Endodontic Practice US - November/December 2014 Issue - Vol7.6

November/December 2014 – Vol 7 No 6

PROMOTING

EXCELLENCE

IN

ENDODONTICS

The rationale for the suggested use of fiber post segments in composite core buildups for endodontically treated teeth

GentleWave™: Root canals cleaned at the speed of sound

ProGlider™: clinical protocol

Technology — the revolution of evolution

Drs. Leendert Boksman and Gary Glassman

Dr. Peet J. van der Vyver

SO SOPHISTICATED IT’S SIMPLE.™

clinical articles • management advice • practice profiles • technology reviews

Dr. Rich Mounce

Dr. Eric Herbranson

Practice profile Dr. Brett E. Gilbert

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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Michelle Manning Email: michelle@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORD. | Jacqueline Baker Email: jbaker@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.endopracticeus.com

A new era in root canal instrumentation and obturation For years, endodontic practitioners were trained to compact gutta percha laterally and/or vertically in order to reduce the sealer interface between the gutta percha and the root canal wall. This was driven by the significant deficiencies in the clinical and biological properties of the historical root canal sealers (e.g., ZOE and resinbased sealers). As a result, the concept of reducing the sealer interface became axiomatic to our profession, and over the past 50 years, the idea of gutta-percha compaction became the core belief of endodontic obturation theory. While practitioners improved compaction techniques over the years (and achieved good clinical outcomes), we must recognize the price that was paid for pursuing Allen Ali Nasseh, DDS, MMSc this theory. Both lateral and vertical compaction techniques have had the unintended consequence of removing important tooth structure in the coronal aspect of the root canal. This greater taper is far more than is required for canal disinfection and is merely directed at accommodating obturation requirements.

These requirements have been, first and foremost, the fitting of pluggers, spreaders, and thermoplastic carriers to the apical one-third of roots.

It’s important to understand, however, that the removal of this critical tooth structure in the coronal portion of the root has negative consequences. Thinning of coronal root dentin decreases a tooth’s fracture resistance, while the additional instrumentation and complex obturation routines decrease the efficiency of the procedure as a whole.

When bioceramic cements were first introduced to our field (MTA, Dentsply Tulsa) and later with the introduction of the second-generation bioceramics like the EndoSequence® BC Sealer™, Root Repair Material (RRM™), and Fast Set Putty (Brasseler USA®), this obturation picture began to change. This change has been driven by the recognition of the superior material properties of bioceramics over all previous generations of root canal cements and sealers. The concept of having a sealer that could act as a filler challenges the original basis of our theories of reducing the sealer interface leading to multiple innovations based on sealer-based obturation.

Furthermore, the second generation of premixed nano-particulate bioceramic compounds such as the EndoSequence bioceramic sealers and cements (Brasseler USA) no longer exhibited the large particle size, clinical handling difficulties, and staining limitations of the first generation MTA materials (both in non-surgical and surgical endodontic applications). Newer techniques are now being developed that allow us to redefine the historical axiom of “limiting the sealer interface” and that will guide us into a new era of endodontic therapy. This new era promises not only biologically based sealers and cements that improve case outcomes, but more efficient and predictable techniques that make saving teeth a more appealing option to patients everywhere. If the promise of bioceramic cements and the fundamental biological advantages they exhibit remains valid, endodontics as a field, and endodontic practitioners as a group, will see dramatic changes in the way root canal instrumentation and obturation evolves in the foreseeable future.

Allen Ali Nasseh, DDS, MMSc President and CEO RealWorldEndo®

www.medmarkaz.com

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© FMC 2014. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

Volume 7 Number 6

Allen Ali Nasseh, DDS, MMSc, received his dental degree from Northwestern University Dental School in 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 RealWorldEndo® (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 on surgical and non-surgical endodontic topics. Dr. Nasseh is in solo private practice (msendo.com) in downtown Boston, Massachusetts.

Endodontic practice 1

INTRODUCTION

November/December 2014 - Volume 7 Number 6

TABLE OF CONTENTS

Practice profile Brett E. Gilbert, DDS

6

Combining clinical excellence and compassion

Case study

Easy endodontics Case studies from Drs. Godfrey Cutts and James Prichard take a look at how ultrasonic technology is simplifying endodontics....................17

Endodontic insight Simplifying endodontics: a single cone obturation technique using EndoREZ速

Dr. Carlos A. S. Ramos discusses his technique for an effective seal...........21

Restorative endodontics: a new biologically based standard of care Dr. Dennis G. Brave discusses minimally invasive techniques and advanced material science.............. 24

Case study

A combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material

12

Dr. Allen Ali Nasseh illustrates a case report for non-surgical root canal treatment and the surgical repair of an extensive external root resorption defect

ON THE COVER Cover photo courtesy of Dr. Peet J. van der Vyver.

Article begins on page 42.

2 Endodontic practice

Volume 7 Number 6

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.

1. Data on file. ©2014 Ultradent Products, Inc. All Rights Reserved.

800.552.5512 ultradent.com

TABLE OF CONTENTS Industry news ..............26 Research

The effect of iodine-containing materials on the bonding strength of AH 26® A study by Drs. Elya Bartanovsky, David Keinan, Joshua Moshonov, and Michael Solomonov encourages caution in the use of iodine-containing material, especially before obturation with sealer based on epoxy resin .......................................................27

Continuing education

42

Technology

ProGlider™: clinical protocol Using clinical case reports, Dr. Peet J. van der Vyver outlines the clinical protocol for the use of the ProGlider™, a single file glide path rotary instrument to facilitate glide path enlargement before canal preparation

Technology — the revolution of evolution Dr. Eric Herbranson reflects on technologies that have changed the practice of endodontics...................32

Step-by-step

Using a dental operating microscope Dr. Antony Esprey explains why he has integrated the dental operating microscope into his practice, the benefits it has provided, the learning process, and the decisions that influenced his choice.......................30

AAE news .........................35

GentleWave™: Root canals cleaned at the speed of sound Dr. Rich Mounce reviews the steps to using the GentleWave™ System ...................................................... 50

Endospective

Implants for the endodontist: to place or not to place?

Dr. Rich Mounce shares his evolving view on implants..............................54

Materials & Continuing education Practice management equipment ........................56 The rationale for the suggested use of fiber post segments in composite core buildups for endodontically treated teeth Drs. Leendert Boksman and Gary Glassman discuss the choices and challenges involved in certain restorations......................................36

4 Endodontic practice

Effortless, fun, and profitable endodontics In part 2 of his series, Dr. Ace Goerig suggests ways to reduce stress in the practice..........................................52

Volume 7 Number 6

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PRACTICE PROFILE

Brett E. Gilbert, DDS Combining clinical excellence and compassion

Dr. Gilbert notes, “Technology helps us in every aspect of our clinical treatment.�

6 Endodontic practice

What can you tell us about your background?

When did you become a specialist and why?

I was born and raised in Baltimore, Maryland. I attended college, dental school, and my postgraduate endodontic residency at the University of Maryland. I moved to the Chicago area in 2003 to pursue my career and life in a city that drew me in with its vast culture and beauty. I practice full time, and I am also a faculty member in the Department of Endodontics at the University of Illinois College of Dentistry. I lecture nationally and internationally on clinical endodontics and present hands-on courses in association with Axis/SybronEndo. I am a Diplomate of the American Board of Endodontics.

As a first-year dental student, I found myself wondering if wearing the many hats of a general dentist suited me. As the son of a successful general dentist, I was able to spend time with many specialists in our area. It was at the office of Dr. Barry Jurist, an endodontist, that I found my calling. I was enamored by the digital radiographs, microscopes, and rotary instruments. I was thunderstruck by the potential of the field.

I was fortunate to be accepted into the Department of Endodontics at the University of Maryland immediately after graduation from dental school.

Volume 7 Number 6

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™

© 2014. All rights reserved.

sonendo.com

PRACTICE PROFILE

Dr. Gilbert’s dedicated staff is committed to patient comfort and care

Is your practice limited solely to endodontics?

My practice is solely limited to endodontics. It was started in 1982 by Dr. Kevin King and has served the northwest side of Chicago for over 30 years. We have six operatories and an experienced and dedicated team of staff members. Located in Niles, Illinois, 20 minutes north of downtown Chicago, Dr. Hammad Khan and I practice together, offering appointments and emergency care 6 days a week.

Your practice is limited solely to endodontics; why did you decide to focus in that area?

At first, the technology grabbed my attention. The advances in technology over the past 20 years have allowed our specialty to grow in efficiency and safety. I found the study of the dental pulp and its myriad of complexities very interesting and challenging. I also recognized how endodontic practice allows you to use your empathy and compassion to foster a sense of calm and reassurance in our patients.

Do your patients come through referrals?

Yes, my practice is a referral-based practice. The great majority of patients visit us based on a direct referral from their general dentist. Others may be referred by a family member, friend, or colleague who has been our patient in the past.

How long have you been practicing endodontics, and what systems do you use?

I have been in private practice limited to 8 Endodontic practice

endodontics for 11 years. I have tried many systems over Dr. Hammad A. Khan and Dr. Brett E. Gilbert the years to help improve Who has inspired you? the efficiency and safety of my treatments.

Three doctors have had a profound I currently use TF™ Adaptive System files, effect on me and serve as my role models. the Apex ID apex locator, and the Elements My father, Michael, was my inspiration to Obturation Unit™ (Axis/SybronEndo). As pursue dentistry and to understand how ultrasonic tips have always been an extremely a doctor can successfully run a business. important part of my ability to locate and clean Two of my inspirations are no longer with us pulpal anatomy, the new tün® ultrasonic tips today. My great uncle, Dr. Joshua Breschkin, (Engineered Endodontics) have been a highan optometrist for 56 years, was a model on performing addition to my armamentarium. In how to be a passionate, precise, and caring an effort to maximize my irrigation efforts, the doctor. Dr. Thom Dumsha, my mentor, was Irrisafe™ tip (Satelec/Acteon) is an easy and a brilliant and logical thinker. He was a model effective way to perform ultrasonic activated on how to be genuine, caring, and to remain irrigation. We are fortunate to have so many who you are once you have attained a high well-engineered and designed instruments to level of success and respect in your field. He help us provide the best possible root canal is a person I always try to emulate. treatment to our patients.

