRM-Fast Set Putty is premixed, resulting in less waste and no threat of cross-contamination. Improved Sanidose syringe delivery ensures a perfect unit dose of moldable and condensable consistency with each and every putty application. BC RRM-Fast Set Putty is extremely resistant to common washout and sets completely in a mere 20 minutes. BC RRMFast Set Putty has an extremely small particle size and, unlike other root repair and pulp capping materials on the market, is completely void of heavy metals such as bismuth oxide that can cause discoloration. Furthermore, a recent study concluded that BC RRM-Fast Set Putty exhibited the fastest set time and best cell adhesion capacity of all materials tested.* For more information about the BC RRM-Fast Set Putty, visit www.BrasselerUSA.com, or call 800-841-4522.

*Documentation available upon request.

Volume 7 Number 4

Sirona balances innovation and ease of use with release of new CEREC 4.3 software Numerous new features enhance clinical safety and make the workflow simpler and more efficient With the new 4.3 update to the CEREC software, Sirona demonstrates its market leadership role in dental CAD/CAM and offers users numerous innovations to improve the clinical quality of restorations and make workflow simpler and more efficient. With this new software update, CEREC has improved the accuracy of virtual models: When creating digital impressions with the CEREC Omnicam, more details are recorded and the jaw represented more accurately — with no increase in the size of the data sets created. The software checks whether the data from the scan is sufficiently networked. If there are gaps in the data set, red arrows immediately provide the user with feedback, indicating the point at which the model must be completed by rescanning. Because of the greater accuracy of the model, it is also possible for edges to be shown more sharply, thus making it easier for the automatic margin finder to recognize the preparation margins. The system is now the first to be able to mill with carbide instruments. Restorations can be processed more rapidly by means of carbide milling. Feedback is also provided by the software for users of the CEREC Omnicam, in the event of undercuts occurring in the course of minimally invasive preparation. The software marks these automatically once the user has set the axis for the model. For more information, visit www.sirona.com.

StarDental® reintroduces the 430 Flex to Classic 430 handpiece line No-hassle conversion for MULTIflex® swivel users DentalEZ® Group, a supplier of innovative products and services for dental health professionals worldwide has reintroduced the 430 SWL Flex to its StarDental® 430 handpiece line. Designed with a new look and equipped with numerous performance-enhancing features, the 430 SWL Flex makes the conversion to the classic StarDental line of high-speed handpieces fast, seamless, and less costly. There is no need to purchase new couplers to make the switch for dental professionals who are currently using MULTIflex® swivels in their practice. The 430 SWL Flex includes solid glass rod fiber optics and is designed with an attractive satin finish. It is available in lubricated or StarDental’s traditional LubeFree™, which provides substantial cost and time savings. The small head and high-torque design of the 430 SWL Flex provides superior oral accessibility and visibility, and the high power enables fast and precise removal of tooth surface and amalgam. Committed to offering high-quality long-lasting choices, DentalEZ provides a 2-year warranty for the lubricated line of high-speed 430 Series handpieces, as well as a 1-year warranty for its traditional LubeFree versions. For more information on the StarDental 430 SWL Flex handpiece, call 877-341-6275, or visit www.dentalez.com/430Flex.

Endodontic practice 53

ENDOSPECTIVE

Optimizing irrigation — consider the possibilities Dr. Rich Mounce discusses trends for creating cleaner canals

he ideal goal of endodontic canal cleaning is to eliminate the smear layer, biofilms, bacteria, clean tubules, and remove all tissue (from orifice to apex). With the current state of the art, this remains an ideal goal not yet realized. This column was written to highlight the current state of the art in endodontics. Presently, there is no literature-based superiority of endodontic irrigation regimens, only trends that are correlated in the literature with creating cleaner canals. Collectively though, there are literature-based irrigation techniques that provide cleaner canals. In general terms, optimizing the following variables leads to cleaner canals: irrigant combinations using a bactericidal agent and smear layer removal agent; greater irrigant volumes; greater concentrations; increased contact times; reduced surface tension; increased temperature; improved apical delivery (with regard to needle type and depth of insertion); and irrigant activation (multisonic, laser, negative pressure, ultrasonic, plastic file agitation, and so on). Eloquently summarized by Stojicic, et al., 2010, “Optimizing the concentration, temperature, flow, and surface tension can improve the tissue-dissolving effectiveness of hypochlorite even 50-fold.” Clinically, the above notwithstanding, no one single variable is primary in creating optimal canal cleanliness using the technology available at this time. Among many possible literature choices, highlights from the endodontic literature illustrating current state-of-the-art thought include the following. All things being equal, sodium hypochlorite (SH) is the irrigant of choice. SH is

