Endodontic Practice US - September/October 2014 Issue - Vol7.5 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING

THE WAIT IS OVER

EXCELLENCE

Instrumentation time efficiency of rotary and hand instrumentation... Drs. Jorge Paredes Vieyra and Francisco Javier Jimenez Enriquez

ENDODONTICS Practice profile

Dr. Randy Garland

For more information visit: www.carestreamdental.com or call 800.944.6365

Endodontic Practice US

September/October 2014 – Vol 7 No 5

Corporate profile

Management of a tooth with a large internal resorption defect

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September/October 2014 – Vol 7 No 5

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Dr. Robert Slosberg

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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

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Volume 7 Number 5

Digital imaging: a paradigm shift in endodontics

n the modern endodontic practice, digital imaging has allowed professionals to go beyond film and 2D technology to treat cases more confidently and effectively than ever before. I’ll be so bold as to say that cone beam computed tomography (CBCT) in particular has been a paradigm shift within the field of endodontics. Unlike 2D radiographs, CBCT scans can provide a complete visual image covering multiple planes, such as axial, coronal, and sagittal. When dealing with difficult diagnostic dilemmas, 2D images can only show so much, and a 3D volume can act as a second opinion — and Dr. Robert Slosberg your worst critic. Preoperative scans can confirm a doctor’s initial diagnosis, or a reveal a previously unseen issue. Postoperatively, CBCT either verifies successful treatment — or shows where the doctor may have been less effective in either diagnosing or treating an infection. Additionally, a 3D rendering is an excellent tool for patient education and can lead to increased case acceptance. Imagine pointing out an issue to a patient on a 3D representation that actually looks like teeth, rather than on a 2D X-ray with distortion or overlap of anatomy. After using a CBCT solution in my practice for the past 5 years, I’ve come to find that there are cases that just cannot be treated effectively without the use of cone beam computed tomography. A clinical case within this issue highlights a resorptive defect I treated earlier in the year. I thought for certain that the patient was heading toward surgery, even with endodontic therapy. However, CBCT scans confirmed accurate mapping of the defect, and the CBCT was the only way to assess the effective permeation of the bioceramic resin used to fill the tooth. Verification from the CBCT scans allowed the patient to avoid surgery and maintain the tooth, at least for now. While opinions may vary, a study commissioned by the American Association of Endodontists found technological competency to be the number one reason a general practitioner would choose one specialist over another. In fact, the patient in the clinical case mentioned above was referred to our practice specifically because her general dentist knew us as “the cone beam guys.” While clinical competency should obviously be the ultimate factor in what makes a good endodontist, patients and other practitioners may pick and choose based on the technology you’re using, as well as your own competency with that technology. And, as Dr. Gary Carr famously said in 2008, shouldn’t endodontists be the real 3D specialists using specialized equipment — CBCT imaging being one of them? Even in the past 5 years, newer units have been released to address issues specific to endodontics. Fields of view can go as small as 5 cm x 3.75 cm and can capture the smallest details of root and canal morphology. Speaking of small, digital imaging units are becoming more compact in order to save valuable practice real estate. I had to renovate and remove part of my private office to install my first CBCT unit in 2009. Now, there are new digital imaging units on the market that can fit inside a coat closet. Regarding radiation exposure, the amount of radiation from one of these focused-field scans is approximately 5-38 microseverts of radiation; that’s one to five digital radiographs or roughly the equivalent of up to 5 days of background radiation from living on planet Earth at sea level. In comparison, a medical CT scan is approximately 2,200 microseverts of radiation. For me, using CBCT technology was a defining moment in my practice — I don’t look at teeth the same way; I don’t think about teeth the same way. As you read through this issue of Endodontic Practice US, I hope that you will gain a better understanding of how digital imaging is changing the profession of endodontics. It has certainly changed the way I practice. Dr. Robert Slosberg Robert Slosberg, DDS, received his Bachelor of Science in microbiology at the University of Georgia and completed his dental training at the University of Tennessee. Following dental school, Dr. Slosberg continued his postdoctoral training at the University of Pennsylvania. He returned to Atlanta in 1990, founding Atlanta Endodontics in 1992. He can be contacted at 770-396-7321; info@atlendo.com; atlendo.com; or @AtlantaEndo.

Endodontic practice 1

INTRODUCTION

September/October 2014 - Volume 7 Number 5

TABLE OF CONTENTS

Practice profile Randy Garland, DDS

Exceeding expectations

Clinical

Pulpal diagnosis of teeth presenting with condensing osteitis prior to endodontic treatment â&#x20AC;&#x201D; a retrospective study Drs. Brian Shaughnessy, Margaret Jones, Ricardo Caicedo, Joseph Morelli, Stephen Clark, and Ms. Jennifer Osborne review the occurrence of teeth presenting with condensing osteitis and their associated pulpal diagnosis over a 2-year period................................... 17

Case study

Management of a tooth with a large internal resorption defect

Corporate profile Sirona

Dr. Robert Slosberg facilitates accurate mapping and obturation of the resportive defect with CBCT imaging ....................................................... 20

Sirona continues to develop innovative products shaping the future of dentistry ON THE COVER Image on iPad courtesy of Carestream. A fracture, not evident on a panoramic radiograph, becomes more obvious with a cross-section report of a dual jaw scan by the Carestream Dental CS 8100 3D extraoral imaging system.

2 Endodontic practice

Volume 7 Number 5

simple, adaptable

endodontic solutions

Perfect delivery. Optimal performance. Easy removal.

UltraCal® XS and Citric Acid 20% UltraCal XS, a uniquely formulated calcium hydroxide paste (pH 12.5), can be easily delivered with the NaviTip® tip exactly where it is needed in the canal. Calcium hydroxide offers strong antimicrobial effects and potentially stimulates the healing of bone to promote healing in infected canals.1 For two-appointment RCTs, no other medicament works better than UltraCal XS. When it comes time to remove UltraCal XS from the canal, look no further than Ultradent’s Citric Acid 20%, delivered with the NaviTip FX tip. Citric Acid 20% easily dissolves calcium hydroxide, and the small fibers attached to the NaviTip FX tip easily scrub the walls of the canal, which also helps remove the smear layer. So you know the canal is ready for obturation.

Use NaviTip® tip to place UltraCal® XS in the canal, and use Citric Acid with the NaviTip® FX® tip to easily remove it.

Don’t change your technique. Make it easier with UltraCal® XS and Citric Acid 20%. Scan to watch a short video of UltraCal XS.

NaviTip tip

NaviTip FX tip with brush fibers

800.552.5512 ultradent.com NaviTip tip delivers UltraCal XS where it is needed in the canal. 1. Gomes BP, Ferraz CC, Vianna ME, Rosalen PL, Zaia AA, Teixeira FB, et al. In vitro antimicrobial activity of calcium hydroxide pastes and their vehicles against selected microorganisms. Braz Dent J. 2002;13(3):155-61.

UltraCal XS ®

TABLE OF CONTENTS

Continuing education

Instrumentation time efficiency of rotary and hand instrumentation performed on vital and necrotic human primary teeth

Case study

Maxillary keratocystic odontogenic tumor with sinus involvement: a multidisciplinary approach Drs. Brian Trava, Neil Thoman, Sharon Brooks, Harry Katz, Mark Persky, and Kathleen Nagy treat an aggressive tumor with comprehensive communication between different modalities of medicine and dentistry .......................................................28 Advanced ESX® instrumentation: segmental crown down and hybridization of tapers Dr. Allen Ali Nasseh discusses a clinical case to demonstrate the application of Advanced ESX instrumentation........30

Drs. Jorge Paredes Vieyra and Francisco Javier Jimenez Enriquez present a randomized control trial to compare the instrumentation time efficiency of rotary and hand instrumentation performed on necrotic human primary teeth.

Abstracts

The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-todate with the most relevant research ...................................................... 44

Notable milestones .......................47

Continuing education Product profile Canal preparation of the MB2 canal with the R25 Reciproc® instrument Dr. Ghassan Yared presents a new concept for the preparation of an MB2 canal without prior hand filing or glide path....................................40

4 Endodontic practice

Brasseler USA® introduces EndoSequence® BC RRM-Fast Set Putty™ Fast set formula with improved Sanidose™ syringe delivery............ 48

Practice development Life after root canal — it’s not just about having enough money Dr. Robert Fleisher ruminates on how to prepare for retirement.................49

Step-by-step

Endo-Eze® FIND™ Apex Locator ...................................................... 51

Endospective

The endodontic canal space: not the place to “horse” around Dr. Rich Mounce discusses strategies for negotiating canals and achieving apical patency.................................54

Industry news ..............56 Volume 7 Number 5

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

Randy Garland, DDS Exceeding expectations What can you tell us about your background? I grew up in southern Orange County and earned a bachelor’s degree in biology at San Diego State University in 1983. There I met my future wife, Kim, at the ripe old age of 20. We traveled with our backpacks around the world for 6 months shortly after I graduated. That gave me a real appreciation for other cultures and opened my eyes to the “real world,” after spending my life living in the Southern California “bubble.” I started dental school at the University of Southern California (USC) in 1984 and became very involved in their Mobile Dental Clinic Program as a sophomore. I was elected as the student leader of that program in my senior year. We provided free dentistry to hundreds of children of migrant farm workers who had no other access to dental care. It was a great learning experience in compassion, patience, and leadership. In my senior year, the dental

Dr. Garland with The GentleWave System™

school started a new 1-year Advanced Endodontics Program for five select fourthyear students who showed considerable interest and aptitude in endodontics. I was accepted and was educated in-depth about retreatment, post removals, complex 6 Endodontic practice

anatomy, and calcified canals. It was like an intro to an endodontic residency. After dental school, I chose to try my hand at general dentistry, but not before another 6-month travel adventure with my wife. After 7 years of general dentistry, I realized that my least stressful days were those that involved a lot of root canals. In 1995, I was accepted to the Graduate Endodontics Program at Loma Linda University. By that time, I had two sons, ages 1 and 3, so juggling the demands of school and being a father was quite a handful.

Do your patients come through referrals? Yes, my entire practice has been based on generating referrals through developing a reputation for high-quality work and treating patients as I would want to be treated.

How long have you been practicing endodontics, and what systems do you use? I’m going on 17 years of endodontics now, but have had a resurgence in my passion for practicing lately. I actually started using the ProFiles® back in 1994, a Volume 7 Number 5

GentleWave ™ ultracleans the entire root canal system. Quickly. Thoroughly. Comfortably. GentleWave’s patented multisonic technology takes you where no file has gone...ever. For the first time, simultaneously ultraclean all canals within minutes—including isthmus, lateral canals, and tubules. Effective in the simplest procedure to the most complex, GentleWave lets you schedule your day with confidence. Imagine giving your patients a cleaner and more comfortable root canal therapy. SEM of a dentin tubule cleaned with GentleWave™

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PRACTICE PROFILE

Operatory

year before I went to Loma Linda. I was very surprised to see that only one of the current residents was using rotary files routinely and none of the faculty. That changed a lot in the next 2 years. Since that time, I have tried many different systems, but settled primarily on the ProTaper® series, sonic and ultrasonic irrigation, and warm vertical gutta-percha obturation. Four years ago I purchased a cone beam CT machine for my office. For the first 21/2 years, I used it sparingly. I would use it when I thought there might be something I was missing. Then, in 1 week, I had two cases come back that were failing. I took scans on both of them and had missed a canal in each. One was on a maxillary molar and the other on a mandibular anterior. I realized at that point that I couldn’t tell what I was missing with traditional radiographs. I made a major philosophical change at that time and began taking CBCT scans on all cases that had significant potential for multiple canals. This covered everything but the maxillary anteriors. I put together a 4-page document explaining my rationale, showed examples, and sent it to all of my referring doctors. Their response was a bit of a surprise. They loved it. They started sending me more cases simply because I had this piece of technology that could help solve some diagnostic dilemmas. Patients were not only impressed, but they understood what was going on with their teeth when they could see a three-dimensional image of it showing periapical lesions, vertical bone loss, etc. 8 Endodontic practice

And the biggest bonus was how much it helped me with diagnosis and treatment. Sure, I found those extra canals. But I also saw fused roots on molars with isthmuses between them, root fractures, resorption, sinus involvement, supernumerary teeth, even the occasional tumor. I was underutilizing a fantastic tool that was sitting right in my office. Now, the new technology that has really stirred my interest is the GentleWave™ from Sonendo®. In a nutshell, this technology manages the same irrigants we’re using now, but combines them with multiple

wavelengths of sound (sonic energy). The system does an amazing job of cleaning out tissue and bacteria from the entire root canal system, including the isthmuses, the lateral canals, and the tubules. I’ve been doing quite a bit of work with the system as well as working directly with Sonendo, and I believe that they are definitely changing the game of endodontics. It’s very exciting to be involved in something that could change the future of our specialty. I have implemented it into my Encinitas, California, practice as a new tool to help me perform endodontics at a higher level.

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PRACTICE PROFILE What is the most satisfying aspect of your practice? I like the fact that I don’t need to “sell” anything. When I practiced general dentistry, there was definitely a feeling that I had to sell the patients on ideal dentistry. In my practice, I just inform the patients of what the problem is, and what I can do to try to fix it. They make an informed decision on their own, and it’s almost always treatment. If they would rather have their tooth extracted, I’m fine with that. It’s all just a lot simpler. Ironically, I find that doing root canals all day gives me very little stress. Most general dentists who don’t like endo would probably think that sounds crazy.

At the end of your career, the money you make or don’t make won’t really be a big deal. What will be important is how you treated all of your patients. You’ll want to be able to look in the mirror and be proud of the level of integrity that you treated every person with whom you dealt, including your staff.

What has been your biggest challenge? My biggest challenge has probably been running the business. If I didn’t have my wife to help with all the paperwork side of the business, I think I would prefer to just work for someone else and let them run the business. It took me about 13 years to finally get the perfect staff together. That has drastically reduced my stress level. I’ve even been able to delegate a lot of management duties to them, which has been great for everyone.

What would you have been if you didn’t become a dentist? Good question. Either a starving musician or working in some area of science.

What do you think is unique about your practice? My entire team has embraced the philosophy of exceeding our patient’s expectations at every opportunity. The staff is polite, friendly, and accommodating. We understand our patients’ fears and address them. There are TVs on the ceilings and headphones for them to enjoy during treatment. I pride myself in taking the time to give painless injections and achieving profound anesthesia. Treatment is thoroughly explained to the patients, and my highly trained and experienced staff work efficiently to keep the treatment time to a minimum. We strive to get compliments from every patient.

What is the future of endodontics and dentistry? I like what I am seeing with the use of sonics and ultrasonics in the endodontic field. It just makes a lot of sense to me. I think there will be new materials coming out for obturation that will be able to fill the elaborate network within the root canal 10 Endodontic practice

Dr. Garland and staff

system. If we are doing less instrumentation, hopefully, we will see a decrease in the rate of vertical root fractures. Personally, I’m getting tired of referring patients to the oral surgeon for implants. In general dentistry, I think there is already a big change going on with systems like CEREC that can fabricate restorations while the patient waits in the chair. I predict that new materials and software will continue to be developed that make that process faster, simpler, and even more accurate.

What advice would you give to a budding endodontist? At the end of your career, the money you make or don’t make won’t really be a big deal. What will be important is how you

treated all of your patients. You’ll want to be able to look in the mirror and be proud of the level of integrity that you treated every person with whom you dealt, including your staff. This advice was given to me by a retired dentist just before I started practicing, and it has guided me through a lot of the gray areas of being a dentist, boss, and business owner.

What are your hobbies, and what do you do in your spare time? I’m an avid surfer and a mediocre tennis player. These, along with running regularly, provide the exercise I crave. To satisfy my creative and wild sides, I sing in an alldentist rock band called Novocaine. We play at some local bars and occasional dental Volume 7 Number 5

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PRACTICE PROFILE

Novocaine

Top 10 Favorites Personal 1. Traveling with my family 2. Being a father 3. Surfing 4. Singing in a band 5. Tennis events, including our last USC Dental School reunion. I still have the travel bug, so my family and I try to get out of the country or

to Hawaii whenever we can. Any chance I get to spend time with my sons, surfing together, or just hanging out, is a treat. EP

Work 6. Laughing with my staff 7. Learning/growing 8. Carestream Cone Beam CT 9. ProTaper® Files 10. Sonendo® - GentleWave™ System

Garland family 12 Endodontic practice

Volume 7 Number 5

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

Sirona Sirona continues to develop innovative products shaping the future of dentistry

or more than 130 years, Sirona has consistently spearheaded technological developments in dentistry beginning with the invention of the first electrically powered dental drill in 1887. As the world’s largest manufacturer of dental technology, Sirona develops, manufactures, and markets a complete line of dental products that drive improved workflow, a better patient experience, and ultimately increase the success of dentists who incorporate Sirona technology within their practices. Through Sirona’s robust product offering of CAD/CAM restoration systems (CEREC); digital intraoral, panoramic, and 3D imaging systems; dental treatment centers; handpieces; and hygiene systems, the company provides innovative solutions for dental practices, clinics, and laboratories.

Sirona executive team (left to right): Walter Petersohn, Executive VP of Sales; Rainer Berthan, Executive VP; Jeffrey T. Slovin, President and CEO; Ulrich Michel, Executive VP and CFO

Comprehensive 3D imaging In all dental disciplines, including implantology, endodontics, and orthodontics, there are numerous questions that can be answered far more easily using 3D X-ray CBCT. Sirona offers several 3D options that provide superior digital image quality at a low dose of radiation making for an efficient workflow and more concise communication with patients.

Sirona production site in Bensheim, Germany

GALILEOS® As the first 3D imaging solution developed by Sirona, GALILEOS® combines X-ray diagnostics, implant visualization, treatment planning, and patient communication in one tool. GALILEOS ComfortPlus, the highend CBCT unit with HD mode, includes a large field-of-view and integrated FaceScan technology. ORTHOPHOS® XG 3D — a hybrid approach ORTHOPHOS® XG 3D combines the advantages of 2D and 3D into one comprehensive unit. With an extensive selection of panoramic and cephalometric programs to choose from, the right 2D diagnostic images are now augmented with the ability to capture 3D X-ray. 14 Endodontic practice

Sirona Center of Innovation in Bensheim, Germany Volume 7 Number 5

Sirona, the dental technology and innovation leader, has served equipment dealers and dentists worldwide for more than 130 years. The company develops, manufactures, and markets a complete line of dental products, including CAD/CAM restoration systems (CEREC), digital intraoral, panoramic and 3D imaging systems, dental treatment centers, and handpieces. Sirona employs a workforce of more than 3,200 at 28 locations worldwide, and markets its products in over 135 countries on all continents. The United States is Sironaâ&#x20AC;&#x2122;s largest single market, followed by Germany, Western Europe, and Asia. The company was spun-off from the Siemens Medical Technology Division in 1997, and since 2006, has been listed on the US NASDAQ stock exchange (symbol: SIRO). In the last fiscal year (October 1, 2012, to September 30, 2013), Sirona reported revenues of $1.1 billion. Sirona develops and manufactures the majority of its products in Bensheim, Germany, the largest research, development, and production location in the dental industry. The company currently employs more than 290 scientists and, over the past seven years, has invested more than $350 million in R&D.