What training have you undertaken?

After my 2-year endodontic residency, I have pursued a passion for continued learning. Much of this comes from my love of teaching. As part of the faculty at the College of Dentistry, University of Illinois at Chicago, I have had the opportunity to work with the postgraduate endodontic residents for over 10 years. I also have been lecturing and presenting hands-on courses around the country and world since 2008. These teaching opportunities create a great learning environment for me as I am constantly re-evaluating technique, philosophy, and literature. I am able to present didactic and clinical instruction based on the ever-increasing evidencebased knowledge gained from the many brilliant research projects being carried out across the world.

What is the most satisfying aspect of your practice?

The ability to create an environment in my office in which patients feel comfortable is very satisfying. My staff and I work extremely hard to be sure each patient’s personal needs and concerns are addressed. There is no more rewarding feeling than to walk into the room to a very anxious patient, and then an hour later, he/she walks out saying how easy the procedures and experience were. This is the measure of success in our practice, and my staff is an integral part in this pursuit.

Professionally, what are you most proud of?

I am most proud of achieving board certification from the American Board of Endodontics. I am also proud that I have Volume 7 Number 6

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PRACTICE PROFILE been able to develop a 2-day endodontic training course for general dentists. This course is designed to provide an immersion experience into endodontics for practicing dentists. I recognized the lack of continuing education opportunities for general dentists to gain clinical knowledge and hands-on skills. It is my goal to provide a clinical course that includes live patient treatment demonstrations to allow the skills learned to be translated directly back to their own offices.

What do you think is unique about your practice?

The level of compassion and care we show to our patients is what I believe allows us to be successful. This approach is one I shared with Dr. Kevin King, now retired, and with Dr. Hammad Khan, my associate. Our staff is experienced, caring, and dedicated to our patient care from the time they call our office for an appointment until their treatment follow-ups are complete.

What has been your biggest challenge?

I feel successful endodontic practice is achieved when you are able to merge the highest level of clinical excellence with a passion for creating a positive and caring experience for patients. This is a challenging goal our team pursues each and every day in our office.

Top 10 List International presentation on retreatment at the AEEDC meeting in Dubai, UAE in 2012

regenerative techniques that we are able to provide to our patients to improve their oral health. The potential for further development in this area of endodontics is incredible.

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

The honest answer is that I have no idea!

I can only remember wanting to be a dentist since I was a small child. It is a great feeling to have been able to achieve this goal.

Successfully communicating and educating patients on the cause of their endodontic disease and the treatments we provide to resolve them are critical to success. When patients give consent for treatment, they should feel completely comfortable that they have had any and all questions and concerns addressed by their doctor. Being able to then communicate the findings and treatment summary to referring dentists is another area of communication critical to success.

What is the future of endodontics and dentistry?

What advice would you give to budding endodontists?

I believe that the future is bright for the dental industry and for endodontics. We continue to strive to improve our armamentarium, techniques, and education to be able to provide patients with an opportunity to save their natural dentitions. The future of endodontics will continue to see an improvement in success rates as we develop better ways to cleanse root canal systems. I am excited about the advances demonstrated in the literature regarding our ability to irrigate root canal systems. The potential for greater success is tremendous by use of waves of energy propagated through our irrigating solutions. Our advances in regenerative endodontics are cutting-edge science.

As endodontists, we are at the forefront of

The most important advice I would give is to be kind to yourself. The only way to attain excellent skills is to learn from your mistakes and procedural errors. As an inexperienced endodontist, you may have incidents and occurrences that will keep you up at night.

My sincere advice is to be kind to yourself, learn from the error, and don’t beat yourself up! You must recognize that even the most experienced endodontist will have a procedural error occur at times. Communication skills must be an ever-evolving skill set.

Recognizing that your ability to communicate with patients, referring dentists, and your staff in an effective way will alleviate pressures and allow you to relax even in the most stressful situations.

What would you have been if you didn’t become a dentist?

10 Endodontic practice

(memorable life and career moments in chronological order) 1. Graduation from the University of Maryland School of Dentistry (magna cum laude) 2. Earning my Certificate in Endodontics from the University of Maryland Dental School 3. Being appointed to the faculty of the Department of Endodontics at UIC 4. Our wedding 5. The birth of our two daughters 6. Being elected President of Illinois Association of Endodontists 7. Lecturing in Dubai at the AEEDC 2012 meeting 8. Achieving board certification from the American Board of Endodontics 9. Being elected President of the NW Side Branch of the Chicago Dental Society 10. Owning my own endodontic practice Website: www.kingendo.com Twitter: @bgilbertdds

What are your hobbies, and what do you do in your spare time?

My family comes first in regards to spare time. With two daughters ages 5 and 7, my free time is simply their time! Exercise is a great stress reliever in my life and a way to stay in shape. I am a passionate Baltimore Ravens fan, and my wife, Kari, and I love to travel. With downtown Chicago just a 30-minute ride away, we have a great deal of fun spending time in the city. Life is good! EP Volume 7 Number 6

CASE STUDY

A combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material Dr. Allen Ali Nasseh illustrates a case report for non-surgical root canal treatment and the surgical repair of an extensive external root resorption defect Introduction The applications of bioceramic compounds in endodontic therapy range all the way from their non-surgical use as a root canal sealer, a pulp capping agent, and a perforation repair material to their surgical applications for root repair and apiecoectomy procedures. The first bioceramic compound introduced, MTA (DENTSPLY Tulsa), was derived from Portland cement and has proven to be a valuable root repair material for surgical applications.1-3 More recently, medically pure nano-particulate bioceramic formulations (that have been engineered from the ground up) have improved on some notable shortcomings of MTA by addressing the clinical handling challenges associated with this first-generation material.4-15 In addition, the removal of heavy metals that can cause tooth staining in MTA-repaired cases has also been addressed with these newer second-generation formulations.

This new family of compounds, known as EndoSequence® BC Sealer™, Root Repair Material (RRM™), and Fast Set Putty (Brasseler USA®), has shown significant clinical handling advantages over MTA for both non-surgical and surgical applications. Due to their nano-particulate size and

Allen Ali Nasseh, DDS, MMSc, received his dental degree from Northwestern University Dental School in 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 on surgical and nonsurgical endodontic topics. Dr. Nasseh is in solo private practice (msendo.com) in downtown Boston, Massachusetts.

12 Endodontic practice

viscosity, these materials can now be used as a sealer and/or filler for root canal obturation, as well as for the surgical repair of root defects and apicoectomies.

This clinical case report demonstrates the use of EndoSequence bioceramic formulations for both the non-surgical root canal treatment and the surgical repair of an extensive external root resorption defect in a single central incisor.

Case report A 26-year-old female presented with a chief complaint of discomfort and swelling around her front tooth (Figure 1). She explained that she was seeking a third opinion after being told twice that tooth No. 9 was not salvageable and had to be extracted. Clinical testing and evaluation revealed erythematous gingival tissues on the buccal aspect of tooth No. 9 with deep probing (+6 mm

Figure 1: Radiograph of tooth No. 9 shows extensive root resorption in the mid-root region Volume 7 Number 6

CASE STUDY with BOP on the buccal and normal probing on the lingual). Testing also revealed that all anterior teeth were within normal limits to thermal and percussion test except for tooth No. 9, which was positive to percussion with severe and lingering response to cold. Upon radiographic examination, tooth No. 9 was diagnosed with extensive external root resorption. A history of protracted orthodontic therapy 10 years ago was noted in the patient’s dental history. A pulpal diagnosis of symptomatic irreversible pulpitis was made, and the prognosis, given the large extent of the resorptive defect, was deemed guarded to questionable at best. Extraction

was deemed the most predictable option.

The patient, however, was very motivated and wanted to attempt to save her tooth despite the guarded prognosis.

The non-surgical endodontic therapy was completed in a single visit using a combination of EndoSequence Root Repair Material (RRM) Putty in a barrier technique and EndoSequence Root Repair Material (RRM) syringeable formulation (Brasseler USA) to fill the entire canal in the following manner.

Following cleaning and shaping to a size 70/.04 EndoSequence File (Brasseler USA), the tooth was further disinfected with fullstrength (7%) sodium hypochlorite. This

was accomplished by using a negative irrigation system (EndoVacÂŽ MacroCannula) (SybronEndo) and a Forza V3 ultrasonic unit with an E11 tip/size 20 U-blade insert (Brasseler USA). Thereafter, a size 70/.04 EndoSequence BC gutta-percha cone (Brasseler USA) was fitted to the apex with tug back. The cone was then trimmed with a scalpel blade so that it would fit 4 mm short of the apex. A 4-mm plug of EndoSequence BC Putty was then condensed to the apex using the fitted cone so that a 4-mm plug of putty filled the apex, creating a barrier (Figure 2). The apical barrier technique has been described previously.16,17

Figure 2: An apical barrier of EndoSequence bioceramic RRM putty was condensed down at the apex prior to back filling the rest of the canal with EndoSequence RRM syringeable bioceramic material

Figure 3: The access was restored with Fuji IX after backfilling the root canal with EndoSequence RRM syringeable bioceramic material

Figure 4: During the surgical visit, a sinus tract was noted on the buccal gingiva

Figure 5: After raising a full thickness mucoperiosteal flap, a large resorptive defect was noted on the distobuccal aspect of the root of tooth No. 9

14 Endodontic practice

Volume 7 Number 6

the buccal aspect of the tooth presurgically (Figure 4). A large external resorption defect was noted on the buccal aspect of the root after a full thickness intrasulcular flap was raised (Figure 5). Using a high-speed round bur and copious amounts of water, the defect was prepared, and all visible resorptive soft tissue in the root was drilled out until the root canal was reached, exposing the set EndoSequence RRM material inside the root canal (Figure 6). Once all the soft tissue was

removed, the remaining preparation and the exposed root surfaces were conditioned with citric acid. The remaining root defect was then repaired with an equivalent amount of bioceramic putty trying to keep the natural curvature of the root (Figure 7), and the flap was sutured closed.