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 endo dontic 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

54 Endodontic practice

more effective than 2% chlorhexidine (CHX) to eliminate biofilms (Del Carpio-Perochena, et al., 2011). CHX retains its antimicrobial activity for at least a week after use clinically. SH does not possess this ability, yet obviously can dissolve tissue, which CHX cannot. (Dametto, et al., 2005; Rosenthal, et al., 2004). Increasing the master apical diameter and placing the irrigating needle near the TWL are required for irrigant replacement apically. How deeply the irrigating needle is inserted is significant, with a deeper insertion more effective than one more distant from the apex. Sedgley, et al., 2005; Hsieh, et al., 2007 found “With a final apical size of 35, a 27-gauge needle would need to penetrate to within 3 mm of working length for irrigant flow.” Stojicic, et al., 2010 also stated: “Weight loss (dissolution) of the tissue increased almost linearly with the concentration of sodium hypochlorite. Higher temperatures and agitation considerably enhanced the efficacy of sodium hypochlorite. The effect of agitation on tissue dissolution was greater than that of temperature; continuous agitation resulted in the fastest tissue dissolution. Hypochlorite with added surface active agent had the lowest contact angle on dentin and was most effective in tissue dissolution in all experimental situations.” Optimized taper helps optimize irrigant delivery. Correlating master apical diameter and canal taper, Brunson, et al., 2010

found: “An increase from ISO #35 to ISO #40 resulted in a percentage gain of approximately 44% in mean irrigant volume ...” and “an increase in taper from 0.02 through 0.08 resulted in percentage gains of approximately 74%, 5.4%, and 2.4% increase (of irrigant volume), respectively.” Activation is an essential part of endodontic cleaning relative to syringe only irrigation (Kuah, et al., 2009; Chopra, et al., 2008; Gutarts, et al., 2005). Finally, a new and novel multisonic cleaning technique is on the horizon (while not yet commercially available at this time): the GentleWave™ technology from Sonendo®, whose first examination in the scientific literature has just been published (Haapasalo, et al., 2014). Haapasalo, et al., concluded, “The novel Multisonic Ultracleaning System achieved a significantly faster tissue dissolution rate when compared with the other systems examined in vitro.” If Sonendo’s full promise is realized, complex instrumentation regimens can become a thing of the past as the device is capable of reaching inaccessible areas of the canal to remove biofilm, tissue, bacteria, the smear layer, and clean tubules to an extent never before seen predictably. This column was written to highlight the current literature-based state of the art in endodontic irrigation. While not by any means exhaustive, it highlights the importance of optimizing all of the variables possible in cleaning canals once they are shaped. EP

REFERENCES 1. Brunson M, Heilborn C, Johnson DJ, Cohenca N. Effect of apical preparation size and preparation taper on irrigant volume delivered by using negative pressure irrigation system. J Endod. 2010;36(4):721-724. 2. Chopra S, Murray PE, Namerow KN. A scanning electron microscopic evaluation of the effectiveness of the F-file versus ultrasonic activation of a K-file to remove smear layer. J Endod. 2008;34(10):1243-5. 3. Dametto FR, Ferraz CC, Gomes BP, Zaia AA, Teixeira FB, de Souza-Filho FJ. In vitro assessment of the immediate and prolonged antimicrobial action of chlorhexidine gel as an endodontic irrigant against Enterococcus faecalis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(6):768-772. 4. Del Carpio-Perochena AE, Bramante CM, Duarte MA, Cavenago BC, Villas-Boas MH, Graeff MS, Bernardineli N, de Andrade FB, Ordinola-Zapata R. Biofilm dissolution and cleaning ability of different irrigant solutions on intraorally infected dentin. J Endod. 2011;37(8): 1134-1138. 5. Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod. 2005;31(3):166-70. 6. Haapasalo M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour M. Tissue dissolution by a novel multisonic ultracleaning system and sodium hypochlorite. J Endod. [online] February 17, 2014. Available at: http://www.jendodon.com/article/S00992399%2814%2900005-3/abstract. Accessed June 19, 2014. 7. Hsieh YD, Gau CH, Kung Wu SF, Shen EC, Hsu PW, Fu E. Dynamic recording of irrigating fluid distribution in root canals using thermal image analysis. Int Endod J. 2007;40(1):11-7. 8. Kuah HG, Lui JN, Tseng PS, Chen NN. The effect of EDTA with and without ultrasonics on removal of the smear layer. J Endod. 2009;35(3):393-396. 9. Rosenthal S, Spångberg L, Safavi K. Chlorhexidine substantivity in root canal dentin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;98(4):488-492. 10. Sedgley CM, Lennan SL, Appelbe OK. Survival of Enterococcus faecalis in root canals ex vivo. Int Endod J. 2005;38(10):735-742. 11. Stojicic S, Zivkovic S, Qian W, Zhang H, Haapasalo M. Tissue dissolution by sodium hypochlorite: effect of concentration, temperature, agitation, and surfactant. J Endod. 2010;36(9):1558-1562.