GALILEOS ComfortPlus

Precise endodontic treatment The 3D X-ray images generated by the ORTHOPHOS XG 3D are a precise culmination of 200 images captured during one revolution. Endodontists will enjoy the ability to instantly view the digital images required for endodontic procedures, combined with the crisp, well-defined 3D volumetric images for revealing canal shapes and anatomies, as well as precise measurements for canal depths, widths, and apicoectomy procedures. CBCT scans of patients with a large number of metal restorations require a higher dynamic range of the dose/image quality ratio. For such cases, Sirona has Volume 7 Number 5

GALILEOS provides true motion in cone beam with the SICAT Function software solution

developed the Endo HD mode. During the Endo HD cycle, 500 images are taken. The additional 300 images (compared to Standard mode) allow ORTHOPHOS XG 3D to construct an image that is lower in noise and higher in contrast, which allows for a faster and more reliable diagnosis of the imaged volume.

Patented integrated technology The practice of implantology is quickly spreading throughout dentistry. Sirona pioneered guided implantology through the

integration of 3D X-ray and CAD/CAM technology. GALILEOS CEREC Integration (GCI) gives the clinician complete control over the entire implant process, starting with the planning and ending with the manufacture of highly accurate abutments and crowns. For years, clinicians have benefited from the comprehensive 3D digital diagnostic and treatment solutions provided by GALILEOS CBCT. The single, 14-second scan transforms a traditional dental office into a center capable of fast, efficient, and accurate implant placements. The increased Endodontic practice 15

CORPORATE PROFILE

The history of Sirona

CORPORATE PROFILE visualization changes the patient-clinician conversation, proving better treatment acceptance, more informed diagnoses, and efficient treatment planning. With the integration of CEREC for the design and fabrication of the implant abutment and esthetic crown, you can be confident that your treatment plan workflow — as well as the entire process from patient presentation to final restoration placement — is completed smoothly and without complications. As the name suggests, GCI is all about the seamless collaboration and data sharing of systems and processes within the dental procedure. GCI allows simultaneous assessment of both the prosthetic and surgical situation, as well as both processes to be fully controlled and accomplished in the dental practice.

GCI’s step-by-step workflow To envision the GCI workflow from start to finish, consider the following steps: 1. During the first patient visit, an optical impression of the bite is taken with CEREC, and the prosthetic restoration is planned using the CEREC software. 2. The GALILEOS 3D scan begins diagnoses of the bone structure and integration of the prosthetic recommendation into the X-ray volume. The implant is planned simultaneously according to the surgical and prosthetic conditions. 3. Next, the surgical guide is ordered in the software, and the planning data is transmitted to SICAT (in the case of the SICAT OPTIGUIDE process). 4. During the second patient visit, the implant is placed using the surgical guide. In the case of immediate loading, it is restored directly with a CEREC temporary prosthesis. If necessary, patient-specific, customized abutments with CEREC can be created and incorporated in this session. 5. With immediately loaded implants, the temporary prosthesis is replaced by the final prosthesis, and the case is completed. With traditionally placed implants — after completion of the healing phase — the implant is provided with a temporary or final prosthesis (with CEREC) in this session. The benefits of GCI include faster and more reliable treatment with fewer complications resulting in higher patient satisfaction with the final outcome. With GCI, you are in complete control of all surgical and prosthetic parameters every step of the way. 16 Endodontic practice

The recorded jaw movement with SICAT Function can be visualized and reproduced at any location in the dentition or mandible

Shaping the future through motion For the first time, GALILEOS provides true motion in cone beam with SICAT Function. SICAT Function is a revolutionary software solution with an integrated 3D workflow. With GALILEOS and SICAT Function, you can use patients’ 3D cone beam scan with their actual recorded jaw motion. This allows for the visualization and a movement-oriented treatment plan. The recorded jaw movement can be visualized and reproduced at any location in the dentition or mandible. With SICAT Function, in-depth patient information is at your fingertips. You’re now provided with an understanding of the condyle-fossa relationship during jaw movement, anatomically correct trajectory, visualization of the specific positioning of the trajectory in 3D, as well as a comparison to conventionally used axial points and the ability to evaluate the occlusion based on the integrated optical surface scans. Continuing investment in research and development (R&D) ensures that Sirona remains the industry leader in dental innovation and quality applications. Our focus on continuous improvement, supported by one of the largest R&D organizations, provides customers with the ultimate in dental products and services, now and well into the future.

The Sirona vision Sirona believes in providing dental practitioners with the tools they need to put and keep them ahead. From optimizing treatment workflow and patient communication, to creating modern practice management

platforms, we’re constantly working to meet and exceed the expectations of our customers. Equally important is our commitment in the field of innovation. In the future, digital networking will play a fundamental role in dental practices, clinics, and laboratories — influencing everything from treatment to patient management. That’s why we place great emphasis on the research and development of digital, network-capable dental technology. It is just one more way in which we are helping to build a stronger dental community prepared for all future challenges. Individuality is also a vital part of our company philosophy. Different markets have different needs, which is why our products are manufactured with features and functions tailor-made to suit their requirements. In offering dental practices, clinics, and laboratories a wide spectrum of individual solutions, we not only make work more effective but boost earnings as well. Consulting is another essential component of this service, and we work closely with dental dealers throughout the world, providing extensive support in marketing and sales promotions. To sum it all up — Sirona means solutions for dental practices, clinics, and laboratories. It is all part of our goal of constantly striving to find new ways of making the best much better and providing customers with the ultimate in dental products and services. For more information on Sirona, please visit www.sirona.com or call 800-659-5977. EP This information was provided by Sirona.

Volume 7 Number 5

Drs. Brian Shaughnessy, Margaret Jones, Ricardo Caicedo, Joseph Morelli, Stephen Clark, and Ms. Jennifer Osborne review the occurrence of teeth presenting with condensing osteitis and their associated pulpal diagnosis over a 2-year period Introduction The most recent publication of diagnostic terminology accepted by the American Association of Endodontists (AAE) and American Board of Endodontics (ABE) includes condensing osteitis as a periapical diagnosis. It is defined as a “diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at apex of tooth.” While it is included on this list of periapical diagnoses, it may not always be used when indicated as the periapical diagnosis. Rather, it may sometimes be used as a radiographic finding

Brian Shaughnessy, DDS, received his dental degree at the University of Michigan and his MSD in endodontics at the University of Louisville. He maintains a private endodontic practice in Victor, New York. Margaret (Annie) Jones, DDS, received her dental degree at the University of Tennessee and is a second-year endodontic resident at the University of Louisville. She plans to practice endodontics in Nashville, Tennessee. Dr. Ricardo Caicedo, DrOdont, is an Associate Professor of Endodontics at the University of Louisville. He teaches in both the Pre-doctoral and Postdoctoral endodontic programs. Joseph Morelli, DDS, MEd, is an Associate Professor in Endodontics at the University of Louisville and serves as Director of the Predoctoral endodontic program. Stephen Clark, DMD, is a Professor in Endodontics at the University of Louisville and serves as Director of the Post-doctoral endodontic program.

Jennifer Osborne Rudy, MA, RDH, is an Assistant Professor in Dental Hygiene at the University of Louisville. She teaches Research Methods and Statistics and is currently pursuing a PhD in Applied Sociology.

Volume 7 Number 5

that is noted secondary to another clinical periapical diagnosis. Condensing osteitis usually presents as a radiopaque area adjacent to and associated with the apex of a tooth that has either a widened PDL or a periapical radiolucency8 (Figure 1). The outer edge of the radiopacity does not have a radiolucent zone, as would be found with focal cementosseous dysplasia. Furthermore, there is no associated expansion of the jaw that would be noted clinically in association with the radiographic finding. Few studies have investigated the prevalence of this radiopaque radiographic finding, with most finding it less than 7% of the time.7 The most extensive published evaluation, which reviewed 1,149 roots receiving endodontic treatment within a 12-month period, found that 2% of roots showed preoperative condensing osteitis.2 Comparatively, the authors found 28% of the roots to have a periapical radiolucency. Condensing osteitis appears to be most often associated with mandibular posterior teeth,1-3 and many have noted it to be found more often in adolescents than in adults.8-9 There is also some evidence that the prevalence may be different for different ethnicities.4 Recently, Green and Walton performed a histologic evaluation of condensing osteitis.5 They identified 16 teeth with a radiographic diagnosis of condensing osteitis in cadaver mandibles and performed block resections in order to examine the teeth and periapex histologically. The results revealed replacement of marrow spaces and cancellous bone by dense, compact bone. Additionally, they noted areas of fibrosis replacing fatty marrow in some of the samples. Interestingly, in 14 of the 16 samples, minimal or no inflammation was found. This led them to speculate that “condensing osteitis is not always an inflammatory lesion but is a bony

Figure 1: Condensing osteitis associated with tooth No. 30 in a patient diagnosed with symptomatic irreversible pulpitis

proliferative response to pulpal inflammation.” The authors, however, did stress that while they did not identify direct inflammation in the bone causing the reaction, “there must be sufficient osteogenic stimulation from inflammatory mediators from the pulp or apical foramen region” to initiate these bony changes. Green and Walton also noted that there was an “association of condensing osteitis with pulpal damage, inflammation, and/or necrosis.” This observation has previously been made by others8 and is consistent with the theory of pulpal inflammation and associated inflammatory mediators initiating the bony changes. Moreover, it has been shown that following root canal treatment of teeth presenting with condensing osteitis, many show complete radiographic reversion to a normal periapex.1,2 It has also been observed that a pulpal diagnosis of either pulpitis or pulp necrosis can be associated with condensing osteitis. The purpose of this study was to review the occurrence of teeth presenting with condensing osteitis and their associated pulpal diagnosis over a 2-year period in a postgraduate endodontic program.

Materials and methods A retrospective records review was performed on patients receiving non-surgical endodontic treatment in the University of Endodontic practice 17

CLINICAL

Pulpal diagnosis of teeth presenting with condensing osteitis prior to endodontic treatment — a retrospective study

CLINICAL Louisville postgraduate endodontic clinic between July 1, 2011, and June 30, 2013. All patients receiving non-surgical root canal therapy during this 2-year period were included. Electronic patient records as well as digital radiographic images were reviewed by two reviewers independently and in duplicate. All patient records had been recorded using axiUm software, and all radiographs were taken using Kodak 6200 sensors and reviewed using MiPACS® (Medicor Imaging) software. Data recorded included patient age and gender, treated tooth number, pulpal and periapical diagnosis, and radiographic presence of a periapical radiolucency, or condensing osteitis. Presence of condensing osteitis was determined jointly with both reviewers achieving agreement. Descriptive statistics, chi-square analysis, and ANOVA with Tukey’s post hoc test in SPSS version 22 were used for analysis. Significance was determined using α less than 0.05.

Results Data was collected from 1967 teeth receiving non-surgical root canal therapy in 1,670 patients. Thirty-five teeth in 35 patients were identified with a radiographic appearance consistent with condensing osteitis. This constituted 1.8% of the treated teeth. The average age of patients in the total patient population treated was 36.7 ± 18.4 years, while the average age of patients presenting with condensing osteitis was 26.3 ± 15.7 years. Table 1 shows the frequencies of patient age groups in cases with condensing osteitis. There was a statistically significant association between age and prevalence of preoperative condensing osteitis with it being more frequent in younger patients (p < 0.01). Condensing osteitis was found more often in female patients (Table 2). However, this was not found to be statistically significant (p = 0.12). As seen in Table 3, condensing osteitis was found most frequently with mandibular first molars. This tooth type accounted for 88.6% of the cases observed (31/35). Condensing osteitis

Condensing osteitis was associated with 6.9% of all mandibular first molars treated in this study population. The most common pulpal diagnosis among cases presenting with condensing osteitis was symptomatic irreversible pulpitis (SIP). This pulpal diagnosis occurred in 22 of the 35 cases (63%). Pulp necrosis was found in 11 of the 35 cases (31%). One case had a pulpal diagnosis of asymptomatic irreversible pulpitis, and one case had a diagnosis of previously initiated (Figure 2).

Figure 2: Symptomatic irreversible pulpitis was the pulpal diagnosis in the majority of cases diagnosed with condensing osteitis in this study

Discussion

lowering the number of cases found with In this study, all radiographs were mandibular second molars. reviewed by two postgraduate endodontic Bony changes due to condensing osteresidents, and agreement was verified by a itis could be just as likely to occur in other areas of the jaws but are more easily seen board-certified endodontist with 38 years with periapical images in the area of the of clinical experience. In order to be classified as condensing osteitis, clear evidence mandibular premolars and first molar, making those the most likely areas to be diagnosed of a focal area that was more radiopaque with condensing osteitis. A similar-appearing than the surrounding bone proximal to the root apex had to be noted. Radiopacities radiopaque lesion, idiopathic osteosclerosis, that were considered to be a superimposihas also been found to occur more often in the tion of a radiopaque structure such as the posterior mandible.6 This could also be attribmylohyoid ridge or mandibular torus were not uted to the same ease of diagnosis in this area, counted as condensing osteitis. It is possible or an indication that the posterior mandible that some cases of condensing osteitis could is a more favorable site for such dense bony changes. A CBCT study could lend important have been obscured by overlapping radiinsight in determining if the osseous changes opaque structures. This leads the authors to believe that our overall prevalence of 1.8%, are more likely to be found in this area or simply though consistent with previous findings,2 more easily detected by periapical radiographs may be a slight underestimation. in the posterior mandible. Additionally, previous investigations The findings of this study support the have found mandibular second molars theory that either an inflamed or a necrotic to account for approximately 20% of the pulp are associated with condensing osteitis. cases of condensing osteitis2; however, It remains unclear if the osseous changes this study did not find any cases associated Condensing osteitis Total treated with mandibular second molars. This could also be Age group (years) Number % Number % due to the superimposition 19 and younger 16 45.7 444 22.6 of radiopaque structures 20-39 14 40.0 732 37.2 that represented normal anatomy obscuring the 40-59 2 5.7 507 25.8 ability to clearly identify 60+ 3 8.6 284 14.4 if there was a change in bony density due to Total 35 100.0 1967 100.0 condensing osteitis. This could have resulted in Table 1: Condensing osteitis was primarily diagnosed in patients aged 39 and younger

Total treated

% of condensing osteities cases

% of total tooth type

Gender

Number

Mand 1st molar

88.6%

6.9

Male

28.6

821

41.8

Mand 2nd premolar

2.9%

0.9

Female

71.7

1145

58.2

Max 1st premolar

2.9%

1.3

Total

100.0

1967

100.0

Max 2nd premolar

5.7%

0.8

Table 2: Condensing osteitis was found more frequently in female patients, but this was not statistically significant 18 Endodontic practice

Table 3: In this study, the great majority of cases of condensing osteitis were diagnosed in mandibular first molars Volume 7 Number 5

CLINICAL

can occur from a necrotic pulp alone, or if the changes occur during the pulpitis stage and are simply noted after the pulp has become necrotic. This study found condensing osteitis associated more often with symptomatic irreversible pulpitis than with pulp necrosis. The mechanism by which these osseous changes occur remains to be investigated. The current theory has been that the osseous changes are associated with chronic lowgrade inflammation. Further investigation into the mediators and process responsible for the formation and maintenance of condensing osteitis, as well as genetic factors that might play a role in the occurrence of these bony changes, rather than the formation of a periapical radiolucent lesion would be beneficial to understanding this entity.

Conclusions In this retrospective review of 1,967 teeth treated over a 2-year period in the graduate endodontics clinic at the University of Louisville, condensing osteitis was diagnosed in 1.8% of the cases. It was most common in mandibular first molars and in patients under the age of 20. Teeth presenting with condensing osteitis had a pretreatment pulpal diagnosis of symptomatic irreversible pulpitis in 62.9% of the cases. EP

Volume 7 Number 5

Figures 3A-3B: Figure 3A is a radiograph at initial treatment of a tooth with condensing osteitis. Figure 3B is a 10-month recall posttreatment of the same tooth illustrating that some remodeling of the periapical area with condensing osteitis has occurred, and normal osseous architecture is returning

BIBLIOGRAPHY 1. Hedin M, Polhagen L. Follow-up study of periradicular bone condensation. Scan J Dent Res. 1971;79(6):436-440. 2. Eliasson S, Halvarsson C, Ljungheimer C. Periapical condensing osteitis and endodontic treatment. Oral Surg Oral Med Oral Pathol. 1984;57(2):195-199. 3. Eversole LR, Stone CE, Strub D. Focal sclerosing osteomyelitis/focal periapical osteopetrosis: radiographic patterns. Oral Surg Oral Med Oral Pathol. 1984;58(4):456-460. 4. Austin BW, Moule AJ. A comparative study of the prevalence of mandibular osteosclerosis in patients of Asiatic and Caucasian origin. Aust Dent J. 1984;29(1):36-43.

5. Green TL, Walton RE, Clark JM, Maixner D. Histologic examination of condensing osteitis in cadaver specimens. J Endod. 2013;39(8):977-979. 6. Sisman Y, Ertas ET, Ertas H, Sekerci AE. The frequency and distribution of idiopathic osteosclerosis of the jaw. Eur J Dent. 2011;5(4):409-414. 7. Boyne PJ. Incidence of osteosclerotic areas in the mandible and maxilla. J Oral Surg Anesth Hosp Dent. 1960;18:486â&#x20AC;&#x201C;491. 8. Neville BW, Damm DD, Allen, Bouquot JE. Oral and Maxillofacial Pathology. 3rd Ed. Philadelphia: WB Saunders, 2008. 9. Basrani B. Endodontic Radiology. 2nd Ed. New Jersey: Wiley-Blackwell, 2nd edition, 2012.