The immediate postoperative radiographs show the extent of the root repair with the putty in this tooth (Figure 8). Following normal postoperative healing, the patient

Figure 6: Using a high-speed round bur and copious amounts of water, the defect was prepared, and all visible resorptive soft tissue in the root was drilled out until the root canal was reached, exposing the set EndoSequence RRM material inside the non-surgically filled root canal

Figure 7: After removal of the resorptive cells in the defect, the cavity was restored with the EndoSequence RRM putty material. The material was manipulated gently to the shape of the original root structure

Figure 8: The immediate suture placement and postoperative radiograph show the extent of defect after it was filled with the bioceramic RRM putty Volume 7 Number 6

Endodontic practice 15

CASE STUDY

The cone was then removed, and the entire remaining canal was filled with syringeable BC-RRM. The access was restored with Fuji IX (Figure 3). The patient was rescheduled for surgical repair of the external defect 2 weeks later. The surgical appointment was not scheduled concurrently in order to allow time for the intraradicular cement to set and to evaluate patient response.

The patient returned for the surgical root repair visit, and a sinus tract was noted on

CASE STUDY

Figure 9: Six months and 2-year recall visits show excellent esthetics and bony healing in the area with reattachment and no dentinal staining

was evaluated at 6 months and 2 years, where the gingival tissue was observed to be fully healed, and probing was found to be within normal limits (Figure 9). At this point, the surgical repair procedure was deemed successful. The postoperative esthetics were completely acceptable to the patient, and no tooth staining was noted as a result of the material used to repair this tooth internally or externally.

Conclusion Extensive external root resorption and other aggressive forms of cervical root resorption are challenging when they cause significant root damage. These lesions can sometimes be monitored requiring no intervention at all. However, when endo-perio involvement results in pulpitis, and later infection of the resorption defect, extraction of the tooth or surgical repair of the root

In cases where direct surgical access with good visualization of the defect can be achieved, the use of modern bioceramic formulations ... may be an excellent clinical choice. are the only viable options. In cases where direct surgical access with good visualization of the defect can be achieved, the use of

modern bioceramic formulations (which are easy to apply to the site and have demonstrated excellent biocompatibility, bonding, and hydrophilic qualities) may be an excellent clinical choice. In this clinical case, the use of nano-particulate premixed bioceramic formulations, both EndoSequence syringeable BC Root Repair Material (RRM) and putty were demonstrated. Long-term follow-up of the healing of the gingival tissues and acceptable esthetics were achieved in a tooth that was otherwise deemed unsalvageable. The ease of clinical handling during surgery and a lack of dentin staining were noted. Further studies in this area are warranted in order to explore the true potential of this family of compounds in root repair applications, as well as all other aspects of endodontic therapy, where direct contact between biological tissues and biocompatible repair material is essential to success. EP

REFERENCES 1. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review — Part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27.

2. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review — Part II: leakage and biocompatibility investigations. J Endod. 2010;36(2):190-202.

3. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review —Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413.

4. Zhang W, Li Z, Peng B. Ex vivo cytotoxicity of a new calcium silicate-based canal filling material. Int Endod J. 2010;43(9):769-774.

5. Ma J, Shen Y, Stojicic S, Haapasalo M. Biocompatibility of two novel root repair materials. J Endod. 2011;37(6):793-798.

6. Alanezi AZ, Jiang J, Safavi KE, Spangberg LS, Zhu Q. Cytotoxicity evaluation of EndoSequence root repair material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(3):e122-125.

7. Ciasca M, Aminoshariae A, Jin G, Montagnese T, Mickel A. A comparison of the cytotoxicity and proinflammatory cytokine production of EndoSequence root repair material and ProRoot mineral trioxide aggregate in human osteoblast cell culture using reverse-transcriptase polymerase chain reaction. J Endod. 2012;38(4):486-489.

8. Alanezi AZ, Jiang J, Safavi KE, Spangberg LS, Zhu Q. Cytotoxicity evaluation of EndoSequence root repair material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(3):e122-125.

9. Hirschman WR, Wheater MA, Bringas JS, Hoen MM. Cytotoxicity comparison of three current direct pulp-capping agents with a new bioceramic root repair putty. J Endod. 2012;38(3):385-388.

10. Zhang S, Yang X, Fan M. BioAggregate and iRoot BP Plus optimizes the proliferation and mineralization ability of human dental pulp cells. Int Endod J. 2013;46(10):923-929.

11. Zhang W, Li Z, Peng B. Effects of iRootSP on mineralization-related genes expression in MG63 cells. J Endod. 2010;36(12):1978-1982.

12. Zhang H, Shen Y, Ruse ND, Haapasalo M. Antibacterial activity of endodontic sealers by modified direct contact test against Enterooccus faecalis. J Endod. 2009;35(7):1051-1055.

13. Lovato KF, Sedgley CM. Antibactieral activity of EndoSequence root repair material and ProRoot MTA against clinical isolates of Enterococcus faecalis. J Endod. 2011;37(11):1542-1546.

14. Candeiro GT, Correia FC, Duarte MA, Ribeiro-Siqueira DC, Gavini G. Evaluation of radiopacity, pH, release of calcium ions, and flow of a bioceramic root canal sealer. J Endod. 2012;38(6):842-845.

15. Zhang W, Li Z, Peng B. Assessment of a new root canal sealer’s apical sealing ability. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(6):e79-82.

16. Real World Endo. One step apexification using EndoSequence BioCeramic putty and root repair material. Real World Endo Web site. https://realworldendo.com/videos/one-step-apexification-usingendosequence-bioceramic-putty-and-root-repair-material. Published November 10, 2013.

17. Nasseh AA. CBL #7: Case review of apical barrier technique. https://realworldendo.com/videos/cbl-7-case-review-of-apical-barrier-technique. Real World Endo Web site. Published June 28, 2014.

16 Endodontic practice

Volume 7 Number 6

CASE STUDY

Easy endodontics Case studies from Drs. Godfrey Cutts and James Prichard take a look at how ultrasonic technology is simplifying endodontics

E

ndodontics has experienced a number of technological advancements in recent years, which have seen it emerge as a far more predictable treatment modality. One particular technology that has enhanced endodontic treatment is ultrasonics. Dr. Sanjeev Bhanderi says: “Ultrasonics energy, when applied to fluid media, has been shown to create two physical phenomena: acoustic streaming (Ahmad, et al., 1987; Lumley, et al., 1991) and cavitation (Walmsley, 1987).

It has seen a re-emergence in endodontics with specifically designed tips that can easily be implemented into dental practice as most general dentists already routinely use the ultrasonic devices in their surgeries for periodontal care.

“The ultimate aim of endodontics is, of course, to biologically restore the health of the supporting periodontal tissues that have been under a microbiological challenge from within the roots. This involves the judicious removal of microorganisms and infected material from the pulp space to reduce the bacterial load to a clinically insignificant level and then seal the anatomy from crown to apex. With a crown-down approach, ultrasonic energy can be utilized at each stage

Godfrey Cutts, LDS, Dunelm, graduated from the Sutherland Dental School, Newcastle upon Tyne in 1961. Godfrey has a special interest in endodontics and has a successful endodontic referral practice in Nuneaton, Warwickshire, UK, to which practitioners from some 50 miles around refer patients for initial treatments, retreatments, and apical micro-surgery. Has he held posts with Oasis Dental Care as Clinical Director and Clinical Advisor. For the past 10 years, he has been holding hands-on courses for GDPs at venues around the UK with a special focus on solutions to everyday endodontic situations.

James Prichard, BDS, LDSRCS, MFGDP, was born and raised in Coventry and qualified at the Royal London Hospital in 1994.

He subsequently returned to general practice in Coventry and since then has established a successful referral practice taking advanced endodontic cases from other dentists. He is a renowned teacher in Endodontics, delivering hands-on courses and lectures throughout the UK. He has held the post of Associate Clinical Teacher and Clinical Supervisor in Endodontics in the Masters Program at The University of Warwick. He gained his Masters Degree (MSc) in Restorative Dental Practice gaining distinction for his dissertation which he completed at the Eastman Dental Hospital. In November 2011, he was awarded his Fellowship from the International Academy of Dental Facial Esthetics in New York City, New York.

Volume 7 Number 6

Satelec P5 Newtron ultrasonic unit

of preparation to progressively reach the hallowed working length.”

Versatility as standard Satelec® Acteon produces a portfolio of endodontic ultrasonic tips for use in its P5 Newtron® ultrasonic unit to treat a variety of different endodontic cases. The P5 Newtron is indicated for scaling, removal of pulp stones, removal of secondary dentin, modifying access cavity, removing cements and temporary dressings, locating canals, cleaning canals, removal of fractured instruments, removal of posts, removal of screws and pins, retreatment, obturation, and apical micro-surgery; and it has restorative applications too.

Dr. Godfrey Cutts runs an endodontic referral practice in Nuneaton. He is passionate about further developing endodontic treatments to improve the outcome for patients.

He says: “The Satelec P5 Newtron is the most versatile instrument in the surgery.

Whereas most products are single use, this is multi-functional. I have two P5 units in constant use and really feel that I couldn’t perform my endodontic treatments without them.” The Newtron technology used in

Satelec piezoelectric generators ensures that the tips work efficiently and effectively to enable clinicians to work with superior precision and reliability.

Dr. Godfrey Cutts pioneered the use of Irrisafe™ irrigation tips in the United Kingdom.

The use of acoustic micro-streaming enhances the effect of irrigants in cleaning canals and the removal of smear layer.

The new irrigation inserts (Irrisafe): • Are parallel and non-cutting • Will not damage the dentinal structure • Size 20-25 allows free oscillation in the canal • Can be pre-bent for use in curved canals • Can be introduced to within 1 mm of working length to produce active apical micro-streaming • Are resistant to fracture, but if they do so, fracture coronally so the instrument can be retrieved with ease Dr. Godfrey Cutts teaches an annual 2-day endodontic retreatment course in the UK with Dr. James Prichard.

They report that Satelec Acteon’s Endo Success™ Kit is an essential part of the course, without which they really couldn’t run it.

Endodontic practice 17

CASE STUDY The following case studies illustrate the versatility of the P5 Newtron.

Case study by Dr. Godfrey Cutts A 50-year-old male patient was referred by his general dental practitioner for retreatment to UL8, which had recently been treated and had remained symptomatic.

Upon examination, there was a draining buccal fistula adjacent to the tooth. The periapical radiograph demonstrated apical periodontitis on all roots (Figure 1).