Volume 7 Number 4

THE NEW STANDARD

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Standard NiTi $25* Controlled Memory NiTi $35*

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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

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

EVENTS

CDA North September 4 – 6, 2014 San Francisco, CA http://www.cdapresents.com/ LA Dental Meeting Dr. Allen Ali Nasseh September 5 – 6 , 2014 Universal City, CA http://ladentalmeeting.com/ American Association of Oral and Maxillofacial Surgeons (AAOMS) September 8 – 13, 2014 Honolulu, HI http://www.aaoms.org/

CE EVENTS

Efficient and Effective Endodontics Dr. Donnie Luper August 1, 2014 Virginia Beach, VA http://www.tulsadentalspecialties.com/ default/education/calendar/coursedetail. aspx?EventID=16757 The Ultradent Summit August 1 – 2, 2014 South Jordan, UT https://www.ultradent.com/en-us/Pages/ default.aspx New Dimensions in Endodontics Dr. Jerry Cymerman August 2, 2014 Destin, FL http://www.ladental.org/lda/ce-and-events Obturation: A Closer Look at Filling the Gaps Dr. Steven Katz August 6, 2014 Pittsburgh, PA http://www.tulsadentalspecialties.com/ default/education/calendar/coursedetail. aspx?EventID=16682

56 Endodontic practice

What Expert Marriage Advice Can Teach Us About Creating Long-Lasting Dentistry Dr. Dan Fischer August 8, 2014 Indianapolis, IN https://www.ultradent.com/en-us/Pages/ default.aspx Efficient and Effective Endodontics Dr. David Landwehr August 8, 2014 New Buffalo, MI http://www.tulsadentalspecialties.com/ default/education/calendar/coursedetail. aspx?EventID=17125 Clinical Application of Localized Field CBCT Dr. Nestor Cohenca August 13, 2014 Redlands, CA http://www.cvent.com/events/august13-clinical-application-of-localized-fieldcbct-in-endodontics-in-redlands-ca/ event-summary-45f90053ccde4bc4beab709758e02908.aspx Current Concepts In Dental Adhesives, Curing Lights, Composites, and Cements Dr. Richard Tuttle August 15, 2014 Hartford, CT https://www.ultradent.com/en-us/Pages/ default.aspx

Stamford, CT https://realworldendo.com/courses New Dimensions in Endodontics Dr. Alex Fleury August 16, 2014 Destin, FL http://www.alagd.org/ Composite Resin Veneer Techniques Dr. Hal Stewart August 22, 2014 Houston, TX https://www.ultradent.com/en-us/Pages/ default.aspx New Horizons in Endodontics Dr. Richie Herman August 22, 2014 Fort Myers, FL https://realworldendo.com/courses New Horizions in Endodontics Dr. Alex Fleury August 22, 2014 Ridgeland, MS https://realworldendo.com/courses Reliable Endodontic Outcomes Dr. Donnie Luper August 22 – 23, 2014 New Braunfels, TX http://www.tulsadentalspecialties.com/ default/education/calendar/coursedetail. aspx?EventID=16900

New Horizons in Endodontics Dr. Keith Evans August 15, 2014 Champaign, IL https://realworldendo.com/courses

Reliable Endodontic Outcomes Dr. George Bruder September 5 – 6, 2014 Philadelphia, PA http://www.tulsadentalspecialties.com/ default/education/calendar/coursedetail. aspx?EventID=16924

ESX® NiTi Rotary Instrumentation and Obturation System, a New Standard of Efficiency in Endodontics Dr. Jerry Cymerman August 15, 2014

New Dimensions in Endodontics Dr. Alex Fleury September 5 – 6, 2014 San Francisco, CA www.cda.org

Volume 7 Number 4

A Safe, Resin-Free Bioactive Solution! a restorative dentin substitute • • • • • • •

Repair of root furcation perforations Internal & external resorptions Direct & indirect pulp capping Restorations of deep caries Root end filling in endodontic surgery Pulpotomies Apexification

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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.

Contact your preferred dental dealer for a limited time offer on Biodentine!

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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. • • • •

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LET’S REDEFINE EXPERTISE The CS 8100 3D is just one way we redefine imaging. Discover more at carestreamdental.com © Carestream Health, Inc. 2014. 10920 EN CS 8100 3D AD 0714