Endodontic practice 19

CASE STUDY

Management of a tooth with a large internal resorption defect Dr. Robert Slosberg facilitates accurate mapping and obturation of the resportive defect with CBCT imaging Abstract A patient presented with advanced internal root resorption of tooth No. 9. The prominent location of this tooth meant the case would be a challenge from an esthetic standpoint; an implant supported crown would have been cost-prohibitive, and veneers would have been necessary to give the patient satisfactory cosmetic results. This option required too much of a cost and time commitment from the patient. The initial treatment plan included filling the tooth with an orthodontic-grade root filling material to be followed by surgery. Visualization from a cone beam computed tomography (CBCT) scan provided accurate mapping of the defect, revealing the apical lingual perforation. Postoperatively, the CBCT scan confirmed the successful permeation of the filling material. This case could not have been treated successfully without the use of the CBCT, both pre- and postoperatively. Placing the medication to obturate the tooth was difficult, yet the CBCT scans provided guidance allowing for measurement of the progress throughout the case. Dental radiographs only offer a 2D representation of the 3D spatial relationship, while CBCT scans allow the clinician to see every angle of a case before they even begin to operate.

discovered during a routine periapical examination of tooth No. 9. Because of the prominent location, it was clear from an esthetic standpoint that it would be a challenge to replace the tooth. In fact, treatment options were heavily influenced by both esthetics and the finances of the patient. An implant-supported crown and veneers may not have given the patient a satisfactory esthetic result. Additionally, such extensive work would have required a greater financial commitment from the patient. The initial treatment plan was to fill the tooth with a conventional orthodontic-grade root filling material to be most likely followed

by surgical debridement; at the time, it seemed that surgery was indeed the only option. However, as we would discover, cone beam computed tomography (CBCT) technology provided accurate mapping and obturation of the defect, eliminating the need for surgery, at least for now.

Figure 1: Pre-op clinical image

Figure 2: Pre-op clinical image showing labial positioning

Figure 3A: Pre-op radiograph 2-3-2014

Figure 3B: Off angle radiograph 2-3-2014

Clinical and radiographic examination The resorptive defect â&#x20AC;&#x201D; the pathological process in which the tooth begins to dissolve â&#x20AC;&#x201D; was initially diagnosed by radiograph; however, the CBCT scan showed the exact extent of the defect, as well as revealed an apical lingual perforation, which presented yet another challenge.

Introduction A healthy, asymptomatic 50-year-old female presented at my office in the spring of 2014, having been referred by her general practitioner. A resorption defect had been Robert Slosberg, DDS, an Atlanta native, received his Bachelor of Science in microbiology at the University of Georgia. He completed his dental training at the University of Tennessee. Following dental school, Dr. Slosberg continued his postdoctoral training at the University of Pennsylvania. He returned to Atlanta in 1990, founding Atlanta Endodontics in 1992. Dr. Slosberg is a specialist member of the American Association of Endodontists, The Georgia Association of Endodontists, the American Dental Association, the Georgia Dental Association, Northern District Dental Society, and the Southern Endodontic study group. He has also worked with Zoo Atlanta and the Yerkes Regional Primate Research Center at Emory University. Dr. Slosberg has even performed a root canal on his beloved golden retriever, Madison.

20 Endodontic practice

Volume 7 Number 5

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CASE STUDY • Medical history: Non-contributory • Diagnosis: Advanced internal root resorption • Immediate treatment plan: Canal obturation and filling

Treatment A coronal access opening was made, and

Figure 4: Pre-op sagittal slice

Figure 6: Pre-op coronal slice

Figure 8: Initial access 22 Endodontic practice

the tooth was packed with calcium hydroxide. This proved challenging as controlling placement of the calcium hydroxide was particularly difficult. A temporary filling was then placed, and the medication was changed over the course of 2 to 3 months. CBCT scans were taken postoperatively to determine where the medication was and where it wasn’t. On the

advice of a colleague, the access opening was extended toward the lingual to facilitate the vertical condensation of the root filling material, in this case, Brasseler bioceramic mineral trioxide aggregate (MTA) cement. On top of the bioceramic putty, a composite resin core buildup of exactly 10 mm deep was placed.

Figure 5: Pre-op axial slices

Figure 7: Measuring the defect

Figure 9: Working length determination

Figure 10: Ca(OH)2 film Volume 7 Number 5

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CASE STUDY

Figure 12: Ca(OH)2 sagittal slice

Figure 11: Ca(OH)2 PA

Figure 13: Clinical image temporization

Figure 14: Clinical image access refinement

Figure 15: Clinical image extention of access opening to facilitate obturation

Figure 16: Clinical image obturation with bioceramic putty

Results CBCT scans allowed for accurate mapping of the defect, and they were the only way to assess the effective permeation of the bioceramic putty.

Discussion Due to the many challenges this case presented, the mapping of the defect was shared among endodontic professionals — trusted colleagues, local study clubs, and endodontic online forums. The majority of the dental professionals recommended extraction and an implant-supported crown. Esthetics and finances directed this individualized treatment plan. Filling the tooth — even if it were maintained for up to 5 years — would allow the patient time to save enough money for an implantsupported crown. For ideal esthetics with an implant supported crown, at least one or more veneers would most likely be necessary; therefore, a steep financial and time commitment would be required from the patient. Surgery was always an option, depending on the outcome of endodontic therapy. This case could not have been treated successfully without the use of CBCT 24 Endodontic practice

Figure 17: Post-op radiograph 4-16-2014

Figure 18: Post-op axial slices

scans. In fact, the patient was referred specifically to our practice because we are known for our use of CBCT technology. CBCT gives us additional information that conventional 2D radiographs cannot. In this case, it facilitated both accurate mapping and obturation of the resportive defect. The scans can answer important questions such as “Can the defect be reached?” Once completed, CBCT answers, “How adequately was the tooth sealed?” In this particular case, CBCT scans were crucial in confirming the placement of the

calcium hydroxide and the bioceramic resin. Placing the medication was a challenge, and CBCT scans measured the progress throughout the case. A CBCT scan can also be a professional’s worst critic. The scan will reveal, “You didn’t get the calcium, medication, or filling material here.” In conclusion, it was a CBCT scan that confirmed the successful condensation of the bioceramic putty used to seal the tooth, and surgery was avoided, at least, in the short term. The patient is asymptomatic and is due for a recall. Volume 7 Number 5

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CASE STUDY

Figure 19: Post-op axial slice

Figure 22: Post-op clinical image composite restoration

Figure 25: 4-30-2014 re-evaluatiion

In the modern endodontic office, cone beam computed tomography is a powerful new tool to aid in the diagnosis and treatment of diseases involving the teeth and supporting structures. Dental radiographs can only offer a 2D representation of the 3D spatial relationship. However, today’s specialists can understand that spatial relationship better with the advent of CBCT. Following a detailed clinical evaluation, including radiographs, it may be necessary to gain more information — information that only CBCT scans can provide. CBCT technology provides a complete visual image covering the axial, coronal, and sagittal 26 Endodontic practice

Figure 21: Post-op coronal slice

Figure 20: Post-op sagittal slice

Figure 23: Post-op clinical image

Figure 24: Measuring the depth of the composite resin

Figure 26: 4-30-2014 re-evaluatiion

planes. Additionally, the 3D rendering is also an excellent tool for patient education and can lead to increased case acceptance. The advent of CBCT and its subsequent introduction into the endodontic specialty have been a paradigm shift. The more scans I have reviewed, the more I realize just how important a 3D scan can be to comprehensive diagnosis; at this point, CBCT scans are taken for most of my endodontic cases, as they can solve the mysteries that are left uncovered by 2D radiography. Returning to the case at hand: “If it were your patient, what would you recommend? Even more importantly, if it were your tooth,

how would you want it treated?”

Lessons learned • Extending the access opening lingually was not ideal, though it was necessary to adequately condense the bioceramic putty. • In hindsight, the tooth could have been strengthened had a fiber post been placed along with composite resin. • What might be the most “obvious” treatment plan — implant-supported crown or even extraction — is not always best for the patient. Using the right technology opens up new treatment plans that can be more beneficial. EP Volume 7 Number 5

CASE STUDY

Maxillary keratocystic odontogenic tumor with sinus involvement: a multidisciplinary approach Drs. Brian Trava, Neil Thoman, Sharon Brooks, Harry Katz, Mark Persky, and Kathleen Nagy treat an aggressive tumor with comprehensive communication between different modalities of medicine and dentistry Introduction The following is a case report of a longstanding lesion diagnosed using 3D CBCT imaging. The ease of cone beam accessibility allows endodontic specialists to diagnose, collaborate, and deliver prompt multidisciplinary treatment to our patients. In 2005, the World Health Organization (WHO) reclassified the odontogenic keratocyst (OKC) into the tumor category as a keratocystic odontogenic tumor (KCOT). The lesion is characterized as being aggressive with a high reoccurrence rate.

complaint of diffuse pain in the maxillary right side of her face. There was some discomfort upon chewing. The patient reported having pain and a root canal completed on tooth No. 3 in 1994. The symptoms continued, and the patient sequentially had an apicoectomy, extraction, and a fixed bridge spanning from teeth Nos. 2-4. The patient also remembered having some type of hard mass removed from her sinus in the 1980s. The patient reported a history of having a bad gag reflex, making it difficult to take dental radiographs throughout her lifetime.

History

Oral exam

A 60-year-old Caucasian female was referred from her general dentist with a chief

Teeth Nos. 2-6 responded to a cold test using an ice chip. Tooth No. 2 was tender

to percussion. All mandibular teeth tested within normal limits (WNL). Gingival tissue looked WNL. The right tuberosity area was depressible.

Radiographic exam A traditional periapical film was attempted and failed due to the patientâ&#x20AC;&#x2122;s gag reflex. A Planmeca 2D panorex was taken. The panorex demonstrated the maxillary right tuberosity was radiolucent and expanded, plus there was degenerative joint disease in the right TMJ (Figure 1). A Planmeca CBCT 8 x 8 image at 90kV/12mA/12.3s was rendered (Figure 2). The CBCT DICOM images were uploaded to BeamReaders for radiographic interpretation. There was a gross expansion

Brian Trava, DMD, is a practicing endodontist in North Jersey. Dr. Trava is a graduate of the University of Medicine and Dentistry of New Jersey, where he was also an associate clinical professor of postgraduate endodontics. Dr. Trava lectures across the country on the use of lasers and the importance of Planmeca 3D CBCT imaging in the field of endodontics. He maintains group practices in northern New Jersey with two Planmeca machines used for diagnosis and treatment. Neil Thoman, DDS, is graduate of Fairleigh Dickenson School of Dentistry. He completed his oral surgery training at Catholic Medical Center of Brooklyn and Queens. He has maintained a practice in Ridgewood, New Jersey, for 33 years. Kathlene Nagy, DMD, is a practicing general dentist. She is a graduate of the University of Medicine and Dentistry of New Jersey. Dr. Nagy maintains a family practice in North Haledon, New Jersey. Harry Katz, MD, devotes his practice to the general care of the ears, nose, and throat with particular emphasis on diagnosis, treatment, and surgery for nasal and sinus diseases. He is a graduate of Columbia University and then went on to complete his medical school, internship, and residency training at New York University Hospital and Medical Center in New York. He maintains a practice in Midland Park, New Jersey.

Figure 1: Traditional panoramic view comparing left and right sides

Sharon Brooks, DDS, earned her dental degree from the University of Michigan in 1973, along with MS degrees in Oral Diagnosis and Radiology (1976) and Radiological Health (1984). Dr. Brooks is a Diplomate of the American Board of Oral and Maxillofacial Radiology and served 5 years as a director of the Board and past president. Dr. Brooks has been working with CBCT since 2004. She joined BeamReaders in 2010. Mark Persky, MD, is an ENT-otolaryngologist in New York, New York, and is affiliated with multiple hospitals in the area, including Mount Sinai Beth Israel and Mount Sinai St. Lukeâ&#x20AC;&#x2122;s-Roosevelt. He received his medical degree from State University of New York Upstate Medical University and has been in practice for 42 years.

Figure 2: Planmeca 3D image with volume of area quantified 28 Endodontic practice

Figure 3: Frontal view shows thin cortex and expansion Volume 7 Number 5

CASE STUDY

of the right maxillary tuberosity distal to tooth No. 2 with extreme thinning of the cortex on all sides (Figure 3). A radiolucent area extended medially into the palate and posteriorly into the pterygomaxillary area (Figure 4). Locules extended anteriorly to the second molar. The floor of the sinus was elevated by the lesion distal to tooth No. 2 in its normal location anterior to the tuberosity. The medial wall of the right sinus was missing, although this may have been a result of the previous surgery. The margins of the lesion appeared curved and well-defined, with an occasional suggestion of fine wispy septa within the lesion (Figure 5).

Figure 4: Axial section shows expansion into the palate and pterygomaxillary area

Figure 5: Planmeca 3D enhancement can provide more diagnostic detail

sinus surgery, accompanied with the sacristy of radiographic history due to difficulty with gagging. There may be a remote possibility that the present lesion may have been recurrent, characteristic with the KCOT, or had started a slow progression after the original sinus surgery in 1980 in which a hard mass was removed. This could have been an associated tooth, which has been reported. The tumor has been reported to have an equal distribution of occurrences from decades 3 to 7.5 The lesion has a reoccurrence rate of 29% to 58%.1,6 The lesion is cystic in nature with a thin lining, described as neoplastic in nature with orthokeratinized and parakeratinized variants, and is closely associated with the ameloblastoma.7,8 Having a multidisciplinary approach to diagnosing and treating patients provides patients such as this with the most efficient treatment and predictable prognosis. Patients that have special needs, such as gag reflexes, autism, and Down’s syndrome, cannot tolerate intraoral radiographs. From an endodontic standpoint, many patients are referred for diagnosis due to pain. An 8 x 8 cm CBCT that can render both a traditional 2D and 3D image offers the advantage of bilateral orthognathic and sinus diagnosis capability. Being able to select an area on a 2D panorex allows the clinician to scout a particular quadrant, or from TMJ to TMJ. Radiographic interpretation for diagnosis will always have its academic foundation based on traditional radiology. Planmeca 3D ProMax® technology provided expediency to upload radiographic files to the cloud or via the Internet for immediate diagnosis and treatment from the appropriate specialists. This allowed much clearer communication between the endodontic specialist, the maxillofacial surgeon, and the ENT.

Conclusion

Differential diagnosis The position of the lesion in the right maxillary tuberosity rather than the maxillary sinus led us to believe it was from a history of odontogenic origin. The lesion gave the appearance of a keratocystic odontogenic tumor. Since the lesion was located only to the maxillary jaw, ameloblastoma would be more likely than myxoma, central giant cell lesions, and nevoid basal carcinoma. The patient was referred to the oral surgeon for consultation and treatment. A preliminary distal wedge excisional biopsy was performed and sent for biopsy. The biopsy showed stratified squamous epithelium covering a core of well-vascularized fibrous connective tissue with a dense infiltrate of neutrophils, lymphocytes, and plasma cells. The pathologist’s impression was acute inflammatory reaction. The patient was referred to an ENT for consultation and treatment. The patient underwent a right Caldwell-Luc procedure. A cystic mass with inspissated secretions was excised. Fragments of benign, partially squamous, and sinonasal type epithelium-lined cyst wall with dense fibrosis marked inflammation. After discussion, with correlation to radiographic results, the final diagnosis was keratocystic odontogenic tumor (KCOT/OKC).

Discussion The World Health Organization reclassified the odontogenic keratocyst as a keratocystic odontogenic tumor in 2005. Clinically, this presents as a swelling with or without pain, less frequent in the maxilla.1 The maxillary involvement ranges from 16.4% to 23.5%, and 1% occurs in the maxilla with sinus involvement.2 The lesion typically grows in an anterior to posterior region.3 The patient presented a history of both a failed root canal and apicoectomy and history of previous Volume 7 Number 5

The KCOT is an aggressive tumor with a high reoccurrence rate. Diagnosis requires comprehensive communication from different modalities of medicine and dentistry. CBCT has definitively enhanced these avenues for a more thorough treatment approach for patients. EP

Acknowledgments

Alexander Filatov, MD, is a pathologist, has 16 years of experience, and practices in Anatomic Pathology and Clinical Pathology. Dr. Stanley Kerpel, DDS, specializes in dentistry, oral and maxillofacial pathology, and pathology, and currently treats patients in Flushing, New York, and Bedford, New York.

REFERENCES 1. Hyun HK, Hong SD, Kim JW. Recurrent keratocystic odontogenic tumor in the mandible: a case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108(2):e7-10. 2. Rabelo GD; Henriques JCG, Macedo JH, Silva CJ; Cardoso SV; Loyola AM, Durighetto AF Jr. Non-syndromic keratocystic odontogenic tumor involving the maxillary sinus: case report. Arq. Int. Otorrinolaringol. (Imper). [Online]. 2010;14(3):364-367. 3. Chi AC, Owings JR, Muller S. Peripheral odontogenic keratocyst: report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005:99(1):71-78. 4. Silva GCC, Silva EC, Gomez RS, Vieira, TC. Odontogenic keratocyst in the maxillary sinus: Report of two cases. Oral Oncology Extra. 2006;42(6):231–234. 5. Oda D. Rivera V, Ghanee N, Kenny MA, Dawson, KH. Odontogenic Keratocyst: The Northwestern USA Experience. The Journal of Contemporary Dental Practice. 2000;1(2)1-8. 6. Madras J, Lapointe H. Keratocystic Odontogenic Tumor: Reclassification of the Odontogenic Keratocyst from Cyst to Tumor. Journal of the Canadian Dental Assoc. 2008;74(2):165-165h. 7. Crowley TE, Kaugars GE, Gunsolley JC. Odontogenic keratocysts: A clinical and histologic comparison of the parakeratin and orthokeratin variants. J Oral Maxillofac Surg. 1992;50(1):22-26. 8. Aggarwal P, Saxena S. Stromal differences in odontogenic cysts of a common histopathogenesis but with different biological behavior: A study with picrosirius red and polarizing microscopy Indian Journal of Cancer. 2011;48(2):211-215.

Endodontic practice 29

CASE STUDY

Advanced ESX® instrumentation: segmental crown down and hybridization of tapers Dr. Allen Ali Nasseh discusses a clinical case to demonstrate the application of Advanced ESX instrumentation Introduction All root canals are not created equal. The root canal shapes we face on a daily basis are as unique as the individual patients who present them. Preparing such a variety of shapes and canal morphologies efficiently with a minimum number of files has been a consistent goal in endodontic therapy. However, a magic file or formula that would make root canal shaping a universal sequence for all canal shapes and types has proven elusive. Even the single NiTi file techniques are mere finishing files, and in many cases, considerable instrumentation is required with other files prior to finishing the shape with them. The ESX® Rotary NiTi Instrumentation System (Brasseler USA) comes as close to the goal as is currently possible. Its goal is to minimize the number of files needed for each root canal procedure while at the same time respecting that all canals are unique. This is accomplished with two specific instrumentation protocols: the Basic and Advanced ESX Techniques that address the varying degrees of case difficulty. Each protocol has its own specific sequence of use for both hand and rotary files based on the level of complexity of the case. This results in the general use of two to five rotary and/or hand files per case based on a given canal morphology.1 The clinical case discussed in this article demonstrates the application of the

Allen Ali Nasseh, DDS, received his dental degree from Northwestern University Dental School (Chicago, Illinois) in 1994 and completed his postdoctoral endodontic training at Harvard School of Dental Medicine in 1997, where he also received a Masters in Medical Sciences (MMSc) degree in the area of bone physiology. He has been a Clinical Instructor and lecturer in the postdoctoral endodontic program at Harvard School of Dental Medicine since 1997 and the Alumni Editor of Harvard Dental Bulletin. Dr. Nasseh is the President and Chief Executive Officer for the endodontic education company Real World Endo® (RealWorldEndo.com.) He is the endodontic advisor to several educational groups and study clubs and is endodontic editor to several peer-reviewed journals and periodicals. He has published numerous articles and lectures extensively nationally and internationally in surgical and non-surgical endodontic topics. Dr. Nasseh is in solo private practice (MSEndo.com) in downtown Boston, Massachusetts.