Local anesthetic was administered, the tooth isolated with rubber dam, and the coronal restoration removed, which revealed an extensive pulp stone that occupied the entire pulp chamber. Instruments from the Satelec Acteon Endo Success™ CAP range (Figure 2) were employed to fragment the pulp stone and locate the canal entrances, including MB2 (Figure 3).

The existing gutta percha was removed and all canals re-instrumented with Race files to ISO #35 .04 taper, irrigated with copious amounts of 3% sodium

hypochlorite, passive ultrasonic irrigation (PUI) with Satelec Irrisafe™ (Figure 4) instruments, and a 1-minute soak with 17% EDTA prior to dressing with calcium hydroxide.

At the second visit, the fistula had healed, so the tooth was again isolated with a rubber dam, the temporary filling, and calcium hydroxide removed with further irrigation with 3% sodium hypochlorite and PUI with Irrisafe.

The canals were then obturated with Kerr Pulp Canal Sealer EWT and gutta-percha, thermal down pack with System B™ (SybronEndo) and MicroSeal backfill. The access cavity was restored with a bonded amalgam core, which demonstrates the extent of the pulp stone that was removed (Figure 5).

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

18 Endodontic practice

Volume 7 Number 6

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

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Furcation perforation, bone loss

Perforation repaired

1 year post-op healing of perforation repair

Images are courtesy of Dr. Robert Levin, DDS of Huntington Beach, California “Response of Human Dental Pulp Capped with Biodentine and Mineral Trioxide Aggregate.” Journal of Endodontics. Elsevier, 15 Apr. 2013. Web. “In Vitro Microleakage of Biodentine as a Dentin Substitute Compared to Fuji II LC InCervical Lining Restorations.” National Center for Biotechnology Information. U.S. National Library of Medicine, Dec. 2012.

Mesut Enes Odabaş, Mehmet Bani, and Resmiye Ebru Tirali, “Shear Bond Strengths of Different Adhesive Systems to Biodentine,” The Scientific World Journal, vol. 2013, Article ID 626103, 5 pages, 2013. doi:10.1155/2013/626103 Human tooth culture: a study model for reparative dentinogenesis and direct pulp capping materials biocompatibility. Odile Téclès, Patrick Laurent, Virginie Aubut, Imad About, J Biomed Mater Res B Appl Biomater. 2008 April; 85(1): 180–187. doi: 10.1002/jbm.b.30933 Chmilewsky, F., C. Jeanneau, P. Laurent, M. Kirschfink, and I. About. “Pulp Progenitor Cell Recruitment Is Selectively Guided by a C5a Gradient.” Journal of Dental Research 92.6 (2013): 532-39. Print.

!

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

800-872-8305 • septodontusa.com From the manufacturers of Septocaine® anesthetics • materials • endodontics • infection control

CASE STUDY Case study by Dr. James Prichard This case study demonstrates how ultrasonics were used to grouch out the access cavities and find additional canals. It also

illustrates Biodentine速 (Septodont) being tamped down using ultrasonics.

Figures 1, 2, and 3 show the use of the ETPR (Figure 1) to loosen a metal post and core from a lower incisor and a scaler placed into a coronal groove (Figure 2) to gently rotate while ultrasonics were applied to loosen the cement.

Figure 4 shows Irrisafe being used in the disto-buccal root of an upper molar to activate sodium hypochlorite to remove tissue from an internal resorption lesion. Figure 5 shows the view of the access cavity and

the defect after use. Figure 6 shows placement of a Biodentine base in the same case (post-obturation) to seal the defect prior to the coronal restoration being placed.

Figure 7 shows three mesial canals in a lower molar having used the ET18BD to trough between the mesio-buccal and mesiolingual canals. Sodium hypochlorite can just be seen in the distal canal. Figure 8 shows an access cavity in an upper second molar.

Ultrasonics are highly versatile tools that can be employed at all stages of endodontic therapy. EP

Figure 3

Figure 4

Figure 1

Figure 2

Figure 5

Figure 6

Figure 7

Figure 8

20 Endodontic practice

Volume 7 Number 6

Dr. Carlos A. S. Ramos discusses his technique for an effective seal

T

he current concept among clinicians is that after complete debridement, total obliteration of the root canal space with a biocompatible material constitutes one of the key factors for successful endodontic therapy because coronal leakage can contribute to root canal treatment failure.1,2 To avoid apical and coronal leakage, a variety of sealers and cements have been tested in combination with gutta percha for root canal sealing. Studies have shown that EndoREZ® (Ultradent Products, Inc.), a urethane dimethacrylate resin-based endodontic sealer, provides an effective seal when used in different obturation techniques, such as single cone or lateral condensation.3–5 The hydrophilic properties of EndoREZ improve the penetration of the sealer into moist dentin and dentinal tubules (Figure 1) up to 1000µm4 and chemically bond to the EndoREZ resin-coated guttapercha points (Ultradent Products Inc.), creating a monoblock obturation (Figure 2).

Aiming to decrease setting time, the EndoREZ® Accelerator (Ultradent Products, Inc.) has been introduced. The combination of EndoREZ and EndoREZ Accelerator speed up the polymerization of the sealer, thus allowing for an immediate continuation of the coronal restoration. It also prevents dislodgement of

Carlos A.S. Ramos, DDS, MS, PhD, graduated in dentistry in 1987 from State University of Londrina, Brazil. During that year, he received a scholarship to study in Japan at the University of Tokyo. In 1990, he received the title of endodontics specialist from the University of São Paulo, Bauru School of Dentistry. From 1991 to 1993, he attended the Master’s program in endodontics at the same university, receiving a Master of Science degree and presenting a dissertation on accuracy of apex locators in vitro. From there, he began the PhD program in endodontics, completing it in 1997 and culminating in his presentation of an in vivo thesis on apex locators. In the same year, he published his first book, Endodontics, Biological and Clinical Foundations. From 1995 to 2012, as professor of endodontics at State University of Londrina, he coordinated the endodontics sector, predoctoral endodontic dental course, and graduate program. Now Dr. Ramos is an Adjunct Professor in the Endodontics Department at Roseman University, College of Health Sciences, Salt Lake City, Utah. He has performed many lectures, hands-on workshops, and conferences both in Brazil and abroad each year, and has published articles in national and international journals.

Volume 7 Number 6

the obturating material when a post space is prepared immediately after obturation, potentially causing early bacterial leakage.

Single cone technique Over the past century, numerous obturation materials and techniques have been introduced in an attempt to obtain a microbiologic barrier within the confines of the root canal system. One major benefit of the single-cone technique is its simplicity.

Studies have shown that the single-cone technique with a suitable resin-based sealer can achieve the same rates of success than other types of obturation methods.6,7 As with any endodontic procedure, some important relevant details must be observed to achieve success in the technical implementation of this type of obturation method using EndoREZ sealer.

instrumentation. To improve lubrication through the initial steps of instrumentation, the peroxide-free File-Eze® EDTA Lubricant (Ultradent Products, Inc.) can be used. Nonperoxide-free lubricants like EndoGel*, EndoSequence*, Glyde*, ProLube*, RC-Prep*, and SlickGel ES* are not compatible with EndoREZ.

Final irrigation

During irrigation

The collagen network of dentin is better preserved when EDTA is used as the final rinse.8 A hybrid layer and resin sealer tags (Figure 1) will be created as a result of dentin surface demineralization by EDTA. After using EDTA for 1 minute, a final flush with distilled water should be done. Chlorhexidine 2% solution can be used (fill the canal and wait 3 to 5 minutes) as a final rinse prior to the obturation procedure. Do not mix sodium hypochlorite with chlorhexidine, as a harmful brown precipitate will form.

Sodium hypochlorite, EDTA, and chlorhexidine can be used as irrigants during

* Trademark of a company other than Ultradent

Figure 1: SEM showing EndoREZ tags up to 1000µm length.

Hydrophilic properties of the sealer improve the penetration of the sealer into moist dentin and dentinal tubules

Figure 2: SEM showing the surface of a resin-coated EndoREZ gutta-percha cone

Figures 3A-3C: Clinical cases using the single cone technique with EndoREZ Endodontic practice 21

ENDODONTIC INSIGHT

Simplifying endodontics: a single cone obturation technique using EndoREZ®

ENDODONTIC INSIGHT

Figure 4. The delivery technique using a Skini syringe and NaviTip tip allows insertion of EndoREZ at the apical third

Auto mixing tip and delivery The canal space should be dried using a capillary tip (Ultradent Products, Inc.), followed by paper points (paper points should be damp 1 mm to 3 mm at tip). The canal should be damp, not desiccated, prior to obturating with EndoREZ in order to take maximum advantage of the hydrophilic properties of the sealer, thus allowing for resin tag penetration and/or the formation of a hybrid layer. EndoREZ is expressed out of the dual barrel syringe with a mixing tip into the back of a Skini syringe (usually one-third of a Skini syringe is more than adequate for a multi-rooted tooth). Filling the Skini syringe to the back flange inhibits air from remaining between the plunger and the sealer. Do not attempt to mix EndoREZ on a paper pad or in a glass slab — being a resin-based sealer, incorporating oxygen during manual mixing will interfere in the sealer setting properties.

EndoREZ should be delivered into the canal using a NaviTip® 29ga tip attached to the Skini syringe (Figures 4 and 5). Based on the final instrument, different levels of insertion can be used. Small diameters — from 25 to 30 (Figure 4, left) allow inserting 2 mm before the working length. For large diameters — from 60 to 80 (Figure 4, right), it is recommended to insert 4 mm before the working length.

The master EndoREZ gutta-percha resin-coated cone has to be inserted to the working length (Figure 6). Be sure to insert the cone using a single gentle movement toward the apical area, avoiding any “pump” movements. Without the use of accelerator, EndoREZ will set in about 20–30 minutes.

In large final shaping diameters, it’s probable that space may remain laterally around the master cone. Accessory resin-coated 22 Endodontic practice

Figure 5. Express EndoREZ with light pressure into canal while withdrawing tip. Keep the NaviTip tip buried in the material while expressing EndoREZ and withdrawing the tip

Figure 6: Insert the master EndoREZ resin-coated cone to working length. Be sure to make one single, gentle movement toward the apical area, avoiding any “pump” movements with the cone. Without the use of the accelerator, EndoREZ will set in about 20 to 30 minutes

gutta-percha cones (20 or 25 .02) can be used, being inserted passively until resistance is achieved.