30 Endodontic practice

Advanced ESX theory for managing molars. However, a brief review of the Basic Technique is required first.

Basic ESX Technique The Basic ESX Technique can be summarized as the instrumentation of a canal to a minimum size 15/.02 hand file to full working length (WL), followed by instrumentation to that length with the ESX Expeditor™ File (15/.05), and thereafter, a single ESX Finishing File (either sizes 25/.04, 35/.04, 45/.04, or 55/.04). A key point here is that both the Expeditor and the ESX Finishing Files are used with a Single Stroke and Clean (SSC)™ operator motion, a motion that helps reduce the torque on the files. The ESX finishing files have a patented file tip called a “Booster Tip,” which makes reducing the number of files possible when combined with the SSC motion. In summary, the Basic ESX technique (for most anteriors and premolars) is a two-file technique (Expeditor + one Finishing File.) The Choice of which Finishing File to use is determined by the level of engagement experienced by the Expeditor

on its journey down to the apex. If significant engagement occurs (~more than 5 strokes to apex), then a 25 Finishing file is used. If moderate engagement is experienced with the Expeditor, then a size 35/.04 is used, and if minimal engagement, then the 45/.04 is used. If additional enlargement is needed after the 45 reaches the apex (remaining tissue in file flutes), then a 55/.04 can be used to finish the preparation.3 Therefore, the Basic Technique algorithm can be shown in Figure 1.

Advanced ESX Technique The Advanced ESX Technique is used in most all molars and difficult premolars and anteriors. These are generally cases that are narrower or curved. For ESX Purposes, we define Advanced cases as follows: “Advanced canals are defined as those canals where working a number 15/.02 hand file straight to the apex (to working length) is not possible or easily accomplished.” In other words, if the No. 15 hand file does not go straight to the apex easily after access opening and minimal orifice shaping, you’re

Figure 1: Shows the ESX Basic Technique demonstrating the fact that once the root canal has been instrumented to a size 15/.02, it will then be enlarged to 15/.05, followed by finishing with one of the ESX Finishing files. All files are used with the Single Stroke and Clean (SSC) Motion Volume 7 Number 5

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CASE STUDY facing an Advanced Case that requires the use of the Advanced ESX Technique (Figure 2). Generally, at least one canal in a multirooted tooth is either narrow, calcified, or curved. Therefore, we can make a general statement that multi-rooted teeth are for the most part advanced cases and require the Advanced ESX Technique. Remember that the technique (Basic or Advanced) is set by the lowest common denominator of a case, meaning the toughest canal in a multi-rooted tooth. Therefore, most molars are advanced. Since the difficulty in Advanced cases is working the apex to a size 15/.02, the purpose of the Advanced Technique is to safely and efficiently prepare the apex to the 15/.02 size, thus allowing the Basic Sequence to follow and complete the preparation. Advanced Technique —> 15/.02 to working length —> Basic Technique The Advanced Technique utilizes three additional files before the Basic Sequence is employed. They are the ESX Scout Files (sizes 15/.02 and 15/.04) in conjunction with the help of the ESX Orifice Opener (20/.08). They work together and take advantage of increasing taper while maintaining an ISO 15 tip to enlarge the canal (Figure 3). This creates a phenomenon of “Hybridization of Tapers,” where files with the same tip sizes but varying constant tapers slowly remove dentin laterally and incrementally in a crowndown fashion (Figure 4).

Hybridization of Tapers In this article, the use of files with the same tip size but varying tapers is referred

Figure 2: Shows the indications for each the Basic and Advanced ESX Technique/Protocol in a given canal shape

Figure 3: Shows the Advanced Technique Files. After exploration with a size 10 hand file and the ESX Orifice Opener (20/.08), the Scout files 15/.04 and 15/.02, and the Expeditor 15/.05, create a sequence of files with the same tip and varying tapers that predictably and efficiently shape the root canal space that was originally explored with a size 10 hand file

Figure 4: Molar cases are all considered Advanced cases. Here, since medial canals were narrow, Available Length (AL) was only half the final Working Length (WL) of those roots. After determining AL and using Hybridization of Tapers to AL and determining the WL, the case was completed easily with one more round of Hybridization of Tapers until WL was achieved. The case was then finished with a single ESX 35/.04 finishing file. All instrumentation was done with the Single Stroke and Clean Motion 32 Endodontic practice

Volume 7 Number 5

CASE STUDY Figure 5: Complex molars require the use of Hybridization of Tapers in a special crown-down manner called Segmental Crown Down. Here, the canal is divided into thirds, and each third is first explored to Available Length and then widened to that length before the next AL is reached. This continues until Working Length is achieved

to as Hybridization of Tapers. As previously mentioned, Advanced cases are those where a size 15/.02 file does not easily reach the apex. In these cases, smaller hand files (sizes 6/.02, 8/.02, or 10/.02) are used to explore the initial Available Length (AL). This available canal length is noted. Available length is the space that a size 10 hand file can achieve by simply placing the file in the canal and advancing it lightly until it stops. Once the AL is noted, the ESX orifice opener (20/.08) is used to open up the coronal third of the root, making sure that the file does not pass beyond the AL. Hybridization of Tapers is then initiated using the Expeditor and the two ESX Scout Files (15/.04 and 15/.02) in descending taper (from 15/.05 to 15/.04 to 15/.02) until the AL is reached. In most cases, this sequence will instrument anywhere between one-half to two-thirds of the root even in complex anatomies. After the AL is reached, an apex locator and a radiograph is used to determine the actual working length (WL) by negotiating beyond the AL and to the WL using appropriate small hand files. Once the working length has been noted and confirmed with a file radiograph, this Hybridization of Taper sequence (15/.05 —> 15/.04 —> 15/.02) is used in a crowndown fashion until the WL is achieved with the Expeditor (15/.05). It’s important to note that each file is used with a Single Stroke and Clean Motion to engagement (not resistance) followed by switching to the next smaller taper file all the way to the WL. This motion is the safest way to use instruments and will dramatically reduce torque on each file. Once Volume 7 Number 5

The root canal shapes we face on a daily basis are as unique as the individual patients who present them. the Expeditor has reached the WL, the case is completed following the Basic Protocol by using the appropriate ESX Finishing File. Most Advanced cases are completed with either a size 25/.04 or a 35/.04 ESX Finishing File (Figure 5).

Segmental Crown Down Excessively difficult cases require even more diligence than typical advanced cases (Figure 5). In such cases, referred to as Advanced2 (Advanced squared!), the canal is broken down into several segments (either thirds or fourths), and each segment is instrumented sequentially in a crown-down fashion. On that basis, small size instruments (sizes 6, 8, and 10 Stainless Steel Hand Files) are used to explore and determine the AL followed by the use of Hybridization of Tapers to that AL. Once the first AL is reached by the 15/.05, a hand file is used again to determine the next AL followed by the same sequence of Hybridization of Tapers. This process of exploration followed by Hybridization of

Tapers helps crown down the canal in several segments in a safe and effective manner. The use of stainless steel hand files to first explore the canal is important, as it allows for these stronger metal files to do the more difficult part of discovery followed by the more efficient rotary files to enlarge the discovered space laterally.

Conclusion The ESX instrumentation system is a versatile instrumentation system that addresses Basic, Advanced, and Super Advanced canal anatomies to be instrumented with the minimum number of NiTi files required for that specific anatomy. This robust algorithm respects the complexity of some clinical cases more advanced users run into while reducing the use of unnecessary files in more basic cases. In addition, the utilization of an advanced bonded bioceramic obturation technique such as EndoSequence® BC Sealer™ (Brasseler USA) can further help maximize the efficiency between the instrumentation and obturation phases of root canal therapy.4 EP

REFERENCES 1. Nasseh AA. Clinical Use of the ESX file system. Inside Dentistry. 2014;10(7):74-77. 2. Nasseh AA. Real World Endo’s Single Stroke and Clean™ (SCC) Motion! Real World Endo. 2014. Available at https:// realworldendo.com/videos/realworldendo-s-single-strokeand-clean-ssc-motion. Accessed August 25, 2014. 3. Nasseh AA. The ESX Rotary NiTi Instrumentation System (6 part tutorial). Real World Endo. 2014. Available at https:// realworldendo.com/videos/the-esx-rotary-niti-instrumentation-system-6-part-tutorial. Accessed August 25, 2014. 4. Koch KA, Brave DG, Nasseh AA. Bioceramic Technology: closing the endo-restorative circle, Part 2, Dent Today. 2010:29(3):98, 100, 102-105.

Endodontic practice 33

CONTINUING EDUCATION

Instrumentation time efficiency of rotary and hand instrumentation performed on vital and necrotic human primary teeth Drs. Jorge Paredes Vieyra and Francisco Javier Jimenez Enriquez present a randomized control trial to compare the instrumentation time efficiency of rotary and hand instrumentation performed on necrotic human primary teeth.

he goal of pulp therapy in the primary dentition is to retain the primary tooth as a fully functional part of the dentition, allowing at the same time for mastication, phonation, swallowing, and the preservation of the space required for the eruption of the permanent tooth (Fuks, 2002; Tziafas, 2004). The premature loss of primary teeth may cause changes in the chronology and sequence of eruption of permanent teeth. Maintenance of primary teeth until physiological exfoliation contributes to mastication, phonation, and esthetics and prevents deleterious habits in children (Fuks, 2005). The primary objectives of cleaning and shaping the root canal system are to remove soft and hard tissue containing bacteria, providing a path for irrigants to the apical third, supplying space for medicaments and subsequent obturation, and retaining the integrity of radicular structure (Fuks, 2002). The choice between pulpotomy and pulpectomy is generally based on the severity of the symptoms clinically and/or radiographically. When indicated, the primary tooth pulpotomy is a relatively simple procedure with generally good clinical results. Moreover, pulpectomy is a heavier treatment for the child and is more complicated due to anatomical complexities that are not found in the permanent tooth (Fuks, 2005). In addition, it is important to preserve the primary tooth until its natural exfoliation time, thus preserving arch integrity. Fuks (2002) reports two therapeutic approaches for vital pulp therapy:

Dr. Jorge Paredes Vieyra works at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico. Francisco Javier Jimenez Enriquez works at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico.

34 Endodontic practice

Educational aims and objectives

This clinical article aims to compare the instrumentation time efficiency of rotary and hand instrumentation performed on necrotic human primary teeth.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the differences between the use of rotary files in primary teeth and manual K-files. • Identify several therapeutic approaches for vital pulp therapy. • Recognize certain instances in which pulpectomy is indicated. • Realize certain instances in which root canal filling in primary molars is contraindicated. • Identify some of the factors related to the success of pulpectomy.

• Indirect pulp treatment (IPT) in cases of deep dentinal cavities • Direct pulp capping (DPC) or pulpotomy in cases of pulp exposure. According to the Guidelines of the American Academy of Pediatric Dentistry (1996), pulpectomy is indicated in primary teeth with carious pulp exposures in which, following coronal pulp amputation, the radicular pulp exhibits clinical signs of hyperaemia, or evidence of necrosis of the radicular pulp with or without caries involvement. Success of pulpectomy depends on elimination of irritants by means of cleaning and shaping the root canal and it is dependent on microbial reduction as a result of chemomechanical preparation. Furthermore, maintaining esthetics will avoid psychological problems related to the loss of teeth. Clinically, the choice of pulp therapy is based on semiology despite the assessment difficulties and imprecision of pulp tests related to deciduous dentition. Reluctance to carry out root canal treatment is based on the difficulty to clean and shape the curved root canals of the primary molars (Fuks, 2005). Pulpectomy on primary teeth with severe pulpal involvement should be considered as a treatment of choice (Rodd, et al., 2006). Clinical success occurs when the tooth is

painless, firm, non-mobile, and without any signs of inflammation or infection (Moskovitz, Sammara, Holan, 2005). The conventional instrumentation technique for primary teeth remains hand instrumentation, which is timeconsuming (Silva, et al., 2004). Root canal filling in primary molars is contraindicated in teeth with the following: 1. Non-restorable crowns 2. Perforation to the pulpal floor 3. Reduced bone support and/or extreme tooth mobility 4. Radiographic indication of extensive internal or external root resorption 5. Periradicular radiolucency involving the follicle of the permanent tooth 6. Underlying dentigerous or follicular cysts 7. In medically compromised children (Moskovitz, Sammara, Holan, 2005; Silva, et al., 2004). A practical pulpectomy technique for the primary dentition should include the following features: • Fast and simple procedures, with short treatment times and a minimal number of appointments • Effective debridement of the root canals without weakening the tooth structure or endangering the underlying permanent teeth Volume 7 Number 5

Patient selection was based on the following criteria: • The aims and requirements of the study were freely accepted by the parents. • Primary molars with at least 11.0 ± 1.0 mm of working length. • Treatment was limited to patients in good health. • All teeth had vital and non-vital pulps without a sinus tract. • Excess of bleeding during a pulpotomy. • Presence of enough coronal tooth and root structure. • No prior pulpectomy treatment on the involved tooth. • Absence of perforation in the internal and/or external furcation area. • No analgesics or antibiotics were used before the clinical procedures began. Exclusion criteria were patients without inclusion requirements or failure to obtain

Assessed for eligibility (n=47 teeth)

Excluded (n=2)

Randomized (n=45)

Materials and methods This study took place at the Universidad Autónoma de Baja California, School of Dentistry in Tijuana, Mexico. The subjects review committee approved the study and all the participants were treated in accordance with the Declaration of Helsinki (www.cirp. org/library/ethics/helsinki). The study was conducted between September 2011 and December 2013. The main inclusion criteria were radiographic evidence of any sign of apical periodontitis or root resorption, teeth where the pulpotomy was started and teeth with diagnosis of pulpal necrosis confirmed by negative response to hot and cold tests. We performed thermal pulp testing, and radiographic interpretation was verified by two certified pediatric dentists. The results from a pilot procedure were used to calculate the sample size. Calculation was performed using the two-sample paired t-test in the Bio Stat 4.0 software (two related samples, mean difference in log 10 colony-forming units before and after instrumentation, alpha 0.01). Fifteen teeth per group were required to obtain statistical power. Volume 7 Number 5

parent’s authorization, and were excluded if they were older than 7 years old, had a positive history of antibiotic use within the past month, diabetic, haemophilic, or if the tooth had root resorption or been previously accessed and initiated a pulpectomy. Once eligibility was conﬁrmed, the parents were informed of the study design, the clinical procedure involved, and the associated risks. Patients aged 4 to 7 years were enrolled in this study, 45 teeth (19 maxillary and 26 mandibular teeth) that had a total of 102 canals and completely formed apices and of minimum 10 mm root length were selected. All selected teeth had mature apexes with no radiographic sign of root resorption (Table 1) (Figure 1). Of the 45 treated primary molars, 31 teeth were diagnosed as having chronic pulpitis, and 14 as having pulp necrosis that

Group one Allocate to one-visit pulpectomy Regime (n=15)

Group two Allocate to one-visit pulpectomy Regime (n=15)

Lost to follow-up: Failed to contact (n=1) Failed to attend (n=0)

Lost to follow-up: Failed to contact (n=0) Failed to attend (n=0)

Lost to follow-up: Failed to contact (n=1) Failed to attend (n=0)

Analyzed (n=15) None excluded

Figure 1: CONSORT flowchart for this study Table 1: Distribution of 45 teeth (102 canals) No. of canals maxillary Teeth - canals

No. of canals mandibular Teeth - canals

Central incisor

4-4

0-0

First molar

8 - 16

17 - 34

Second molar

7 - 21

9 - 27

Total

19 - 41

26 - 61

Endodontic practice 35

CONTINUING EDUCATION

• Few procedural complications • Maintaining tooth function until it is naturally shed (Kuo, et al., 2006). The majority of studies report a significant reduction of bacteria with an increase in preparation size and irrigation (Kuo, et al., 2006). On the other hand, Peters and Wesselink (2002) demonstrated that more than 30% of the root canal walls remained untouched even by modern rotary nickeltitanium instrumentation techniques. But not all the nickel-titanium instruments can closely follow the original root canal path, and procedural errors such as ledges, overinstrumentation, and apical transportation could be present. Mechanical debridement — combined with antibacterial irrigation using 0.5% sodium hypochlorite — can render 40%-60% of the treated teeth bacteria negative (Kakehashi, Stanley, Fitzgerald, 1965; Hulsmann, Hahn, 2000; Fuks, Papagiannoulis, 2006). In addition to mechanical debridement and antibacterial irrigation, dressing the canal with calcium hydroxide has been shown to increase the percentage of bacteria-negative teeth to around 70% (Coll, Sadrian, 1996; Eidelman, Holan, Fuks, 2001). The aim of this study was to compare the instrumentation time efficiency of rotary and hand instrumentation performed on vital and necrotic human primary teeth.

CONTINUING EDUCATION responded negative to hot and cold tests; and, clinically, all pulps were confirmed to be necrotic on entrance into the pulp chamber. Informed consent was obtained and written by the parents from each patient. A #0 periapical radiograph was taken for each tooth in buccolingual projection to allow proper selection. The selected teeth included seven second maxillary molars (three canals each), eight first maxillary molars (two canals each), four central incisors (one canal each), 17 first mandibular molars (two canals each), nine second mandibular molars (three canals each) for a total of 45 teeth with 102 canals (Table 1). The standard session time recommended by the pediatric dentists was approximately 20-35 minutes to allow for acceptable time for completion of treatment. All treatment was performed by the authors. As a novel treatment in pediatric dentistry, we included electronic apex locator (EAL), EndoVac (SybronEndo) system, and LightSpeed® LSX™ instruments. The teeth were randomly divided into three groups (each tooth was considered as an experimental unit): • Group one (n = 15): The root canals were prepared manually with K-files (Dentsply Maillefer, Switzerland) and step-back technique up to size #35 • Group two (n = 15): The root canals were instrumented with rotary LightSpeed LSX instruments (Discus Dental). They were used to complete the canal preparation to a size #50 for the anteriors and molar teeth to size #40 • Group three (n = 15): The root canals were instrumented with ProTaper® files (Denstply Maillefer, Switzerland, and in the United States, Dentsply Tulsa Dental Specialties) using SX S1 to F2; 0.5% NaOCl was used for irrigation. The instrumentation time was measured for all the procedures, and the results were analyzed with the student’s t-test. All statistical procedures were computed with SPSS 21.0 (SPSS Inc., U.S.). The student t-test was used to compare data whether there were statistically significant differences between the results obtained clinically. Significance was set at p < 0.05. After local anesthesia by 2% lidocaine with 1:100,000 epinephrine and rubber dam isolation, the tooth was disinfected with 2.5% NaOCl. All caries were removed and endodontic access cavities made with sterile high-speed carbide #331. The cervical third of each canal was flared with a SX ProTaper file. 36 Endodontic practice

Table 2: Instrumentation time (minutes) for different groups of teeth Type of instrumentation

Anterior teeth

Maxillary first molars

Maxillary second molars

Mandibular first molars

Mandibular second molars

Step-back

7.22 ± 1.91

20.10 ± 5.2

20.14 ± 5.4

20.24 ± 5.12

22.38 ± 6.70

LSX

3.40 ± 0.56

8.03 ± 3.80

10.45 ± 4.77

9.37 ± 2.19

10.40 ± 3.62

ProTaper

3.49 ± 0.59

9.23 ± 4.27

11.35 ± 4.97

9.77 ± 3.99

11.35 ± 4.97

Each canal was irrigated consequently with 2.0 cc 0.5% sodium hypochlorite. The final rinse was aspirated, but no attempt was made to dry the canals. Working length was established with the Root ZX® EAL (J Morita) and confirmed radiographically. The canals were negotiated and enlarged with K-files hand instruments until reaching an ISO #20 at the working length. The Root ZX was used in accordance with the manufacturer’s instructions. The buccal clip was attached to the patient’s lip, and the probe was connected to a stainless steel 15 K-file. The file was advanced within the root canal to a point just beyond the major foramen, as indicated by the flashing “apex” bar on the liquid crystal display of the EAL. When the file was in position, the LCD display showed a flashing bar between “apex” and “1.” Measurements were considered to be correct if the instrument remained constant for at least 4 to 5 seconds. A digital photograph was taken and stored. The position of the file tip for each root canal was evaluated by two examiners; if the two examiners disagreed, a third previously calibrated researcher was asked to make the final decision. The final WL was established to be 1 mm coronal to the major foramen (Fuks, 2006). For group one, the root canals were prepared manually with K-files and step-back technique up to size #35. For group two, LightSpeed LSX rotary instruments were used to complete the canal preparation to a size #50 for the anteriors and molars to size #40. For group three, the root canals were instrumented with ProTaper files using SX, S1 (21 mm) to F2 (21 mm). For irrigation, 0.5% NaOCl was used; the original protocol suggested by ProTaper for permanent teeth was simplified for this study. After completion of canal instrumentation, all canals were irrigated with distilled water for 30 seconds using the EndoVac irrigation system. The EndoVac system is able to apply the irrigant to working length and evacuate it using apical negative pressure.

The negative pressure avoids forcing the irrigant beyond the apex into the periapical tissues (Nielsen, Baumgartner, 2007). The canals were dried with sterile paper points and obturated at the same appointment using calcium hydroxide and iodoform paste by using pluggers or syringes. Access cavities of anterior teeth were etched and restored with Fuji IX (GC Corp, Japan). For posterior teeth, a build-up restoration was placed by using the same etching technique and Fuji IX or temporary metallic crown. A stopwatch with alarm was used to record instrumentation time for each group (Table 2). Children were recalled for clinical and radiographic examinations, which were evaluated based on the criteria of Coll and Sadrian (1996), at 6-month intervals for a follow-up period of 2 years. Teeth that exhibited no symptoms of pain, tenderness to percussion, swelling, sinus tract, or pathological mobility were judged clinically successful (42 teeth). Teeth that showed no evidence of periradicular or interradicular radiolucency, internal or external root resorption, or periodontal ligament space widening were judged radiographically successful. Radiographic evidence of pulp canal obliteration was noted, but it was not regarded as failure.

Results After a thorough examination, 47 patients were included at the beginning of the study; two patients did not enroll in the study (Figure 1). Of the 45 treated primary teeth, 31 teeth were diagnosed as having chronic pulpitis (68.88%), and 14 as having pulp necrosis (31.11%). Six- to 12-month recall examinations are shown in Table 3. The clinical and radiographic success rates were 95% at the 12- to 24-month follow-up time, and no obvious differences among different quadrants and tooth types were found. Only 4% (two out of 45) of the treated teeth experienced pain following the initial instrumentation, while 24% (11 out of 45) had pain after the root canal filling. However, the pain was mild, temporary, and subsided in Volume 7 Number 5

Anterior teeth

Type of variable Preoperative root resorption

Maxillary first molars

Maxillary second molars

Mandibular first molars

Mandibular second molars

Sum

None

Short

Complete

Long

Pulpectomy exfoliated

None

Pulpectomy extracted

None

Pulpectomy lost Length of fill

a few days. A small area of expanded radiolucency was found in the furcal area in one case at the 6-month recall, and in another case at the 12-month recalls, which were recorded as radiographic failure, although clinically no signs or symptoms were found (Table 3). The entire first visit, including local anesthesia, rubber dam placement, and root canal preparations, was generally completed within 18-20 minutes. Of this time, canal preparation using rotary instruments only took approximately 8 to 12 minutes. Ledges or over-instrumentation were not encountered, and neither instrument separation nor lateral perforation occurred. With regard to canal filling quality, 29 cases (64.44%) were flush-filled, five cases (11.11%) were under-filled, and 11 cases (24.44%) were over-filled. The over-filled Vitapex® was gradually resorbed within 9 months with no clinical symptoms or signs. There were no cases in which temporary restoration was found to be defective prior to crown placement (Table 3). The mean time spent for rotary root canal preparation and hand preparation for the three groups were 20.10 ± 7.86, 9.37 ± 2.19 minutes, and 10.45 ± 4.77 minutes,

respectively. The difference between the 3 times was significant (p < 0.001). The preparation time with group one and K-files was significantly higher than in groups two and three with rotary instrumentation, with a p = 0.005 (Table 2).

Discussion One of the most important concerns in pediatric dentistry is loss of primary molars leading to space loss. Several factors contribute to the clinical success of pulpectomy, such as biomechanical cleaning (Crespo, et al., 2008), type of restoration (Moskovitz, Sammara, Holan, 2005), number of visits (McDonald, Avery, 2008), and root canal filling material. The success of pulpectomy was related significantly to the amount of preoperative root resorption. Primary teeth with minimal or no preoperative root resorption had

significantly higher pulpectomy success than those with excessive (> 1 mm) resorption. This finding confirmed what the other PE studies had indicated (Coll, Sadrian, 1996; Eidelman, Holan, Fuks, 2001). Excessive root resorption likely made it difficult to resolve the periapical infection with the PE procedure. The amount of preoperative root resorption seems to be the most important radiographic diagnostic criterion in determining whether a pulpectomy will likely succeed (Coll, Sadrian, 1996). According to Finn (1967), the main differences between deciduous and permanent teeth are that deciduous teeth are smaller in all dimensions than permanent teeth, and the mesiodistal/buccolingual crown ratio in temporary teeth is larger than in permanent teeth. Primary tooth dentin is softer and less dense than that of the permanent tooth, and the roots are shorter, thinner, and

Figure 4: Radiograph of tooth LLe of a 4-year-old patient

Figure 2: Radiograph of tooth LRe of a 5-year-old patient Volume 7 Number 5

Figure 3: Radiograph of teeth URa, ULa, and ULb of a 4-yearold patient

Figure 5: Radiograph of tooth LLe of a 4-year-old patient Endodontic practice 37

CONTINUING EDUCATION

Table 3: Factors affecting pulpectomy success

CONTINUING EDUCATION more curved, often with undetectable root tip resorption. Chemomechanical preparation of the root canal includes both mechanical instrumentation and canal irrigation, and is principally directed toward the elimination of microorganisms from the root canal system (Moskovitz, Sammara, Holan, 2005). Canal preparation is one of the most important phases of primary root canal treatment and is mainly aimed at the debridement of the canals (Coll, Sadrian, 1996). Root canal instrumentation is essential to reduce infected content and create a root canal shape, allowing for a well-condensed root filling. The mean time spent for each step of the pulpectomy is essential to allow faster procedures with maintenance of quality and security, as well as reducing the patient’s and professional’s fatigue (Pinheiro, et al., 2012; Mortazavi, Abbasi, Khodadadi, 2006). The mean time spent for the instrumentation of groups two and three was similar and was lower than the one reported by Mortazavi, et al. (2006); their study was carried out in vivo and was therefore more time-consuming. Although the study assessed clinical success rates, they also found no significant differences between rotary and hand instrumentation. Because many pulpal ramifications cannot be reached mechanically, copious irrigation during cleansing and shaping must be maintained. We support the view that both chemical and mechanical cleaning affects root canal cleanliness. Furthermore, a key factor in the architecture of the rotary files may be their flute design (Khadivi, et al., 2007). Anatomic characteristics of root canals in deciduous teeth may be dramatically changed by the presence of physiologic or pathologic root resorption (Moskovitz, Sammara, Holan, 2005; Prove, Symons, Meyers, 1992; Saito, et al., 1991), leading to problems related to root perforations. The manual and rotary instruments produced less dentin removal on anterior teeth compared with other groups of teeth. This is explained by the root canal width and insufficient size of instruments (Barr, Kleier, Barr, 2000). Therefore, although our protocol recommends instrumentation up to size 40, use of the combined techniques is suggested to allow more effective instrumentation. However, the produced dentin removal must be evaluated to establish the file size, which may provide higher security to dental tissues and avoid excessive dentin removal and resulting increased fragility of the tooth structure. 38 Endodontic practice

Even though the fourth canal is not commonly present in maxillary molars (Joseph, Varma, Mungara, 2005), care must be taken considering the pattern of physiologic resorption guided by the position of the permanent tooth. The lack of studies regarding root canal instrumentation in primary teeth and the results obtained in the present study highlight the importance of more research to develop safer and faster protocols for the treatment of deciduous teeth with compromised pulp tissue. Because endodontic treatment is the last option for maintenance of primary teeth affected either by caries or trauma in the oral cavity, it should follow the same biologic principles applicable to permanent teeth, aiming at success and thereby contributing to healthy development of the permanent dentition and the entire stomatognathic system. Instrumentation by manual or rotary techniques is safe to the deciduous tooth and permanent tooth bud, provided that all steps and precautions are strictly followed,

allowing disinfection of dental tissues and contributing to the repair of infectious and inflammatory processes.

Conclusion Clinically, time efficacy in primary molar endodontics, especially with the unpredictability and difficulty of canal morphology, is invaluable. The use of rotary files in primary teeth has several advantages when compared with manual K-files: • The efficiency in both preparation time and root canal shape • A decreased working time that helps maintain patient cooperation by diminishing the potential for tiredness • The shape of the root canal is more conical, favoring a higher quality of the root canal filling and increasing clinical success. EP

Acknowledgments The authors would like to thank Professor Dr. Michael Hülsmann (Göttingen) and Dr. Clovis Monteiro Bramante for their valuable assistance in reviewing this manuscript.

REFERENCES 1. American Academy of Pediatric Dentistry. Guidelines for pulp therapy for primary and young permanent teeth: reference manual. Pediatr Dent. 1996;18:44. 2. Barr ES, Kleier DJ, Barr NV. Use of nickel titanium rotary files for root canal preparation in primary teeth. Pediatr Dent. 2000;22(1):77-78. 3. Coll JA, Sadrian R (1996) Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatr Dent. 1996;18(1):57-63. 4. Crespo S, Cortes O, Garcia C, Perez L. Comparison between rotary and manual instrumentation in primary teeth. J Clin Pediatr Dent. 2008;32(4):295-298. 5. Daito M, Kawahara S, Kato M, Okamoto K, Imai G, Hieda T. Radiographic observations on root resorption in the primary dentition. J Osaka Dent Univ. 1991;25(1):1-23. 6. Eidelman E, Holan G, Fuks AB. Mineral trioxide aggregate vs. formocresol in pulpotomized primary molars: a preliminary report. Pediatr Dent. 2001;23(1):15-18. 7. Finn SB. Morphology of the primary teeth. In: Finn SB, et al. Clinical pedodontics. 3rd ed. Philadelphia, Pennsylvania:WB Saunders Co.;1967:18-49. 8. Fuks AB. Current concepts in vital primary pulp therapy. Eur J Paediat Dent. 2002;3(3):115-20. 9. Fuks AB. Pulp therapy for the primary dentition. In: Pediatric Dentistry: infancy through adolescence. St Louis, MO: Elsevier;2005: 118-130. 10. Fuks AB, Papagiannoulis L. Pulpotomy in primary teeth: review of the literature according to standardized criteria. Eur Arch Paediatr Dent. 2006;7(2):64-71. 11. Hülsmann M, Hahn W. Complications during root canal irrigation—literature review and case reports. Int Endod J. 2000;33(3):186-193. 12. Zoremchhingi, Joseph T, Varma B, Mungara J. A study of root canal morphology of human primary molars using computerised tomography: an in vitro study. J Indian Soc Pedod Prev Dent. 2005;23(1): 7-12. 13. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol. 1965;20:340-349. 14. Khadivi Nia Javan N, Mohajeri Baradaran L, Azimi S. SEM study of root canal walls cleanliness after Ni-Ti rotary and hand instrumentation. Iran Endod J. 2007;2(1):5-10. 15. Kuo CI, Wang YL, Chang HH, Huang GF, Lin CP, Guo MK, Li UM. Application of Ni-Ti rotary files for pulpectomy in primary molars. J Dent Sci. 2006;1:10-15. 16. McDonald RE, Avery DR. Dentistry for the child and adolescent. 7th Edition. St. Louis: Mosby; 2000:401. 17. Mortazavi M, Abbasi A, Khodadadi E. Comparison of the success rate and cleaning time of pulpectomy and necrotic primary molar teeth using manual and rotary instruments. Journal of Dentistry, Shiraz University of Medical Science. 2005;6:111-119. 18. Moskovitz M, Sammara E, Holan G. Success rate of root canal treatment in primary molars. J Dent. 2005;33(1):41-47. 19. Nielsen BA, Craig Baumgartner J. Comparison of the EndoVac system to needle irrigation of root canals. J Endod. 2007;33(5):611-615. 20. Peters LB, Wesselink PR. Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms. Int Endod J. 2002;35(8):660-667. 21. Pinheiro SL, Araujo G, Bincelli I, Cunha R, Bueno C (2012) Evaluation of cleaning capacity and instrumentation time of manual, hybrid and rotary instrumentation techniques in primary molars. Int Endod J. 45(4):379-385. 22. Prove SA, Symons AL, Meyers IA. Physiological root resorption of primary molars. J Clin Pediatr Dent. 1992;16(3):202-206. 23. Rodd HD, Waterhouse PJ, Fuks AB, Fayle SA, Moffat MA. Pulp therapy for primary molars. Int J Pediatr Dent. 16 Suppl:15-23. 24. Silva LA, Leonardo MR, Nelson-Filho P, Tanomaru JM. Comparison of rotary and manual instrumentation techniques on cleaning capacity and instrumentation time in deciduous molars. J Dent Child (Chic). 2004;71(1):45-47. 25. Tziafas D. The future role of a molecular approach to pulp-dentinal regeneration. Caries Res. 2004;8(3):314-320.

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Instrumentation time efficiency of rotary and hand instrumentation performed on vital and necrotic human primary teeth 1. The goal of pulp therapy in the primary dentition is to retain the primary tooth as a fully functional part of the dentition, allowing at the same time for ___________, and the preservation of the space required for the eruption of the permanent tooth. a. mastication b. phonation c. swallowing d. all of the above 2. According to the Guidelines of the American Academy of Pediatric Dentistry (1996), ___________ is indicated in primary teeth with carious pulp exposures in which, following coronal pulp amputation, the radicular pulp exhibits clinical signs of hyperaemia, or evidence of necrosis of the radicular pulp with or without caries involvement. a. pulpectomy b. pulpotomy c. foliation d. extraction 3. The majority of studies report a _____________ of bacteria with an increase in preparation size and irrigation. a. significant increase b. significant reduction c. minor increase d. total elimination

Volume 7 Number 5

4. On the other hand, Peters and Wesselink (2002) demonstrated that ______ of the root canal walls remained untouched even by modern rotary nickel-titanium instrumentation techniques. a. 5% b. 10% c. 20% d. more than 30% 5. Mechanical debridement â&#x20AC;&#x201D; combined with antibacterial irrigation using 0.5% sodium hypochlorite â&#x20AC;&#x201D; can render _______ of the treated teeth bacteria negative. a. 10%-20% b. 30% c. 40%-60% d. 75% 6. In addition to mechanical debridement and antibacterial irrigation, dressing the canal with calcium hydroxide has been shown to increase the percentage of bacteria-negative teeth to around _____. a. 50% b. 60% c. 70% d. 95% 7. The success of pulpectomy was related significantly to the amount of ____________.

a. b. c. d.

postoperative resorption mechanical treatment preoperative root resorption crown ratio

8. Chemomechanical preparation of the root canal includes both mechanical instrumentation and canal irrigation, and is principally directed toward the ________ of microorganisms from the root canal system. a. control b. elimination c. identification d. reduction 9. Root canal instrumentation is essential to _____, allowing for a well-condensed root filling. a. reduce infected content b. create a root canal shape c. postoperative root resorption d. both a and b 10. Even though the fourth canal is ________ in maxillary molars, care must be taken considering the pattern of physiologic resorption guided by the position of the permanent tooth. a. not commonly present b. always present c. never a factor d. of insufficient size

Endodontic practice 39

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Canal preparation of the MB2 canal with the R25 Reciproc® instrument Dr. Ghassan Yared presents a new concept for the preparation of an MB2 canal without prior hand filing or glide path

he canal preparation of the MB2 canal in a maxillary molar is challenging (Ibarrola, et al., 1997), considering the complexity of the canal anatomy (Verma, Love, 2011) and the presence of calcifications (McCabe, Dummer, 2012), mainly in the coronal third of the canal. Usually, small hand files are used to establish patency and create a glide path. However, these files lack rigidity for the negotiation of narrow spaces and are prone to fracture. Therefore, pathfinding hand files with an enhanced rigidity (such as C-Pilot®, VDW Dentsply, and C+ Files, Dentsply Maillefer, Switzerland) were introduced (Allen, et al., 2007). However, the efficacy of these files remains questionable (Allen, et al., 2007). Moreover, another concern associated with the use of hand files for glide path is the possible occurrence of iatrogenic complications and canal transportation, regardless of the proficiency of the clinician (Berutti, et al., 2009). Engine-driven files — such as PathFile™ instruments (Dentsply Maillefer) and the Mtwo 10/.04 instrument (VDW, Germany) — have been introduced for glide path management. Studies have shown that the incidence of canal transportation associated with enginedriven files used for glide path management is lower compared to small hand instruments (Berutti, et al., 2009). However, the management of the glide path with these engine-driven instruments requires the use of additional instruments — one to three instruments, depending on the system. Also, recent studies have shown the increased incidence of buckling associated with these instruments (Lopes, et al., 2012a).