Working time Light cure EndoREZ with a curing light for 40 seconds.

Initial surface polymerization with curing light (without Figure 7: Radiographic image of a lower incisor with apical lesion (left). Under EndoREZ Accelerator) is less SEM (right), the apical foramen shows large areas of resorption than 0.3 mm thick and aids in immediate restoration. Do not expect that all of the sealer will be set at this with the foramen. In cases of chronic apical moment. lesion, the foramen area is resorbed (Figure 7) and could favor sealer extrusion. In this Working time with EndoRez Accelerator particular situation, a calcium hydroxide EndoREZ Accelerator reduces EndoREZ interappointment intracanal medication is set time from 20 to 30 minutes to about 5 recommended for 3 weeks before obtuminutes. If using the single cone technique, ration. Calcium hydroxide will be able dip the master cone to its full length in the to generate an apical calcified area and vial and insert the cone at the working length. prevent sealer extrusion. Small amounts of EndoREZ outside the canal at the periapical Apical resorption area will be resorbed after a certain period Special attention needs to be paid to of time, based on the amount of sealer the apical stop position and the relation extruded. EP

REFERENCES 1. Madison S, Wilcox LR. An evaluation of coronal microleakage in endodontically treated teeth: part III. In vivo study. J Endod.

1988;14(9):455–458.

2. Saunders WP, Saunders EM. Coronal leakage as a cause of failure in root canal therapy: a review. Endod Dent Traumatol.

1994;10(3):105–108.

3. Zmener O, Pameijer CH, Serrano SA, Vidueira M, Macchi RL. Significance of moist root canal dentin with the use of methacrylatebased endodontic sealers: an in vitro coronal dye leakage study. J Endod. 2008;34(1):76-79.

4. Kim YK, Grandini S, Ames JM, Gu LS, Kim SK, Pashley DH, Gutmann JL, Tay FR. Critical review on methacrylate resin–based root canal sealers. J Endod. 2010;36(3):383-399.

5. Zmener O, Pameijer CH. Clinical and radiographical evaluation of a resin-based root canal sealer: a 5-year follow-up. J Endod.

2007;33(6):676–679.

6. Somma F, Cretella G, Carotenuto M, Pecci R, Bedini R, De Biasi M, Angerame D. Quality of thermoplasticized and single point root fillings assessed by micro-computed tomography. Int Endod J. 2011;44(4):362-369.

7. Yilmaz Z, Deniz D, Ozcelik B, Sahin C, Cimilli H, Cehreli ZC, Kartal N. Sealing efficiency of BeeFill 2in1 and System B/Obtura II versus single-cone and cold lateral compaction techniques. Oral Surg Oral Med Oral Pathol Oral Radiol and Endod. 2009;108(6):e51-e55.

8. Osorio R, Erhardt MC, Pimenta LA, Osorio E, Toledano M. EDTA treatment improves resin-dentin bonds’ resistance to degradation. J Dent Res. 2005;84(8):736–740.

Volume 7 Number 6

simple, adaptable

endodontic solutions

A decade of success EndoREZ facts SAVES TIME For more than 10 years, EndoREZ has given you the ability to buy time.

When used conventionally, EndoREZ will be completely set in 30 minutes.

And when used with EndoREZ Accelerator, this time can be reduced to only 5 minutes. Compare this to the approximate 10-hour set time other sealers may require, and it’s clear: EndoREZ makes every RCT faster.

UNMATCHED HYDROPHILICITY AND ADAPTABILITY EndoREZ contains a special hydrophilic organophosphate methacrylate monomer that increases its hydrophilicity and produces a resin with a strong affinity for moisture with resin penetration of 1200μ into the tubules.

EndoREZ penetrates into tubules and adapts to the walls like no other sealer on the market.

Don’t change your technique.

Make it easier with EndoREZ. Scan to watch a short video about EndoREZ.

800.552.5512 ultradent.com Use NaviTip to easily deliver EndoREZ to the entire anatomy of the canal in one step.

©2014 Ultradent Products, Inc. All Rights Reserved.

EndoREZ

®

ENDODONTIC INSIGHT

Restorative endodontics: a new biologically based standard of care Dr. Dennis G. Brave discusses minimally invasive techniques and advanced material science

I

t is unlikely that G.V. Black, 1836-1915 (considered the Father of Restorative Dentistry), could have imagined the direct bonding of modern-day composite materials to coronal dentin, or that Louis I. Grossman, 1902-1988 (the recognized Father of Endodontics), could have imagined bioceramic sealers that could bond to radicular dentin. But both of these giants of our profession advocated the latest theory, techniques, and technology of their day.

They could only dream about the future … and the future is here and now!

All of us recognized the need for “retentive preparations” for the successful placement of an amalgam restoration (when there was no other option). Many of us continue to use “condensation techniques” and consider them a requirement for the successful filling of root canals (but now there are other options).

It should be remembered that these techniques were advanced based on the physical and chemical properties (limitations) of the materials that were available to us at the time.

Today we have new and better materials that do not require these techniques.

It should be stated from the outset that the reason for restoring a cavity and/or performing a root canal are both the same — to restore a tooth to its natural function and to preserve that tooth in that state for as long as possible. Let’s start with the latest materials, technology, and techniques available to accomplish that task in endodontic therapy.

Dennis Brave, DDS, is a Diplomate of the American Board of Endodontics and a member of the College of Diplomates. He received his DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his certificate in Endodontics from the University of Pennsylvania School of Dental Medicine. He is an Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas Odontologic Honor Society Member. In endodontic practice for over 25 years, he has lectured extensively throughout the world and holds multiple patents, including the VisiFrame. Dr. Brave was voted one of “Baltimore’s Best” Endodontist by Baltimore Magazine. Formerly an associate clinical professor at the University of Pennsylvania, Dr. Brave currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on endodontics, Dr. Brave is a cofounder of Real World Endo.

24 Endodontic practice

We should be maintaining the innate strength of the tooth through the use of root canal sealers that bond to the radicular dentin and instrumentation and obturation techniques that do not require the excessive removal of dentin.

You were probably taught that gutta percha needs to be heated and condensed to achieve 3D obturation, that your endodontic sealers are the weak link in your root canal procedure, and that it didn’t matter how you got to the apex, only that you got there. Well, that was in the past. Present-day material science has antiquated these and many other concepts that you may have learned and are still using.

If we concede that the fundamentals of root canal therapy are cleaning, shaping, and obturation, then it would make sense to look carefully at how each part of the procedure interfaces and supports the other. In addition, it is also important to consider how each part of the procedure supports the objective of maximizing the long-term retention of the endodontically treated tooth.

Let’s consider the past and current stateof-the art in root canal sealers. Approximately 50 years ago, Dr. Louis Grossman acknowledged that the then current-day sealers (zinc oxide and eugenol and resin-based sealers) left much to be desired. They were hydrophobic, shrunk upon setting, were not very biocompatible, lacked resistance to wash out, and generally were irritating if extruded past the apex. Because of these less-thanstellar characteristics, it became accepted theory and practice to try and reduce the sealer interface to the thinnest possible thickness in the root canal. It being well understood that the thicker the sealer interface, the greater the shrinkage, the more irritating, etc. So, all of our obturation techniques (warm vertical, cold lateral, and even heated

carrier-based) were developed based on the recognition that the then current sealers were at best poor and that the gutta percha should displace as much sealer as possible.

Present-day material science has allowed us to produce nanoparticle bioceramic root canal sealers (EndoSequence® BC Sealer™, Brasseler USA) that meet all of Dr. Grossman’s ideal requirements for an endodontic sealer. They do not shrink upon setting, are biocompatible, are osteogenic by their nature, are hydrophilic, antibacterial, and produce hydroxyapatite upon setting.

They are also highly radiopaque, premixed, and will produce a true chemical bond to the dentin and gutta percha when used with a bioceramic-coated cone (BC Sealer and BC Points, Brasseler USA). Because we are now able to chemically bond to the radicular dentin (right down to the apex), we are now able to produce a true monoblock for the first time. This is why it can be said that the restoration of an endodontically treated tooth should begin at the apex.

What about “condensation techniques” that have used (as a bases of their acceptance) the idea that we should replace the sealer with gutta percha? That the sealer is the weak link in the chain and should be reduced to the thinnest layer possible in the root canal? They are antiquated and without merit when we can now say that we have root canal sealers that are superior to gutta percha in the canal. At best, gutta percha takes up space and is inert.

It should be acknowledged that we still deliver the sealer and provide a retreatment Volume 7 Number 6

Volume 7 Number 6

not dictate shaping! In doing so, we have excused preparations that have removed good tooth structure (dentin) at the expense of the long-term prognosis of the tooth.

Teeth (canals) that are overly prepared and weakened to accommodate filling techniques in the long-term lead to unnecessary fractures and their removal.

Minimally invasive root canal shaping is really what we should be focused on in an effort to preserve as much radicular dentin as possible. We should be maintaining the innate strength of the tooth through the use of root canal sealers that bond to the radicular dentin and instrumentation and obturation techniques that do not require the excessive removal of dentin. We have begun to look carefully at shaping and recognize that all instrument systems are not the same and do not accomplish the same goals. Some years ago, it was recognized that constant tapered file systems would consistently produce (versus variable tapered) minimally invasive shapes in the root canal. Further, that synchronization of all the

parts of the procedure (i.e., the instruments, paper points, gutta percha, and posts) would lead to the removal of less structurally important dentin. Posts were designed to fit the space that the last rotary instrument actually produced. Thus, the first drill-less post system was developed with the recognition that the preservation of radicular dentin was critical to the responsible restoration of an endodontically treated tooth.

Those that claim that root canals fracture and don’t hold up for the long term do not recognize the importance of maintaining the inherent strength of a tooth throughout the root canal procedure by the use of minimally invasive techniques and technology.

Root canals that are carried out with instrumentation systems designed to retain as much coronal radicular dentin as possible and are restored utilizing bonded obturation (BC Sealer) will stand up to the test of time.

Restoration of an endontically treated tooth should begin at the apex. Through the use of minimally invasive techniques and advanced material science, this is now a reality. EP

Endodontic practice 25

ENDODONTIC INSIGHT

path with a bioceramic coated cone.

However, traditional condensation is not necessary because of the hydraulic nature of the bio-ceramic sealer.

But this is not the end of the story.

Actually, it is just the beginning! For years the techniques used to prepare and shape canals have focused on trying to not only clean the canal, but also produce a shape that will provide for the difficult task of condensing gutta percha. Something we now understand is actually completely unnecessary. Cleaning, it turns out, can be accomplished with minimal coronal enlargement, particularly if facilitated with ultrasonics and good irrigation techniques.

All that is really required is to produce a shape that allows the canal to be cleaned responsibly to the apex. A size 35/.04 preparation to the apex has been documented as all that is needed in most canals. We now have hydraulic obturation techniques utilizing flowable nanoparticle bioceramic technology that do not require excessive canal enlargement. Obturation should

INDUSTRY NEWS Sonendo® closes $35 million equity financing round to advance development and commercialize treatment for root canal therapy Sonendo® Inc., announced the completion of equity financing totaling $35 million. The proceeds from the financing will be used to further technology development, fund clinical studies, and commercialize Sonendo’s GentleWave™ System for root canal therapy. The financing round was led by Meritech Capital Partners, with new investor SEB Private Equity joining Fjord Ventures, OrbiMed Advisors, and NeoMed Management to form the investor syndicate.

Sonendo President and CEO Bjarne Bergheim noted, “Our investors share our mission of transforming endodontic therapy: delivering ultraclean root canal therapy for patients; and predictability, efficiency, and practice differentiation to the clinician.”

For more information, visit www.sonendo.com.

Gendex™ announces new website launch Gendex™, a leader in dental imaging, stands by its promise to be Always by Your Side with its newly designed website, Gendex. com. The new website allows dental practitioners to simplify their imaging search on any device whether on a phone, tablet, or laptop. The new Gendex.com offers many improved and modern, user-friendly features. The content is uniform and offers a widerange of imaging solutions, all in one place. When browsing the new site, the user will experience a cleaner and more manageable website designed with the busy practitioner in mind. One of the most significant enhancements is the new look, which allows viewers to navigate on any Internet-ready device. Information has been reorganized, making it possible to view the site on smaller screens without losing important content.

The brand-new Gendex website connects the clinician to the entire product family with ease. Explore digital intraoral sensors, panoramic X-ray, Cone Beam 3D, PSP, imaging software, and more. Take a 360 degree product tour or check out the enhanced support section — faster and easier. Gendex is dedicated to improving the dental practice and advancing patient care through comprehensive solutions and exceptional support.

26 Endodontic practice

DEXIS™ debuts its imaging software for Mac® DEXIS announced the full launch of DEXIS™ Mac, a new software that integrates the true functionality of Apple products with the functionality of the DEXIS imaging system. This new software combines the tried-and-true workflow that DEXIS users appreciate into a native Mac platform that requires no parallels. DEXIS Mac is compatible with the awardwinning single-sized DEXIS™ Platinum sensor, which provides images of remarkable quality and efficient workflow.

The quad view and quad control custom interface offers fewer and more meaningful buttons in logical groupings and functions.

While navigating through the screens, only those options that are pertinent for that given function are visible. The streamlined workflow of DEXIS imaging suite and its reliable tools are also integral to DEXIS Mac. Users can switch between mouth and history views, and all images for the tooth can be seen through the cascading images feature that is unique to this DEXIS platform. Clinicians also have the option to compare the same tooth’s images side-by-side.

DEXIS Mac also provides true integration with Mac-based practice management programs Viive™ and MacPractice®, and retains popular features such as the Integrator. The software also provides immediate access to the DEXIS go™ and DEXIS photo™ apps.

For more information, visit www.dexis.com.

Candy Ross elected to ADA Foundation Executive Committee as Vice President of Grants Candy Ross, RDH, Director of Industry and Professional Relations, Dental Technologies, North America, for KaVo Kerr Group, was elected Vice President of Grants of the ADA Foundation (ADAF). Described as “dentistry’s premier philanthropic and charitable organization,” the ADAF is active in providing educational grants, including dental student scholarships and affiliated dental scholarships; a variety of grants related to access to care and oral health outreach, including grants related to Give Kids A Smile®; and charitable assistance through its Disaster Assistance Grant Program and Relief Grant Program. The ADAF also provides funding for the Dr. Anthony Volpe Research Center (formerly the Paffenbarger Research Center) in Gaithersburg, Maryland. For more information about the ADAF, visit www.adafoundation.org.

Volume 7 Number 6

A study by Drs. Elya Bartanovsky, David Keinan, Joshua Moshonov, and Michael Solomonov encourages caution in the use of iodine-containing material, especially before obturation with sealer based on epoxy resin Abstract The purpose of this study was to examine the influence of iodine-containing irrigation solutions or dressings, or the addition of iodoform powder to AH 26® (Dentsply) on the bonding strength of AH 26. The iodinecontaining materials in endodontics showed good antibacterial and antifungal properties, as well as good penetration to the dentinal tubules. The remaining iodine can affect the quality of sealing by reducing the contact surface between the sealer and the dentin and also by interfering with sealer setting. A total of 100 freshly extracted human teeth were selected. The root canals were enlarged using GTÒ files to size 50 and taper 12% at the apex. The teeth were divided into four groups: 1. Control group Canals were laterally compacted with gutta percha using AH 26 as the sealer.

2. Iodoform powder group Applying the same protocol, iodoform powder was added to AH 26 during preparation.

3. IKI group Prior to obturation, the canals were irrigated with 5% IKI for 10 min.

4. Metapex™ (Meta Dental Corp.) group Canals were medicated with Metapex for 2 weeks, irrigated and laterally compacted using gutta percha and AH 26 as sealer.

When this study was performed, Dr. Elya Bartanovsky was from the Department of Endodontics, The Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel.

When this study was performed, Dr. David Keinan was from the Department of Endodontics, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel and the Department of Endodontics, Medical Corps, Dental Center, Sheba Medical Center, Tel-Hashomer, Israel.

When this study was performed, Dr. Joshua Moshonov was from the Department of Endodontics, The Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel.

When this study was performed, Dr. Michael Solomonov was from the Department of Endodontics, The Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel, and the Department of Endodontics, Medical Corps, Dental Center, Sheba Medical Center, Tel-Hashomer, Israel.

Volume 7 Number 6

Clinicians have been searching for new and more efficient irrigants, dressings, and methods of elimination or at least maximum reduction of microorganisms from the root canal system, which consists of main, lateral, and accessory canals, isthmuses, and dentinal tubules.

All samples were kept in moist gauze for 1 week at 37ºC. Then, 3-mm thick root sections were made, and the shear strength between the gutta percha with the sealer and the dentin was measured. Our findings show that iodine-containing compounds reduce the bonding strength of AH 26. The addition of iodoform powder reduced the bonding strength to the greatest extent.

Introduction One of the main goals of endodontic treatment is to heal or prevent apical periodontitis.1 In case of infection, the success of the treatment depends on the extent of bacterial elimination from the root canal system. This is mainly achieved through meticulous chemo-mechanical preparation of the canals, supplemented with antibacterial irrigation and intracanal antimicrobial medication between visits when required.2,3 Currently, calcium hydroxide is the most widely used dressing, and sodium hypochlorite is the most popular irrigant. However, total elimination of the microorganisms from the root canal system cannot be predictably achieved by applying the above-mentioned measures.4 Earlier studies showed the resistance of Enterococcus faecalis5 and Candida albicans6 to the irrigation solutions and dressings usually used in the course of endodontic treatment. The two microorganisms are the most frequently found during retreatment or posttreatment of periodontitis.7 Furthermore,

the efficacy of calcium hydroxide and sodium hypochlorite is influenced by dentinal tubule infection, and some microoganisms are able to penetrate tubules up to the CDJ.8 Therefore, clinicians have been searching for new and more efficient irrigants, dressings, and methods of elimination or at least maximum reduction of microorganisms from the root canal system, which consists of main, lateral, and accessory canals, isthmuses, and dentinal tubules.

One of the debatable points in endodontic treatment is the use of iodine-containing disinfectants such as IKI, povidone-iodine for irrigation and Metapex, Vitapex® (Neo Dental International Inc.), or ENDOFlas (calcium hydroxide mixed with iodoform) as intracanal medication.9 These iodine-containing materials have shown good antibacterial and antifungal properties.10 Moreover, they exhibit low cytotoxicity,11,12 and are fast acting.13 They also have a good penetration ability.14 However, due to this property they penetrate deep into the dentinal tubules, rendering complete cleaning of the root canal system of iodine impossible. The remaining iodine can affect the quality of sealing by reducing the contact surface between sealer and dentin, as seen, for example, with calcium hydroxide15 or by interfering with sealer setting, particularly if the canals are medicated between appointments.16 Many clinicians tend to mix known materials in an attempt to create new and Endodontic practice 27

RESEARCH

The effect of iodine-containing materials on the bonding strength of AH 26®

RESEARCH Table 1: MPa values achieved in the failure point of the sealer of each group Metapex (4) N=25

N=25

Iki (3)

Iodoform (2)

Control (1)

0.001392

0.001225

0.001337

0.001756

minimum

0.02292

0.02578

0.00932

0.02735

maximum

0.020

0.022

0.005*

0.024

average

N=25

N=25

*p < 0.05

better sealers. The addition of iodoform to AH 26 is one of the most popular do-ityourself prescriptions and aims “to create a good sealer with prominent antibacterial properties.” However, the problem is that such modifications can affect the basic physical properties of the sealer material and decrease the quality of sealing.

Aim The purpose of this study was to examine the effect of iodine-containing irrigation solutions, dressings, or the addition of iodoform powder to AH 26 on its bonding strength.

Materials and methods A total of 100 freshly extracted human teeth comprising single-rooted premolars with one canal, upper incisors, and palatal roots of upper molars were used in this study. After extraction, all teeth were stored in moistened gauze. In the course of the chemo-mechanical preparation, the coronal and the middle-third of the canals were enlarged with GT NiTI 0.12 to size 50, and the apical third was manually prepared with SS instruments to MAF size 30-45.