Professor Ghassan Yared, DDS, MSc, is an endodontist practicing in Ontario, Canada. He completed his endodontic specialty training at University Paris VII (Paris, France) in 1987 and obtained his MSc from the Lebanese University (Beirut, Lebanon) in 1994. Professor Yared has supervised the research projects of graduate endodontic students at the University of Toronto and has published extensively in peer-reviewed international endodontic journals. He has also given numerous lectures and continuous education courses worldwide.

40 Endodontic practice

Educational aims and objectives

This clinical article aims to present a new concept for the preparation of an MB2 canal without a glide path, thus eliminating the concerns associated with the use of small path-finding hand and engine-driven files.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 43 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify a new concept for the preparation of an MB2 canal without a glide path. • Recognize the concerns associated with the use of small pathfinding hand and engine-driven files. • Realize the clinical procedure involved in using this technique. • Read about the safety aspects of using the R25 Reciproc instrument. • Realize some of the challenges involved in this procedure.

Moreover, patency of the canal with a small hand file has to be established prior to the use of the PathFile™ instruments for the management of a glide path; therefore, the possible complications resulting from the use of small hand files in narrow spaces are still a concern. Also, the engine-driven instruments used for the management of a glide path are used in a continuous rotation; therefore, there is an increased risk of fracture from binding (Alves Vide, et al., 2012), especially in a narrow canal with a complicated anatomy (such as the MB2 canal in a maxillary molar). In many cases, the use of engine-driven instruments may not be possible at the beginning of the canal preparation procedure due to the obliteration of the canal at its orifice and/or in its coronal third with calcifications; the use of very small hand files may also not be possible. In similar situations, the clinician will typically use fine ultrasonic tips to remove the calcifications and to reach a level in the canal where the use of small hand or enginedriven instruments for glide path will become possible. The use of ultrasonic tips for the removal of calcifications can cause canal blockages and ledges, resulting in a more complicated procedure. The objective of the present article is to present a new concept for the preparation of an MB2 canal without a glide path, thus eliminating the concerns associated with the use of small pathfinding hand and engine-driven files.

Clinical procedure Guidelines have already been established for the use of Reciproc instruments for the initial canal preparation; they include the forward and reverse angles, speed settings on the motor, the pressure applied on the instrument, the pecking and brushing motion with the instrument, the canal preparation without establishing a glide path, and the need for establishing a glide path in some cases. (Visit www.endodonticcourses.com/ literature for more details.) One major benefit of the Reciproc system is its simplicity, regardless of the nature of the procedure and the degree of canal calcification and curvature. The guidelines for using the Reciproc instruments for initial endodontic treatments in canals with different degrees of calcification and curvature, as well as in MB2 canals, are the same. The access cavity preparation, the straight line access guidelines as well as the irrigation protocol remain unchanged, similar to a standard initial treatment procedure. The orifice of the MB2 canal has to be located before using the Reciproc instrument. The use of fine ultrasonic tips may be required for this purpose. The Reciproc instrument is not used to locate the orifice. An R25 Reciproc instrument is used for the management of an MB2 canal in a maxillary molar. Before starting preparation, the length of the root canal is estimated with the help of an adequately exposed and Volume 7 Number 5

Creating a glide path during the use of the Reciproc instruments: indication and management A glide path may also have to be created in some MB2 canals when the R25 stops Volume 7 Number 5

advancing in the canal or if advancement becomes difficult. In this case, pressure should not be exerted on the R25. The instrument should be removed from the canal and the canal irrigated. If the R25 still advances with difficulty, or if it does not advance, it should be removed from the canal, and the canal irrigated once again. At this point, hand files sizes 10 and 15 should be used to create a glide path to the working length. The R25 would then be used until the working length has been reached. If, however, the progress of the R25 instrument were still difficult or not possible, the canal preparation would need to be completed with hand files.

Figure 1: An abrupt apical curvature

Using hand files to finish the apical canal preparation In some canals, the size 10 file used for the working length determination (after the R25 has reached two-thirds of the estimated working length) has to be pre-curved; otherwise it cannot reach working length. This indicates the presence of an abrupt apical curvature (Figure 1). The use of the R25 is contraindicated in this instance. The canal preparation has to be finished with hand files. However, in most of the cases, the size 10 file used for the working length determination will reach that length without being pre-curved (indicating the presence of a gradual curvature) (Figure 2). The R25 will be used to working length to complete the preparation.

Discussion Glide path management can be a challenging and complicated procedure that requires the combined use of different manual stainless steel and engine-driven nickel-titanium instruments in order to be accomplished safely (Lopes, et al., 2012b). One major benefit of the Reciproc system is its simplicity regardless of the nature of the procedure, the degree of canal calcification and curvature. The guidelines for using the Reciproc instruments for initial endodontic treatments in canals with different degrees of calcification and curvature as well as in MB2 canals are the same. I have been using the described technique for the management of MB2 canals for almost 5 years. The first main challenge in the management of an MB2 canal is the progress of the instrument in the coronal third of the canal. This challenge is caused by the presence of calcifications at the orifice of the canal and its coronal third. As a general rule, the pulp calcification process occurs in a corono-apical

Figures 2A and 2B: Gradual curvature

direction (McCabe, Dummer, 2012). Once these calcifications are removed, the instruments will advance easily toward the apical third of the canal (Amir, et al., 2001). According to an evaluation of MB2 canals that Iâ&#x20AC;&#x2122;ve treated, once the canal orifice was located (the tip of a fine endodontic explorer will catch in the orifice), obtaining canal patency and the creation of a glide path are not required to allow the progress of the R25 into the coronal third of MB2 canals regardless of the degree of calcification at the orifice of the canal and/or in its coronal third. Interestingly, despite the dimensions of the R25 (a diameter of 0.25 mm at the tip and a 0.08 mm/mm taper on the apical 3 mm) and despite the severe narrowness of the MB2 canal in some situations, the R25 will consistently remove the canal calcification Endodontic practice 41

CONTINUING EDUCATION

angulated preoperative radiograph. The silicone stopper is set on the R25 instrument at two-thirds of that length. In this new concept, obtaining patency of the MB2 canal and creating a glide path will never be attempted prior to using the R25 instrument. The tip of the R25 instrument will be placed at the orifice of the canal; the clinician will feel that the tip is catching in the orifice. The R25 is then activated in reciprocation to advance into the coronal third of the MB2 canal. Depending on the severity of the calcification and the width of the orifice of the canal, the advancement of the R25 may be slow; however, it will be progressive. The R25 will always be able to advance into the coronal third of the canal regardless of the width of the canal and the severity of the calcification at the orifice of the canal or in its coronal third. The R25 will act as an orifice opener due to its increased cutting ability and the relative strength at its tip. Once the calcification at the orifice and the coronal third of the MB2 canal is overcome, the R25 will advance easily in the canal in an apical direction. The Reciproc instrument is used in the canal with a slow in-and-out pecking motion without pulling the instrument completely out of the canal. The amplitude of the in-and-out movements should not exceed 3-4 mm. Only very light pressure should be applied. The instrument will continue advancing easily in an apical direction. After three in-and-out movements, when more pressure is needed to make the instrument advance further in the canal or when resistance is encountered, the instrument is pulled out of the canal to clean the flutes. A size 10 file is used to check patency to two-thirds of the estimated working length. The canal is copiously irrigated. The Reciproc instrument is used until it has reached two-thirds of the estimated working length, as indicated by the stopper on the instrument. The instrument is then removed from the canal, the canal is irrigated, and a size 10 file is used to determine the length. The Reciproc instrument is then re-used in the same manner until the working length has been reached. Upon reaching working length, the Reciproc instrument is withdrawn from the canal. The Reciproc instrument can also be used in a brushing motion against the lateral walls.

CONTINUING EDUCATION at the orifice of the canal and in its coronal third. It will advance into the middle third of the canal without the need to use ultrasonic tips or orifice opener instruments. In similar situations, the use of small hand or enginedriven pathfinding files will not be possible until the removal of the coronal calcification is accomplished with an ultrasonic tip. The use of ultrasonic tips can result in more complications such as canal blockages, canal ledges, or root perforations. The efficiency of the R25 in the management of the coronal third of MB2 canals in a safe and consistent manner can be explained by the following reasons: 1. The R25 instrument is very efficient in cutting dentin. The R25 instrument has a design similar to Mtwo instruments, which have been shown to cut dentin very efficiently compared to other rotary instruments. 2. The tip of the R25, due to its diameter and the taper, is advantageously more rigid than the tip of the existing rotary pathfinding files. The tip of the R25 will not buckle when confronted with canal narrowness and calcification in contrast to the rotary pathfinding instruments. 3. Histological studies have shown that canal patency (natural path of least resistance) exists regardless of the degree of canal calcification and despite the fact that canals may appear completely calcified visually or radiographically (Patersson, Mitchell, 1965; Schindler, Gullickson, 1988; Torneck, 1990; Kuyk, Walton, 1990). Being very efficient in cutting, especially in the absence of buckling, the tip of the instrument, unlike the existing pathfinding instruments, will engage the canal orifice and will start cutting and advancing even if the canal appears to be completely calcified. The R25 will follow the natural path of least resistance, the existing canal space, regardless of the severity of the calcification at the orifice or in the coronal third of the canal. 4. The R25 combines two features, which greatly contribute when used together to the maintenance of the canal curvature. First, the R25 is made from an M-Wire nickel-titanium alloy, which confers to the instrument a relative flexibility. Second, is the use of a reciprocation movement, which has been shown to be favorable to the maintenance of the canal curvature. 5. It should be obvious to the reader, from points 1 to 4, that the R25 will force its way into the natural path of least resistance. Despite the narrowness of the 42 Endodontic practice

MB2 canal and the presence of severe calcifications, the R25 will safely advance in the coronal third of the canal. The risk of instrument fracture is greatly reduced as the forward and reverse angles set on the motor for the reciprocating movement are lower than the angle of fracture of the instrument. Even if the instrument binds in the narrow canal space, it will not fracture because the motor will reverse the rotation when the angle set on the motor is reached; the angle at fracture will not be reached. In addition, the incidence of instrument binding is reduced (VarelaPatiño, et al., 2010). This can be explained by the combination of the pecking movement, an incomplete forward rotation, and the reverse rotational movement, which disengages the tip. 6. The safety in using the R25 for the management of MB2 canals is also the result of a reduced torsional fatigue. When an engine-driven instrument is used in a canal, it will engage the canal walls and cut dentin. This will subject the instrument to stresses in torsion. The repeated stresses on the instrument from the repeated cutting procedure will cause changes in the metal. The changes in the metal can be either reversible or irreversible (leading to fatigue and fracture), depending on the degree of rotation of the instrument when it is engaging the canal walls. The changes will be irreversible (fatigue will develop, and fracture will ultimately occur) when the angle of rotation is greater than the angle at which the elastic limit (elastic angle) of the instrument is reached.

In single file reciprocation, the forward and reverse angles used are not only lower than the angle of fracture of the instrument; they are also lower than the elastic angle. Therefore, torsional fatigue is greatly reduced despite the repeated engagement of the canal walls by the R25 when used for the preparation of a calcified MB2 canal. Once the R25 has prepared the coronal third of the MB2 canal, a second challenge may be encountered due to the complex anatomy of the MB2 (Verma, Love, 2011). In this situation, the R25 will stop from advancing in the canal, or its advancement may become difficult. The R25 is immediately removed from the canal. Patency has to be checked, and a glide path is created. The management of the MB2 canal with the R25 in this situation is similar to the management of any other calcified canal. The only difference is that the incidence of complex anatomy encountered is probably greater in the MB2 canal. Based on an evaluation of MB2 canals that I’ve treated, a glide path is required in only 7% of the MB2 canals once the coronal third is prepared to allow the R25 to advance further apically in the canal. An additional 13% (i.e., total of 20%) of the canals require a glide path before the R25 reaches the 0.5 mark on the Root ZX apex locator, and 5% (i.e., total of 25%) will require a glide path before the R25 reaches the apex mark on the Root ZX apex locator. EP

Acknowledgment

Professor Dr. Ghassan Yared is the inventor of single file reciprocation and was involved in the development, field testing, and research of Reciproc. He serves as a consultant to the Reciproc product range.

REFERENCES 1. Allen MJ, Glickman GN, Griggs JA. Comparative analysis of endodontic pathfinders. J Endod. 2007;33(6):723-726. 2. Alves Vde O, Bueno CE, Cunha RS, Pinheiro SL, Fontana CE, de Martin AS. Comparison among manual instruments and PathFile and Mtwo rotary instruments to create a glide path in the root canal preparation of curved canals. J Endod. 2012;38(1):117-120. 3. Amir FA, Gutmann JL, Witherspoon DE. Calcific metamorphosis: a challenge in endodontic diagnosis and treatment. Quintessence Int. 2001;32(6):447-455. 4. Berutti E, Cantatore G, Castellucci A, Chiandussi G, Pera F, Migliaretti G, Pasqualini D. Use of nickel-titanium rotary PathFile to create the glide path: comparison with manual preflaring in simulated root canals. J Endod. 2009;35(3):408-412. 5. Ibarrola JL, Knowles KI, Ludlow MO, McKinley IB Jr. Factors affecting the negotiability of second mesiobuccal canals in maxillary molars. J Endod. 1997;23(4): 236-238. 6. Kuyk JK, Walton RE. Comparison of the radiographic appearance of root canal size to its actual diameter. J Endod. 1990;16(11):528-533. 7. Lopes HP, Elias CN, Siqueira JF Jr, Soares RG, Souza LC, Oliveira JC, Lopes WS, Mangelli M. Mechanical behavior of pathfinding endodontic instruments. J Endod. 2012;38(10):1417-1421. 8. Lopes HP, Elias CN, Mangelli M, Lopes WS, Amaral G, Souza LC, Siqueira JF Jr. Buckling resistance of pathfinding endodontic instruments. J Endod. 2012;38(3):402-404. 9. McCabe PS, Dummer PM. Pulp canal obliteration: an endodontic diagnosis and treatment challenge. Int Endod J. 2012;45(2):177-197. 10. Patterson SS, Mitchell DF. Calcific metamorphosis of the dental pulp. Oral Surg Oral Med Oral Path. 1965;20:94-101. 11. Schindler WG, Gullickson DC. Rationale for the management of calcific metamorphosis secondary to traumatic injuries. J Endod. 1988;14(8):408-412. 12. Torneck CD. The clinical significance and management of calcific pulp obliteration. Alpha Omegan. 1990;83(4):50-54. 13. Varela-Patiño P, Ibañez-Párraga A, Rivas-Mundiña B, Cantatore G, Otero XL, Martin-Biedma B. Alternating versus continuous rotation: a comparative study of the effect on instrument life. J Endod. 2010;36(1):157-159. 14. Verma P, Love RM. A Micro CT study of the mesiobuccal root canal morphology of the maxillary first molar tooth. Int Endod J. 2011;44(3):210-217.

Volume 7 Number 5

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Canal preparation of the MB2 canal with the R25 Reciproc速 instrument 1. The canal preparation of the MB2 canal in a maxillary molar is challenging, considering the complexity of the canal anatomy and the presence of calcifications, mainly in the _________ of the canal. a. coronal third b. apical two-thirds c. mid root d. apical third 2. Usually, small hand files are used to ______. a. establish patency b. create a glide path c. promote continuous rotation d. both a and b 3. Before starting preparation, the length of the root canal is estimated with the help of a(n) ___________. a. high resolution digital intraoral camera image b. adequately exposed and angulated preoperative radiograph c. lowest radiation setting CBCT scan d. tomogram 4. The R25 will act as an orifice opener due to its ______.

Volume 7 Number 5

a. b. c. d.

rounded outer core increased cutting ability the relative strength at its tip both b and c

5. The amplitude of the in-and-out movements should not exceed ____. a. 1-2 mm b. 3-4 mm c. 5-6 mm d. 7 mm

c. size 9 file d. size 10 file 8. The guidelines for using the Reciproc instruments for initial endodontic treatments in canals with different degrees of calcification and curvature as well as in MB2 canals are _________. a. very different b. the same c. complicated d. challenging

6. _________ may also have to be created in some MB2 canals when the R25 stops advancing in the canal or if advancement becomes difficult. a. An alternative treatment plan b. A stereolithic canal c. A glide path d. A reverse angle

9. The tip of the R25, due to its diameter and the taper, is advantageously _______ than the tip of the existing rotary pathfinding files. a. more rigid b. less rigid c. non-flexible d. less sharp

7. In some canals, the _________ used for the working length determination (after the R25 has reached two-thirds of the estimated working length) has to be pre-curved; otherwise, it cannot reach working length. a. size 7 file b. size 8 file

10. The risk of instrument fracture is greatly reduced as the forward and reverse angles set on the motor for the reciprocating movement ____ the angle of fracture of the instrument. a. are lower than b. are higher than c. are equal to d. have no effect on

Endodontic practice 43

CE CREDITS

ENDODONTIC PRACTICE CE

ABSTRACTS

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

Age and timing of pulp extirpation as major factors associated with inflammatory root resorption in replanted permanent teeth Bastos JV, Ilma de Souza Cortes M, Andrade Goulart EM, Colosimo EA, Gomez RS, Dutra WO Journal of Endodontics (2014) 40(3): 366-71 Abstract Aim: External root resorption (ERR) is a serious complication after replantation, and its progressive inflammatory and replacement forms are significant causes of tooth loss. This retrospective study aimed to evaluate the factors related to the occurrence of inflammatory ERR (IERR) and replacement ERR (RERR) shortly after permanent tooth replantation in patients treated at the dental trauma clinic at the School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil. Methodology: Case records and radiographs of 165 patients were evaluated for the presence, type, and extension of ERR and its association with age and factors related to the management and acute treatment of the avulsed tooth by using the logistic regression model. Results: The patient’s age at the moment of trauma had a marked effect on the ERR prevalence and extension. The patients older than 16 years at the moment of trauma had less chance of developing IERR and RERR (77% and 87%, respectively) before the pulp extirpation, regardless of the extension of the resorption. The patients older than 11 years of age at the moment of trauma showed the lowest indices of IERR (P = .02). Each

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, England. He is also training program director for endodontics in London.