During cleaning and shaping, irrigation was performed using 10-15 ml of 2.5% NaOCl. Following instrumentation, the canals were irrigated for 1 minute with EDTA followed by 1 minute of NaOCl, and finally 1 minute of EDTA.17 Before obturation, all the canals were dried with paper points, until there was no visible sign of moisture.

The roots were randomly divided into four groups of 25 teeth each: 1. Control group The canals were filled with gutta percha, using AH 26 and complementary guttapercha points by lateral compaction with a NiTi finger spreader. Upon completion of obturation, a No. 4 Mashtou Plugger was used to add a vertical condensation component in the coronal third of the canals. The specimens were then sealed with temporary Coltozol (Weach company in all materials and instruments) filling.

28 Endodontic practice

Figure 1: A bar graph presents the MPa values achieved in the failure point of the sealer of each group

2. Iodoform powder group Using the same protocol, iodoform powder was added to the AH 26 in a 1:6. ratio during mixture of its components.

3. IKI 5% irrigation solution group After chemomechanical preparation and smear layer removal, the canals were irrigated with 5% IKI for 10 minutes and then dried with paper points. The canals were filled with gutta percha and AH 26 using the lateral condensation technique as described above for the control canals.

4. Metapex group After drying with paper points, the canals were medicated with Metapex, and the teeth were sealed coronally with Coltozol filling. After 2 weeks, the teeth were reopened, irrigated with NaOCl, and instrumented with an MAF one size larger than before. The canals were then irrigated for 1 minute with EDTA, followed by NaOCl and EDTA to remove the smear layer18 and dried using paper points. The canals were filled with guttapercha and AH 26 using the lateral condensation technique as described above for the control canals.

All samples were kept in moist gauze for 1 week at 37ºC, in order to get complete setting of the sealers. One week later, all the teeth were decoronated with a diamond bur just below the CEJ. The other cut was 3 mm below the CEJ in order to get 3 mm root slices.

The 3 mm thick slices were glued to a Plexiglas frame and placed in a perpendicular plane to the upper jaw of the Instron 3366

device. A modified pin was fixed to the upper jaw of the Instron 3366 device in order to test the bond strength between the obturated mass of gutta percha and sealer to the dentin walls. The upper pin penetrated freely without touching canal walls. Shear strength between the gutta percha with the sealer and dentin was measured. A T-test was used for statistical evaluation of the differences.

Results The minimum and maximum shear strength values (in MPa) for all four groups are shown in Table 1. The differences between group 1 and group 2 and 4 were statistically significant (p < 0.05). There were also significant (p < 0.05) differences between group 2 and groups 3 and 4. The mean values are marked (Figure 1).

Discussion The result of our study confirms that iodine-containing materials affect the sealer’s physical qualities. This magnitude of this effect is varied by different materials.

Tagger, et al.,18 developed effective model to measure the adhesion of endodontic sealers to the dentin surface. They used flat dentin slices placed in an Instron device with a chisel fixed to the upper moving jaw. In order to mimic more accurately the conditions in the root, we modified this model. We used 3-mm root slices in which the sealers contact the dentin of the canal walls, and we also used a 1-mm diameter pin, which was fixed to the moving jaw.

Volume 7 Number 6

REFERENCES 1. Ørstavik D, Pitt Ford TR. Apical periodontitis. Microbial infection and host responses. In: Ørstavik D, Pitt Ford TR, eds. Essential Endodontology: Prevention and Treatment of Apical Periodontitis. Oxford: Wiley Blackwell; 1998: 1-8.

2. Reit C, Dahlen G. Decision making analysis of endodontic treatment strategies in teeth with apical periodontitis. Int Endod J. 1988;21(5):291–299.

3. Sundqvist G, Figdor D, Persson S, Sjogren U. Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85(1):86–93.

Volume 7 Number 6

4. Reit C, Molander A, Dahlen G. The diagnostic accuracy of microbiologic root canal sampling and the influence of antimicrobial dressings. Endod Dent Traumatol.

1999:15(6):278–283.

5. Evans M, Davies JK, Sundqvist G, Figdor D. Mechanisms involved in the resistance of Enterococcus faecalis to calcium hydroxide. Int Endod J. 2002;35(3):221–228.

6. Waltimo TM, Orstavik D, Sirén EK, Haapasalo MP. In vitro susceptibility of Candida albicans to four disinfectants and their combinations. Int Endod J. 1999;32(6):421-429.

7. Sundqvist G, Figdor D, Persson S, Sjogren U. Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85(1):86–93.

8. Peters LB, Wesselink PR, Buijs JF, Van Winkelhoff AJ. Viable bacteria in root dentinal tubules of teeth with apical periodontitis. J Endod. 2001;27(2):76–81.

9. Cartwright JW, Todd MJ. A comparison of endodontic medications. Gen Dent. 1982;30:334-337.

10. Walton JG, Thompson JW, Seymour RA. Textbook of Dental Pharmacology and Therapeutics. New York, NY: Oxford Medication Publications; 1994.

11. Barnhart BD, Chuang A, Lucca JJ, Roberts S, Liewehr F, Joyce AP. An in vitro evaluation of the cytotoxicity of various endodontic irrigants on human gingival fibroblast. J Endod.

2005;31(8):613-635.

12. Masillamoni CR, Kettering JD, Torabinejad M. The biocompatibility of some root canal medicaments and irrigants. Int Endod J. 1981;14:115-120.

13. Kvist T, Molander A, Dahlén G, Reit CJ. Microbiological evaluation of one- and two-visit endodontic treatment of teeth with apical periodontitis: a randomized, clinical trial.

J Endod. 2004;30(8):572-576.

14. Fuss Z, Mizrahi A ,Lin S, Cherniak O, Weiss EI. A laboratory study of the effect of calcium hydroxide with iodine or electrophoretically activated copper on bacterial viability in dentinal tubules. Int Endod J. 2002;35(6):522-526.

15. Kim SK, Kim YO. Influence of calcium hydroxide intracanal medication on apical seal. Int Endod J. 2002;35(7):623-628.

16. Nandini S, Velmurugan N, Kandaswamy D. Removal

efficiency of calcium hydroxide intracanal medicament with two calcium chelators: volumetric analysis using spiral CT, an in vitro study. J Endod. 2006;32(11):1097–1101.

17. Abbott PV, HejkoopPS, Cardaci SC, Hume WR, Heithersay GS. An SEM study of the effects of different irrigation sequences and ultrasonics. Int Endod J. 1991;24(6):308-316.

18. Tagger M, Tagger E, Tjan AH, Bakland LK. Measurement of adhesion of endodontic sealers to dentin. J Endod.

2002;28(5):351-354.

19. Lin S, Kfir A, Laviv A, Sela G, Fuss Z. The in vitro antibacterial effect of iodine-potassium iodide and calcium hydroxide in infected dentinal tubules at different time intervals. J Contemp Dent Pract. 2009;10(2):59-66.

20. Fuss Z, Mizrahi A ,Lin S, Cherniak O, Weiss EI. A laboratory study of the effect of calcium hydroxide with iodine or electrophoretically activated copper on bacterial viability in dentinal tubules. Int Endod J. 2002;35(6):522-526.

21. Safavi KE, Spangberg LS, Langeland K. Root-canal dentinal tubules disinfection. J Endod. 1990;16(5): 207-210.

22. MolanderA, Reit C, Dahlen G. The antimicrobial effect of calcium hydroxide in root canals pretreated with 5% iodine potassium iodide. Endod Dent Traumatol.

1999;15(5):205-209.

23. Orstavik D, Eriksen HM, Beyer-Olsen EM. Adhesive properties and leakage of root canal sealers in vitro. Int Endod J. 1983;16(2):59-63.

24. Lee KW, Williams MC, Camps JJ, Pashley DH. Adhesion of endodontic sealers to dentin and gutta-percha. J Endod.

2002;28(10):684-688.

25. Stewart GG. A comparative study of three root canal sealing agents (Part 1). Oral Surg Oral Med Oral Pathol.

1958;11:1029–1041.

26. Hensten A, Jacobsen N. Allergic reactions in endodontic practice. Endod Topics. 2005;12(1);44–51.

27. Iijima S, Kuramochi M. Investigation of irritant skin reaction by 10% povidone-iodine solution after surgery. Dermatology.

2002:204(suppl 1);103–108.

28. Kupietzky A, Waggoner WF, Galea J. The clinical and radiographic success of bonded resin composite strip crowns for primary incisors. Pediatr Dent. 2003;25(6):577-581.

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Endodontic practice 29

RESEARCH

Clinicians have also been trying to add during the course of endodontic treatment more and more efficient irrigants and/ or dressing materials in order to eliminate microorganisms from the root canal system.

Several studies have shown good results by using iodine-containing materials.19-22 However, the influence of those materials in the adhesive strength of the endodontic sealers was not studied. The concept of tight seal of the root canal space by endodontic sealers in order to prevent leakage is well established.23-25 Our study further encourages the prudent clinician to take care while using iodine-containing material. The greatest extent of reducing bond strength was found due to addition of iodoform to AH 26 powder, while irrigation with 5% IKI for 10 minutes had the weakest effect on AH 26 bonding strength. The accepted explanation for the reduced shear strength to some degree is due to reduced contact surface between AH 26 and the dentin wall15 due to remnants of the material. The different results may be explained by the dependence on the quantity of the iodine compound, its fluid, or particle form, and the duration of contact between the iodine compound and the dentin wall.

In addition, practitioners must be aware of a possible allergic reaction to iodine compounds26,27 and the possibility of color changes in the tooth.28 Our findings serve as a basis for the following recommendations: 1. Iodoform powder should not be added to AH 26, because it strongly affects the bonding strength of the sealer.

2. Iodine-based antibacterial dressings should not be the first choice of treatment for endodontic infection.

3. The clinical implication of reduced bonding strength may result in increased microleakage leading to late failure.

Our results warrant further investigation of the influence of antibacterial iodinecontaining irrigants and dressings on such known sealers as AH Plus® and members of the ZnOE group. EP

TECHNOLOGY

Using a dental operating microscope Dr. Antony Esprey explains why he has integrated the dental operating microscope into his practice, the benefits it has provided, the learning process, and the decisions that influenced his choice Dentistry has always been limited by the small field — the tooth — something that is further impeded by the mouth. This difficulty has made diagnosis and execution of treatment somewhat difficult. To be able to see the field of vision unimpeded has long been the dream of all dentists. Unfortunately, even with 20/20 vision, this has in the past been a random affair with haphazard results.