44 Endodontic practice

day that elapsed between the replantation and the pulp extirpation increased the risk of developing IERR and RERR by 1.2% and 1.1%, respectively, and also raised the risk of severe IERR by 0.5% per day. Conclusion: The risk of mature teeth developing severe IERR before the onset of endodontic therapy was directly affected by the timing of the pulpectomy and was inversely proportional to age. Systemic antibiotic therapy use had no effect on the occurrence and severity of IERR in mature teeth. The occurrence of RERR before the onset of endodontic treatment stimulates further investigations of the early human host response to trauma and subsequent infection.

Results: Eighty-two patients with 101 treated teeth met the inclusion criteria. The recall rate was 87.2%. Of these microsurgically treated cases, the overall healing rate was 93.1%. At the 0.05 significance level, age, sex, tooth position, size of periapical radiolucency, biopsy result of periapical lesion, and presence of a sinus tract appeared to have no significant effects on the outcome (P > .05). Conclusion: Microsurgical endodontic treatment using Super EBA as the root-end filling material is a favorable option for posttreatment endodontic disease.

Evaluation of microsurgery with Super EBA as root-end filling material for treating posttreatment endodontic disease: a 2-year retrospective study

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

Li H, Zhai F, Zhang R, Hou B Journal of Endodontics (2014) 40(3): 345-50

Abstract Aim: This retrospective study assessed the effects of microsurgical treatment of posttreatment endodontic disease using Super EBA (Bosworth, Skokie, IL) as a rootend filling material and evaluated the potential prognostic factors in relation to outcome. Methodology: Data were collected from patients diagnosed with posttreatment endodontic disease who then underwent endodontic microsurgery between April 2007 and October 2010. The effect was evaluated 2 years after the operation. Surgical procedures were performed by a single endodontic specialist. After surgery, operation records were recorded including preoperative, intraoperative, and postoperative factors from the clinical and radiographic measures. For statistical analysis of the predisposing factors, the dependent variable was the dichotomous outcome (i.e., success versus failure).

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

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 Rud’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 Rud’s criteria, the overall success rate of cases with four 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 Volume 7 Number 5

Traditional endodontic surgery versus modern technique: a 5-year controlled clinical trial Tortorici S, Difalco P, Caradonna L, Tete S Journal of Craniofacial Surgery (2014) 25(3): 804-7 Abstract Aim: In this study, the outcomes of traditional apicoectomy versus modern apicoectomy were compared by means of a controlled clinical trial with a 5-year follow-up. Methodology: The study investigated 938 teeth in 843 patients. On the basis of the procedure performed, the teeth were partitioned into three groups. Differences between the groups were the method of osteotomy (type of instruments used), type of preparation of retrograde cavity (different apicoectomy angles and instruments used for root-end preparation), and root-end filling material used (gray mineral trioxide aggregate or silver amalgam). Outcome (tooth healing) was estimated after 1 and 5 years, postoperatively. Results: Clinical success rates after 1 year were 67% (306 teeth), 90% (186 teeth), and 94% (256 teeth) according to traditional apicoectomy (group one), modern microsurgical apicoectomy using burns for osteotomy (group two), or using piezo-osteotomy (group three), respectively. After 1 year, group comparison results were statistically significant (P < 0.0001). Linear trend test was also statistically significant (P < 0.0001), pointing out larger healing from group one to group three. After 5 years, teeth were classified into two groups on the basis of root-end filling material used. Clinical success was 90.8% (197 teeth) in the silver amalgam group versus 96% (309 teeth) in the mineral trioxide aggregate group (P < 0.00214). Multiple logistic regression analysis found that surgical technique was independently associated to tooth healing. Conclusion: Modern apicoectomy resulted in a probability of success more than 5 times higher (odds ratio, 5.20 [95% confidence interval, 3.94-6.92]; P < 0.001) compared with the traditional technique.

Abstract Aim: To effectively engage patients in clinical decisions regarding the management of teeth with apical periodontitis (AP), there is a need to explore patients’ perspectives on the decision-making process. This study surveyed patients for their preferred level of participation in making treatment decisions for a tooth with AP. Methodology: Data were collected through a mail-out survey of 800 University of Toronto Faculty of Dentistry patients, complemented by a convenience sample of 200 patients from 10 community practices. The Control Preferences Scale was used to evaluate the patients’ preferences for active, collaborative, or passive participation in treatment decisions for a tooth with AP. Using bivariate and logistic regression analyses, the Gelberg-Andersen Behavioral Model for Vulnerable Populations was applied to the Control Preferences Scale questions to understand the influential factors (P < .05). Results: Among 434 of 1,000 respondents, 44%, 40%, and 16% preferred an

active, collaborative, and passive participation, respectively. Logistic regression showed a significant association (P < .025) between participants’ higher education and preference for active participation compared with a collaborative role. Also, immigrant status was significantly associated with preference for passive participation (P = .025). Conclusion: The majority of patients valued an active or collaborative participation in deciding treatment for a tooth with AP. This pattern implied a preference for a patient-centered practice mode that emphasizes patient autonomy in decision making.

Current trends in endodontic treatment by general dental practitioners: report of a United States national survey Savani GM, Sabbah W, Sedgley CM, Whitten B Journal of Endodontics (2014) 40(5): 618-24 Abstract Aim: In the United States, almost 70%

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Clinical decision making for a tooth with apical periodontitis: the patients’ preferred level of participation Azarpazhooh A, Dao T, Ungar WJ, Chaudry F, Figueiredo R, Krahn M, Friedman S Journal of Endodontics (2014) 40(6): 784-9 Volume 7 Number 5

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Endodontic practice 45

ABSTRACTS

endodontic microsurgery when comparing 1-year follow-up periods with longer followup periods.

ABSTRACTS of root canal treatment (RCT) is performed by general dentists (GPs), yet little is known about their treatment protocols. Methodology: A paper survey was mailed to 2,000 United States GPs with questions about the types of endodontic cases treated, routine treatment protocols, use of newer technologies, and endodontic continuing education (CE). Results: Completed surveys were returned by 479 respondents (24%). GPs who perform RCT (84%) reported providing anterior (99%), bicuspid (95%), and molar (62%) RCT and retreatment (18%). Rubber dam was used always (60%), usually (16%), sometimes (13%), and never (11%). Newer technologies used by GPs included digital radiography (72%), magnification (80%), electronic apex locator (70%), and nickeltitanium rotary instrumentation (74%). Compared with GPs with more than 20 years of experience, those in practice for less than 10 years were more likely to use rubber dam (P < .05), nickel-titanium rotary instrumentation (P < .001), apex locators (P < .001), and magnification (P < .01). In contradistinction, GPs in practice for more than 20 years were more likely to perform retreatments (P < .05). Women were less likely to perform retreatment or molar RCT (both P < .05). GPs with more than 5 hours of CE were more likely to use rotary instrumentation (P < .001), irrigant activation devices (P < .01), and apex locators (P < .001) and perform molar RCT (P < .001) and retreatment (P < .05), but no more likely to use rubber dam. Conclusion: Recent GP graduates (less than 10 years) were more likely to adopt new technologies and use rubber dam than those who practiced for more than 20 years. More experienced GPs were more likely to take on complicated cases than those with fewer years of practice. There was no association between hours of CE and compliance with rubber dam usage.

A study of the endodontic workforce in Australia in 2010 Motearefi P, Abbott PV International Endodontic Journal (2014) 47(5): 477-86

Abstract Aim: To investigate the current workforce situation for specialist endodontists in Australia to help plan for the future of the specialty. Methodology: An online questionnaire was sent via email to all registered endodontists that were identified from the Australian and New Zealand Academy of Endodontists database and the Australian Dental Association Directory. The questionnaire comprised 46 Endodontic practice

questions on demographic characteristics, practice type, teaching and research activities, busyness, and expected retirement time. All results were transferred to a statistical software program (SPSS v.19) for analysis. Results: The response rate was 50%. The majority of respondents (84%) were male. The most common (64.5%) type of practice was single-location private practice. The majority (93%) of endodontists are located in state capital cities. Many respondents (61%) did some teaching. A minority of respondents (16%) were currently involved in research. The next available non-emergency appointment was more than 1 week away for 84% of respondents. More than half the respondents (52%) do not have allocated time for emergency patients. Only 18% of respondents plan to retire in the next 5 years and another 15% within 5 to 10 years. Although 58% of practice owners indicated that they have sufficient space and facilities to employ another endodontist, only 33% would consider employing or having an associate join their practice. Conclusion: Most endodontists in Australia are male private practitioners who work in a single state capital city location. Many teach, but few carry out research. They are fully booked with routine patients and have no spare scheduled appointments for emergencies; these have to be seen at the end of the day, or between scheduled patients. There will be a steady rate of retirement in the future, and only just enough newly qualified endodontists are being trained to maintain the specialty workforce at current levels.

Cavitation measurement during sonic and ultrasonic activated irrigation Macedo R, Verhaagen B, Rivas DF, Versluis M, Wesselink P, van der Sluis L Journal of Endodontics (2014) 40(4): 580-3 Abstract Aim: The aims of this study were to quantify and to visualize the possible occurrence of transient cavitation (bubble formation and implosion) during sonic and ultrasonic activated irrigation (UAI). Methodology: The amount of cavitation generated around several endodontic instruments was measured by sonochemiluminescence dosimetry inside four root canal models of human dimensions and varying complexity. Furthermore, the spatial distribution of the sonochemiluminescence in the root canal was visualized with longexposure photography.

Results: Instrument oscillation frequency, ultrasonic power, and file taper influenced the occurrence and amount of cavitation. In UAI, cavitation was distributed between the file and the wall extending beyond the file and inside lateral canals/isthmuses. In sonic-activated irrigation, no cavitation was detected. Conclusion: Cavitation was shown to occur in UAI at clinically relevant ultrasonic power settings in both straight and curved canals but not around sonically oscillating instruments, driven at their highest frequency.

Free available chlorine concentration in sodium hypochlorite solutions obtained from dental practices and intended for endodontic irrigation: are the expectations true? van der Waal S, Connert T, Laheij A, de Soet J, 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 per cent 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. It is recommended to purchase NaOCl from professional suppliers, because this group showed the most reliable content of free available chlorine. EP Volume 7 Number 5

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NOMAD® reaches a new milestone: 15,000 handheld units shipped

BruxZir® Solid Zirconia surpasses 5 Years of clinical use Glidewell Laboratories announced that BruxZir® Solid Zirconia crowns and bridges have successfully passed the 5-year mark in clinical usage and have reached this important milestone with over 5 million units prescribed by U.S. dentists. Even as BruxZir Solid Zirconia passed the 1-year and 2-year marks with good results from respected clinical studies, many dentists expressed the desire to see how the material might perform over extended years of clinical service before they would elect to utilize it within their own practices. Now, 5 years later, BruxZir Solid Zirconia is one of the most prescribed brands of full-contour zirconia restorations, a status owed to the countless dental and laboratory professionals who have adopted the material into their workplaces. As a result of its strength and unique vital translucence, BruxZir Solid Zirconia has revolutionized the landscape of dentistry by replacing bilayer restorations with a high-strength, esthetic monolithic option. For more information, visit http://www.glidewelldental.com

Aribex™, Inc., worldwide leader in handheld X-ray technologies, sold its 15,000th NOMAD® handheld X-ray system. Since its creation in 2004, NOMAD has quickly climbed to the top of the intraoral X-ray market and recently became a proud brand of the KaVo Kerr Group. The device’s breakthrough technology has revolutionized intraoral X-ray, and now it has become mainstream in the world of dentistry. NOMAD requires no walls, no installation, and no spacereducing cabinets. This leaves the staff free to arrange their operatories in the most effective workflow for them. Because operators are fully shielded from radiation while using NOMAD, they also have the freedom to stay with patients when taking X-rays, which minimizes retakes and expedites the X-ray process. In addition to heightened workflow, flexibility is an influencing factor in choosing NOMAD. It allows dental offices to have one NOMAD for multiple operatories, cutting equipment costs and opening up ways to take X-rays more conveniently. Oral surgeons and endodontists are now able to take NOMAD with them into procedures and take X-rays under anesthesia. Aribex is the worldwide leader in portable and handheld X-ray products and a proud brand of the KaVo Kerr Group. Aribex NOMAD X-ray systems are now in use in clinical, remote and mobile facilities throughout the world, from the finest professional offices to humanitarian missions reaching underserved populations that desperately seek care. NOMAD significantly decreases costs and provides hundreds of safe, high-quality images for dental and veterinary applications on a single-battery charge. For more information, visit www.aribex.com.

Volume 7 Number 5

Endodontic practice 47

PRODUCT PROFILE

Brasseler USA® introduces EndoSequence® BC RRM-Fast Set Putty™ Fast set formula with improved Sanidose™ syringe delivery

rasseler USA®, a leading manufacturer of quality instrumentation, is pleased to introduce EndoSequence® BC RRM-Fast Set Putty™. Made with a fast set formula and equipped with an improved Sanidose™ syringe delivery, BC RRM-Fast Set Putty provides users with superior handling and excellent healing properties. BC RRM-Fast Set Putty is highly biocompatible, extremely antibacterial (+12 pH), 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 properties. BC RRM-Fast Set Putty is premixed, resulting in less waste and a reduced threat of cross-contamination. The improved Sanidose syringe delivery ensures a perfect unit dose of moldable and condensable putty with every application. BC RRM-Fast Set Putty is extremely resistant to washout and sets in 20 minutes. BC RRM-Fast Set Putty has an extremely small particle size and, unlike other root

repair and pulp capping materials, BC RRM is completely void of heavy metals such as bismuth oxide which have been shown to 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.* “The accelerated hydration reaction of EndoSequence BC RRM-Fast Set Putty improves treatment efficiency and resistance to washout,” remarked Dr. Allen Ali Nasseh, Clinical Instructor, Harvard School of Dental Medicine. “BC RRM-Fast Set Putty represents the next logical step in root repair and retro-fillings. It truly exemplifies the many benefits of premixed ceramics.” For more information about the BC RRMFast Set Putty, call 800-841-4522 or visit www.BrasselerUSA.com. *Documentation available upon request.

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. Over the past 38 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, visit www.brasselerusa.com. EP This information was provided by Brasseler USA.

48 Endodontic practice

Volume 7 Number 5

PRACTICE DEVELOPMENT

Life after root canal — it’s not just about having enough money Dr. Robert Fleisher ruminates on how to prepare for retirement

here are so many articles about everything that you become pretty much overwhelmed and can never expect to read them all. So you pick and choose. You like to learn about the latest and greatest materials, devices, and techniques. You go to CE courses, conventions, and seminars. You even let insurance salespeople into your life so you can be ready for catastrophes of anything imaginable. Yes, you are prepared for just about everything that could come your way in the office.

What many endodontists severely neglect to plan for is what happens after root canal. Sure, they dream about retirement, but they never actually do the proper planning, not just for the obvious financial needs, but for emotional and psychological issues as well. An all-encompassing plan is needed to help navigate what should be the best years of your life. With better health and longevity, these best years should be many more in number than in previous generations. Perhaps there are no lectures, seminars, or CE courses to prepare for the day you are ready to wrap up your life as a professional, but here are some ideas that may help. When I finally decided to leave practice after 34 years, I made some interesting observations. Upon making the announcement to colleagues whom I had worked with for all those years, I heard two dissimilar

reactions. There were those who said, “What on earth are you going to do with yourself?” Then there were those who said, “You lucky dog.” While these remarks may appear puzzling to some, I immediately realized that our profession, and probably folks in all walks of life, produce two kinds of people: those who have hobbies and those who don’t. While that may be distilling the idea to a most basic form, it really makes sense. Life is filled with people who are ready and want retirement because they have things they want to do, and there are those who either don’t have things to do, or they can’t make it happen for one reason or another. There are those who spend their careers so engaged that it defines their very essence, while others use their work-life as a means to an end. There are those who go to every professional meeting, take on more than the

Robert Fleisher, DMD, graduated from Temple University School of Dental Medicine in 1974 and received his certificate in endodontics from the University of Pennsylvania in 1976. He taught at Temple University and the University of Pennsylvania and is now a member of the Affiliate Attending Staff — Albert Einstein Medical Center, Philadelphia, Department of Dental Medicine, Division of Endodontics, Philadelphia, Pennsylvania. Dr. Fleisher is the founding partner of Endodontics Limited, P.C., one of the larger endodontic practices in the United States. After retiring from practice, he now devotes his time to writing about practice management, aging, and health issues, and fiction with a medical bent. You can read about all of Dr. Fleisher’s methods to improve bedside manner in his book, Bedside Manner — How to Gain Your Patients’ Respect, Love & Loyalty, at www.bedsidemanner.info. Dr. Fleisher can be reached at: drfleisher@bedsidemanner.info.

Volume 7 Number 5

required CE, and attend conventions in every city. Their friends are all dentists, they talk dentistry, and they probably have a collection of dental figurines that they proudly display next to their primitive dental instruments (recently removed from use in their offices) that belong in the Smithsonian. These are the dentists who probably brush and floss 5 times a day. Others do the minimal amount to still be called a dentist, and they participate in almost nothing. Of course, there are those who balance their professional lives with their personal lives, trending a little bit toward one side or the other. Retirement is really all about balance. If you find yourself with no plans for a future without your profession, you didn’t maintain the proper balance. There is hope and remedy if you take the appropriate steps now. And now refers to the young set of endodontists who skipped over this article because, in their minds, the last thing they are thinking about is retiring. If you are ready to retire tomorrow, it may be a little late. The planning for retirement should begin in your residency program. While emphasizing the psychological aspects of retirement is a must, you can’t do all of the fun things you dream about if you Endodontic practice 49

PRACTICE DEVELOPMENT don’t have the funds to make your dreams come true. Some doctors live beyond their means, and that means they may never have enough to retire. Don’t let that happen to you. Most professionals are very much cognizant of the need to plan ahead. That’s how they became professionals in the first place. They made sacrifices in the early stages of life so that they could live better lives, and most have even considered a financial plan for retirement. If you are young now (and not skipping over this article), heed the warning to take appropriate steps to have an easy go at it in later life. I remember several endodontists over the years telling me how their plans for retirement were shattered as a result of one of the few, albeit inevitable, recessions that everyone has to experience. Market corrections and recessions can easily set your plans back by 10% to 50% when times are bad. These folks had to work several more years to get back to where they would feel comfortable retiring. While this is not a treatise on investing (though I have a good tip if you call me later), all the basic clichés about investing and finance do, in fact, apply. If you follow their intended meanings, you will be able to retire on time and in fashion: Don’t put all your eggs in one basket (Sancho Panza): Don’t invest in things you don’t understand (common sense): A fool and his money are soon parted (P.T. Barnum): A penny saved is a penny earned (Ben Franklin). OK, I don’t want thousands of calls, so here’s the tip: 80% of the investment professionals who spend every day of their lives studying markets and looking to invest your money don’t do as well as a fund that tracts the S&P 500. Consider an investment in the S&P as a bedrock. If you like to live on the edge, go for the fancy investments: Become a venture capitalist for everyone who knows you probably have a few bucks to fleece; listen to your friends when they offer up tips. The sad truth is that you will probably lose a great deal of your hard-earned money and work many more years than you expected if you aren’t prudent about investing carefully and saving money to retire. And remember, there are often unexpected consequences of retirement. You may suddenly miss all of those perks you wrote off as business expenses. If you worked for a practice that provided you with a car, gasoline, phone, and entertainment allowances for practice promotion and getaways, those benefits will vanish. You have to be prepared financially to retire well. Just as important as financial concerns are for retirement, your mind and soul 50 Endodontic practice

Heed the warning, plan ahead, and make sure that your life after work can be just as rewarding as it was during work. must be ready. The last thing you want to experience is cognitive dissonance (sure, cancer is really the last thing) at a time you are supposed to be looking forward to and enjoying so much life has to offer. What I learned from those conversations with my colleagues was that for many, they were not ready for a world beyond their professional life and not because of a deficiency of funds. The lack of psychological and emotional preparation for retirement results in boredom, dissatisfaction, and even depression when individuals spend their entire being defined by one and only one part of their life and that part of their life comes to an end with retirement. Find hobbies that interest you, now. Don’t wait for the day you retire to find things to do outside of dentistry. Not that you can’t wait until the last minute, but for a richer experience, it is best to anticipate with joy and look forward to this new life rather than finding a need to explore your interests after you retire. You can consider volunteering for church or civic groups, going to museums and lectures from your local colleges. Maybe even enroll in a college level course for something that interests you other than dentistry. Start your own charity or foundation. That is sure to keep you busy in a whole new endeavor. There are so many things out there, but often you find life is too busy to search out hobbies and interests while you are actively engaged in your profession. That is a mistake. You need to be well rounded (easily accomplished with the standard America diet). While it may not be easy to see at this stage of your busy life, it is imperative to find other interests before you make the transition to retirement. Become involved in organizations. Consider traveling to exotic lands and even simple places nearby that you never had time to explore. Consider mentoring young people as well as offering time to engage the elderly. For some, playing golf in the morning and bridge in the afternoon is all it takes. For others, a more meaningful existence is required. Only you can decide what works for you, but you really need to develop these skills and interests along the way to retirement. Having a passion for several things you

would like to devote your time to helps make leaving the workplace more comfortable emotionally. Anticipation of good things to come is a very strong antidepressant and can help you through the latter years of practice. Many people will ask you if you miss working. That has much to do with how much you liked your work. If you dreaded going to the office, you won’t miss it. If you really liked your profession, you will most certainly miss it. Many professionals ease their way out by working fewer and fewer hours until they leave from a part-time position. This approach often makes the transition easier for them. Others have to leave abruptly because of disability, and for them, the same rules apply — those who liked their work will miss it; those who hated their work won’t — but rather look at their disability as a blessing. In either case, those who are forced to leave practice without the option of slowing down will likely have a level of melancholy that can best be obscured by redefining themselves with new interests or even a new profession if their health allows. The last thing you want to do is to spend your golden years without any gold, without any interests and bored to death. You don’t want to awaken each day with nothing to look forward to. There are those who don’t plan financially, emotionally, or psychologically for a life after root canal, and they actually find that they have to go back to work to keep busy or to pay the bills. This is not the outcome you want to experience, especially after all of your hard work and dedication to become an endodontist, build a practice, and care for so many in need. You don’t want to crash and burn. Heed the warning, plan ahead, and make sure that your life after work can be just as rewarding as it was during work. It’s now time to go back to your usual fare of reading material. It’s time to peruse the catalog of the latest devices that you can incorporate into your practice. It’s time to take, yet another, CE course so you will be able to renew you dental license. Just don’t forget to make some time to plan for the day that you no longer have to, or want to renew that license. EP Volume 7 Number 5

STEP-BY-STEP

Endo-Eze® FIND™ Apex Locator

ccurate working-length determination has a profound influence on ideal canal preparation, microbial disinfection, and hermetic sealing of the root canal system. However, the location of the appropriate apical position has constituted a persistent challenge in clinical endodontics, largely because different opinions exist regarding the ideal apical limit of the root canal instrumentation and obturation. Radiographs have been commonly used to determine the working length. However, radiographic assessments of the working length may prove inaccurate, depending on the direction and the extent of the root curvature and the position of the apical foramen in association with the anatomic apex. By measuring the electrical properties of the apical part of the root canal, such as resistance and impedance, it should be possible to detect the canal terminus. The root canal system is surrounded by dentin and cementum, both insulators to electrical current. At the apical foramen, however, there is a small isolation interruption in which conductive materials within the canal space (tissue, fluid) are electrically connected to the periodontal ligament that is itself a conductor of electric current. Therefore, various electronic methods have been developed that use a variety of other principles to detect the canal terminus. While the simplest devices measure resistance, other devices measure impedance using high frequency or multiple frequencies.

Figure 1: Endo-Eze FIND apex locator unit

Endo-Eze® FIND™ Apex Locator Endo-Eze FIND (Figure 1) is a batteryoperated portable device designed for foramen localization, using a multifrequencydependent impedance method. With features like a full-color screen, compact design, fully automatic measurements, audio feedback with volume control, and automatic turn off, FIND caters to the user. It offers highly accurate apical foramen localization in wet and dry canals, and it displays numerical values to indicate the file progression, making it easy to identify the position of the foramen and any time the file extends beyond the foramen.

Operative step-by-step sequence • Turn on the device. • Ensure that the measuring cable is Volume 7 Number 5

properly connected. The cable symbol should appear after the connection is made (Figure 2). • Before placing the instrument inside the canal: ✓✓ Perform contact between the electrodes (file clip and lip clip). The “connection test” symbol should appear on the status bar of the display, indicating proper connection (Figure 2). ✓✓ After access, verify that the tooth is well isolated and that there are no metal restorations projecting into the canal entrances. Metal restorations divert the circuit, diminish impedance, and give a false-positive result.

Figure 2: Connection symbols cable connected

connection test

Endodontic practice 51

STEP-BY-STEP ✓✓ A partial pulpectomy before electronic measurements should be performed. This must be limited to approximately 5 mm short of the tooth length on the X-ray image (Figure 3). ✓✓ Place the lip clip in the corner of the patient’s mouth. ✓✓ It is important that the canal contain an irrigation solution; the pulp chamber should not contain an excess of it.

incisal reference point and subtracting 1 millimeter (or 0.5 mm) of the pointed measurement using an endodontic ruler.

Precautions during electronic measurements

Figure 4: Endo-Eze FIND display showing the position of the file at the last millimeters of the apical third

Figure 3: Partial pulpectomy before measurement

• The endodontic instrument selected to explore the undebrided apical portion of the canal, and the associated electronic working length, must be 5 mm longer than the temporary working length, which was measured on the initial radiograph. This is due to the need for available space to place the file clip between the rubber stop and the instrument handle. • Insert the selected instrument to the temporary working length. Ensure that the tip of the instrument is in contact with the internal walls. Very thin instruments may give a false-positive result. Use instruments of a diameter close to the anatomic diameter. • Connect the file clip to the file. The EndoEze FIND will automatically detect that root canal measurement has started. If the electrical contact is good, and the conductivity of the root canal is sufficient, the file icon inside the small tooth image will stop blinking, and a double-beep audio signal will sound. • Introduce the file apically in the direction of the apical foramen, turning it gently in a clockwise direction, perceiving the start of movement on the monitor. The monitor of Endo-Eze FIND is shown in Figures 4 to 6. • When coming closer to the final reading, an intermittent alarm sounds. Continue with the instrument in an apical direction until the alarm sound is continuous, which will place the readout in the position of the foramen exit (0.0). 52 Endodontic practice

Figure 5: Endo-Eze FIND showing the position of the file at the last millimeters of the apical third

Figure 6: Endo-Eze FIND showing the position of the file at the apical foramen

• At this time, the operator must proceed to mark the working length, sliding the rubber stop to the chosen occlusal or

Some points must be observed during electronic measuring, irrespective of the model used: ✓✓ Acquire a reliable diagnostic radiograph, preferably with the parallel technique, using an XCP System locator (in which the cone is lined up with a ring outside the mouth of the patient, while biting down on the X-ray holder). The real temporary working length, measured from a proper initial radiograph normally differs from 0% to 15% from the definitive working length measurement. ✓✓ In case of vital pulp, perform a partial pulpectomy removing at least twothirds of the pulp tissue volume. Clinically, it has been noticed that in cases of irreversible pulpitis, placement of an instrument in the cervical third can result in a measurement that indicates a point close to the foramen. When partially removing tissues, abundant irrigation followed by aspirating excess fluid helps the measurement return to normal. ✓✓ The number of the instrument used for measurement must match the anatomic diameter of the canal. Larger-size instruments will not reach the apical third. Thin instruments make apical placement and reading difficult, due to the lack of control over penetration. ✓✓ The electrodes (file clip and lip clips) must be free of oxidation products, which may have developed as a result of contact with irrigation solutions. ✓✓ The irrigation solution in the root canal cannot be beyond the canal entrance(s). The canals must be moist when measurements are made, preferably using a sodium hypochlorite solution. ✓✓ When the bar indicator on the display screen starts to oscillate up and down, remove the instrument from the canal. Irrigate, aspirate excess irrigation solution, and start the procedure again. Verify that the tip of the file is well adapted to the dentin walls. Verify the presence of contact between the file and metal restorations (if present). Verify the presence of excess pulp tissue in case of an irreversible inflamed pulp. Verify that the battery is fully charged. EP This information was provided by Ultradent.

Volume 7 Number 5

simplifying

INTRODUCTING

endodontics

UNSURPASSED ACCURACY UNRIVALED RELIABILITY 1

FILE AT FORAMEN

SIMPLIFY YOUR ENDODONTIC TREATMENTS Endo-Eze FIND apex locator helps you avoid overinstrumentation by providing accurate and reliable measurements to help notify you when you’ve reached the ideal working length.

800.552.5512 ultradent.com

ENDOSPECTIVE

The endodontic canal space: not the place to “horse” around Dr. Rich Mounce discusses strategies for negotiating canals and achieving apical patency

chieving and maintaining apical patency are at the heart of all cleaning and shaping strategies, as optimal microbial disinfection and three-dimensional obturation are only possible when patency has been obtained. A lack of patency predisposes the procedure to clinical failure due to microbes and tissue left in the canal, in addition to a myriad of potential clinical iatrogenic misadventures. This column was written to discuss principle-driven clinically effective strategies for negotiating canals and achieving apical patency. Among other goals of canal preparation, it is desirable to keep the canal at its original position and to keep the apical foramen at its original position and size. Achieving these goals requires effective and safe use of stainless steel hand files (SSHF) to gain apical patency. Effective canal negotiation and achievement of apical patency are the precursor to glide path preparation. An excellent glide path makes nickel titanium (NT) canal preparation safer. Without an adequate glide path, clinicians must “horse” (force) their NT instruments to gain length rather than allowing the NT file to flow down the canal. Such force is antithetical to safe and effective canal shaping with NT files. Tactile control of SSHF requires straightline access, removal of the cervical dentinal triangle, and shaping the coronal third with orifice openers prior to apical negotiation. In my hands, after the preceding steps, a new SSHF is used for every insertion into the canal, for any purpose, every time. Said differently, after sterilization, SSHF is used for one single insertion, into one

Rich Mounce, DDS, is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, an endodontic supply company also based in Rapid City (605-791-7000). Dr. Mounce can be reached at RichardMounce@MounceEndo. com, MounceEndo.com. Twitter: @MounceEndo. Dr. Mounce has a commercial interest in MounceFiles and is a Mani dealer.

54 Endodontic practice

Clinical case treated using Mani K files and MounceFiles with Controlled Memory applied with the concepts discussed in the article

canal, and then discarded, and a new SSHF is subsequently inserted. Using a new SSHF for every insertion saves time and money as tactile control and efficiency are improved along with reduced iatrogenic misadventure. While a description of every type of hand file used for canal negotiation is beyond the scope of this column, suffice it to say that I use a No. 6 Mani K file as the first hand file into every canal, regardless of the canal diameter. Assuming that the No. 6 provides apical patency, I can quickly move to a No. 8 SSHF (regardless of the type of hand file required). If a No. 8 or No. 10 SSHF is inserted first (in lieu of a No. 6 K file), and these will not advance easily, and/or the canal is not negotiable, the clinician will never know if a No. 6 might have negotiated the canal and/or if the No. 8 or No. 10 SSHF blocked the canal. For curved and calcified canals, I use Mani D Finders, as they are much stiffer than K files or triangular (more flexible) SSHF. Insertion is passive, yet intentional. Attention must be paid to the resistance to advancement of the file. If the clinician feels as though he/she is pushing the file into a sponge, generally, there is more negotiable canal to be explored. If the file hits a hard wall and bounces off, either the canal is blocked (and/or possibly transported), or the canal

Mani D Finders

makes an acute curvature away from the main canal. Attenuating the direction and pressure of insertion is essential as too much pressure can cause the creation of a false pathway that ultimately leads to perforation. Too little pressure can leave the clinician without enough power to break through a blockage in an otherwise negotiable canal. All canals are curved to one degree or another; all SSHF used to negotiate canals should also be curved to one degree or another as well. Customizing SSHF curvature is an art, and, in general terms, the more acute the canal curvature, the more acute the curve that must be put on the SSHF. Canals can be curved with cotton pliers or Endo-Bender® pliers (SybronEndo), or both, depending on the particular canal requirements. Many curved and calcified canals will require multiple insertions to gain length. Once apical patency is obtained, canals can be efficiently and safely enlarged using a reciprocating handpiece like the NSK ER-10. This column has discussed several nuances of using stainless steel hand files to negotiate curved and calcified canals. Emphasis has been placed on choosing the right-sized file for the task, pre-curving, and carefully interpreting the tactile feedback the canal is providing. I welcome your feedback. EP Volume 7 Number 5

INDUSTRY NEWS DEXIS® digital X-ray system, now in place at the Noor Foundation Dental Clinic, is helping to meet the growing needs of the uninsured in San Luis Obispo. DEXIS® has donated a DEXIS Platinum intraoral digital sensor, DEXIS Imaging Suite, and related image management software to the Noor Foundation’s Dental Clinic, a volunteer-based, nonprofit organization that provides free dental services for those in its community who might otherwise go without care. DEXIS provided the Noor Foundation’s charity clinic with robust digital imaging hardware and software. This donation allows the clinic to operate with leading technology that can help the volunteer healthcare providers improve and streamline patient care. DEXIS is an industry leader in developing high-quality digital imaging solutions for the dental community. Since its introduction to the United States in 1997, DEXIS has become the most highly awarded intraoral digital X-ray system with numerous awards from dental researchers and well-respected dental publications. The company has a strong history of supporting national and international outreach programs, including Give Kids A Smile®, TeamSmile®, and Mission of Mercy®. For more information about DEXIS, visit www.dexis.com. The SLO Noor Foundation was established in December of 2009 as a 501(c)3 to provide free, high-quality acute, nonemergent healthcare to those who could not otherwise afford to access care in San Luis Obispo County. It is the mission of the SLO Noor Foundation to provide the underserved and disadvantaged of SLO County with the free access to quality acute, non-emergent care they deserve regardless of race, ethnicity, religion, immigration, or socioeconomic status. Learn more at www.slonoorfoundation.org.

Chicago-area dental equipment company builds education/sales center Planmeca USA has opened the University of Planmeca, a new multipurpose facility adjacent to its main North American plant in northwest suburban Roselle, Illinois.The University of Planmeca is a unique 10,000-square-foot space that features room for 60 students in a Wi-Fi setting complete with comprehensive audiovisual capabilities for virtually any classroom setting. The space is ideal for clinicians, dealers sales representatives, study clubs, and dental associations to hold their regular meetings and receive training on Planmeca imaging units. In addition to product

56 Endodontic practice

demonstrations, the location offers to host educational programs or develop customized training courses on issues pertinent to dental imaging professionals. The showroom portion of the facility includes five operatories highlighting different imaging equipment, each with a unique specialty focus. Dentists interested in making an appointment to see the facility can do so by contacting their local sales rep at www.planmecausa.com/na/how-to-buy Planmeca is the largest privately held company in the dental equipment market and the third-largest company in the field. With a North American office located in Roselle, Illinois, and international headquarters in Helsinki, Finland, Planmeca is well-established in high-tech dental markets worldwide and has considerable market share in the United States, Japan, and several European countries. Planmeca’s dental product line includes dental X-ray equipment, dental digital imaging and software applications, dental care units and equipment, and dental cabinetry and furniture. For more information, visit www.planmecausa or Facebook at www.facebook.com/PlanmecaUSA.

Ultradent holds 2014 Annual Summit Ultradent Products, Inc., held its 2014 Ultradent Summit continuing education event on August 1–2, 2014, at its South Jordan campus. The Summit featured an all-star lineup of speakers who covered topics such as esthetics and technological advances in dentistry and a hands-on practicum in endodontics, composite veneers, and a course on becoming a tooth-whitening specialist. The 122 attending clinicians and staff members earned up to 16 CE credit hours during the two-day event. The event kicked off with a seminar from Dr. Dan Fischer, who presented his lecture “Close to Home: What Expert Marriage Advice Can Teach Us About Creating Quality, Long-Lasting Dentistry.” After lunch, doctors and staff participated in a seminar given by Ultradent’s director of research and development, Neil Jessop, titled, “The Relationship Between Conservative Dentistry and Bond Strengths.” The evening ended with a dinner hosted by Dr. and Mrs. Fischer at their home. Day 2 of the Ultradent Summit began with a lecture from Dr. Renato Leonardo titled, “Technological Resources and Biological Concepts in Minimally Invasive Dentistry.” Later, Dr. Hal Stewart presented his lecture “Minimally Invasive Direct Veneers and Composites,” followed by the concluding seminar by Shannon Pace Brinker, “Becoming a Whitening Specialist.” The Ultradent Summit events ended with a steak dinner, bonding awards, prizes, and networking. For registration, pricing, and information on next year’s event, please call 800-552-5512. Ultradent Products, Inc., is a leading developer and manufacturer of high-tech dental materials, devices, and instruments worldwide. Ultradent’s vision is to improve oral health globally. Ultradent even works to improve the quality of life and health of individuals through financial and charitable programs. For more information about Ultradent, visit ultradent.com.

Volume 7 Number 5

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

THE WAIT IS OVER

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

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

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