Changed perspective However, with the advent of loupes, this difficulty seemed to be overcome, and the restricted vision of a dentist was improved.

Using loupes required some initial orientation stages, but once they were mastered, the tooth became something that was big enough. Dentists were now able to see things that previously were only guessed at.

The dentist could now make accurate assessments and diagnose more easily.

It was now possible to see the fracture lines that could have been responsible for the patient’s discomfort. Guesswork was reduced, and the field opened up a myriad of options available to the patient. Loupes changed the perspective of dentistry.

As a general dental practitioner, loupes served me well, and once I started to use them, I was no longer able to work without them. It was a quantum leap from the days when I would be peering into a patient’s mouth trying to get the best view of the tooth that was causing problems.

Under the microscope This journey of discovery was further enhanced with the advent of the microscope and, once again, I was able to multiply my field of vision.

The microscope opened up an entirely different work environment. So much more is visible via the range of six different levels

Antony Esprey, BDS (Rand), PDD(Stell), is principal dentist of Weybridge Dental Care in Surrey, England. He has obtained his Canadian National Board Certificate and is a member of the American Academy of Cosmetic Dentistry, the British Academy of Cosmetic Dentistry, and the Association of Dental Implantology UK.

30 Endodontic practice

of magnification. This allows the dentist to detect dental problems when they are small, which in turn, lets the dentist diagnose more accurately, as well as advise and show the patients their options. This means that the small problems don’t escalate into problems that are difficult to treat, time-consuming, expensive, and invasive. This benefits both the dentist and the patient.

When microscopes were first introduced in dentistry, I thought that there would not be much use for them in general dentistry.

I thought that they were the domain of the specialist endodontists. However, since purchasing one, I have been overwhelmingly convinced that there is great use for them in general dentistry as well.

nose. Posture and comfort for the dentist are enhanced with correct setup and use.

Once the learning curve has passed, the postural benefits of microscope use become apparent (Figure 1).

Correct installation and positioning of the microscope in the surgery are vital to ensure easy access and regular use. I opted for a high wall-mounted Global unit, which eliminates any clash with existing equipment such as X-ray units (Figure 2).

Transitions Once I made the decision to purchase a Global microscope, my mindset had to shift from using loupes to using a microscope.

The transition from headband loupes to microscope was postural. Loupes can move around, whereas the microscope is relatively fixed. Overcoming this obstacle was relatively slow as it takes time to readjust to a different visual field. However, once achieved, the benefits of using a microscope are obvious, and working without it would now be impossible for me.

There are several adjustments that dentists need to make once they have taken the step to start using a microscope. I have enjoyed using it and adapted to it. Every time I used it, I became more confident and familiar with it. I now never work without it.

Here are some of the factors that helped me to become more accomplished at using it.

Figure 1: Using a microscope has postural benefits

Sitting comfortably Adjusting the height of the microscope to suit my sitting position and then the patient chair allows for most situations to be visualized almost immediately with minimal adjustment. Smaller adjustments will be accomplished by moving the chair slightly, the microscope slightly, or adjusting the fine focus on the microscope.

If the swivel settings are loose, then it is easy to move with your hand, head, or

Figure 2: A high wall-mounted Global unit Volume 7 Number 6

provided through its UK distributor DP Medical Systems Ltd. Dental assistants also have to make a few changes to the way Improved outcomes they assist the dentist. For example, The microscope provides they have to adjust to a slightly numerous benefits for dentists, different aspirating technique so nurses, and patients. Patients are that they are not obstructing the impressed with the technology, dentist (Figure 3). They also have the level of care offered by microto develop a different technique for dentistry, and the ability to view passing instruments. They must conditions that previously could place instruments in the dentist’s only be described by the dentist. hand with the tips of the instruments This enables the dentist to involve facing in the direction needed for the patient in treatment decisions the surface being worked on. Dental Figure 3: The dental assistants will have to adjust the way they assist the dentist and the rationale for treatments. I assistants also need to render the consider investment in technology instruments nonstick while placing vital to maintain the practice ethos of quality specification to suit, gaining familiarization composites. They need to turn the amber care. I decided to introduce the microscope during the learning curve and the provimicroscope filter on and off when teeth are to my practice for all of these reasons sion of long-term technical support. The being restored with composites. and particularly to improve outcomes and modular concept of the Global microscope At times, it does help to have the light predictability. Early signs indicate that these enables me to add new developments and switched off to prolong the working time latter objectives are being fulfilled. My enthuupgrades as they become available with with composites and for the assistants to siasm for precision dentistry has been further minimum cost implications. I chose Global view textures on the screen via the camera. advanced. EP for its reputation for quality and service Endodontics lends itself especially well to the microscope, and here the skill of the dental assistants is of paramount importance. They need to be excellent at assisting with the sterilization, irrigation, and obturation of the canals.

A whole new world Using a microscope improves the predictability of most procedures. Once using the microscope has been accomplished, a different world awaits. In this new world: • Gingival health is clearly shown and crevicular status accurately determined.

• Enamel textures and dentin characteristics are more visible.

• The marginal bevels and finish lines are very clear.

• Crown margins can be very precise, and preparations can be very exact.

• Pulpal health during procedures can be assessed and minute exposures detected.

• One can travel down root canals and never miss extra canals.

Once you start using the microscope, you can never go back to working without it; it opens up a new world of possibilities.

Going global My Global microscope incorporates a fully adjustable, silent (no fan) LED light with composite filter, a digital stills/video camera for documentation, patient education, and nurse participation. Support from the manufacturer and supplier (for me that’s Global and DP Medical Systems) is important from the outset in choosing the correct Volume 7 Number 6

Endodontic practice 31

TECHNOLOGY

Assistance please

TECHNOLOGY

Technology — the revolution of evolution Dr. Eric Herbranson reflects on technologies that have changed the practice of endodontics

B

irthdays are a time for reflection. I realized at my last one I had become an official “Old Guy” in this specialty of ours.

I’ve pretty much seen it all in my career.

In graduate school, we were well aware of Dr. Herbert Schilder’s emphasis on 3D anatomy and his rediscovery of Dr. Walter Hess’ forgotten work on canal anatomy.

The image in Figure 1 was an epiphany for me because it showed that Hess and Schilder were right about canal anatomy and defined the challenges of endodontics.

This was the time warm gutta percha with its hoped-for 3D obturation was the hot new technique, and we all made the effort to learn its secrets, so we could do it the way the guys in Boston did it.

I was 1 year out of graduate school when Dr. Schilder published his, now iconic, five mechanical objectives for shaping. For me, this time was the start of a life long journey of inquiry with adoption and replacement of ideas as research and technology advanced.

It was engaging and fun. I remember how thrilled I was when the Obtura gun and

System B™ were introduced because I could take my ugly Bunsen Burner off the operatory delivery system. Patients never did like the look of those! First big technology change!

Then along came NiTi rotary file systems.

The flexibility of the metal made an enginedriven file system relatively predictable and safe in curved canals. This was a true leap forward for us and lead to many permutations

in design that continues to this day. The discussion all centered around the instruments and obturation methods. It was all about the process of doing endodontics, not so much about why we were doing it.

The surgical operating microscope came next, and I consider this to be the biggest technology change we’ve had. These microscopes allowed us to see. I took it on faith

Figure 1: A silicon rubber cast of a shaped upper first molar canal system. Developed while in graduate school in 1973, it has been used in numerous publications and lectures

Dr. Eric Herbranson is a practicing endodontist in San Leandro, California, who conducts training and informative seminars around the world.

This article is sponsored by SS White® Endodontics.

32 Endodontic practice

Figure 2: A model from the 3D Interactive Tooth Atlas developed from high-resolution micro-CT scans showing the exquisite detail possible with this technology Volume 7 Number 6

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TECHNOLOGY

Figure 3: The latest multi-taper NiTi files featuring profiles with deep shape for ease of irrigation and obturation and smaller upper diameter for flexibility and dentin conservation. 25/06 vTaper, SS White Burs Inc.

they would improve my clinical results and became an early adopter. I actually replaced my overhead lights with a scope in each operatory to force myself to use them. The first week I had my scopes, I did a retreatment on a symptomatic tooth I’d treated a couple of years previously. Working through a crown, I’d found the MB2 and MB3 canals but had missed the MB1. It was easily found with the scope, and I never looked back at my decision to adopt them. Most of you, I’m sure, have had similar experiences.

Computers started to help us in the mid-1990s. I became acquainted with a computer-imaging expert at Stanford Medical School who introduced me to the, then new, micro-CT technology. That ultimately led to the development of the 3D Interactive Tooth Atlas, which allowed us to see the anatomy of real teeth blown up on a computer screen while interactively manipulating the models. It became another validation for Dr. Hess and a robust example of the anatomical issues we deal with. The first computers we used to visualize these scans were $100,000 workstations. Thanks to Moore’s Law (that states that processor speeds, or overall processing power for computers, will double every 2 years), by the time the Tooth Atlas was commercialized a couple of years later, any normal PC was powerful enough to drive the program.

This growth in computer power eventually allowed for the development of the CBCT technology we have now. 3D imaging is a game changer because these scans are just good enough to see dental anatomy specific to our particular patient, and we have a much clearer picture of where the bone is around the teeth. That is a real advantage in diagnosis and treatment. But it has also raised questions and misconceptions we need to resolve. We’re still not sure of the significance of all we see on the scan, and some findings can be misinterpreted. I’ve seen people diagnose vertical root fractures when what they were looking at was scan artifact. Some more education is in order.

34 Endodontic practice

Most changes have been evolutionary — some disruptive, like NiTi files, the microscope, and CBCT imaging. But I look at the issues that are being discussed now and what is on the horizon, and I can’t help but feel the changes are going to accelerate and could be revolutionary in nature.

Sometimes the technologies reinforce each other to allow us to make paradigm shifts. This has happened with the goal of conservation to improve tooth strength.

The newest multi-taper file systems have smaller flute diameters at the D8 to D16 area of the file while still creating adequate room at the apex for irrigation and obturation.

These design changes and heat treating have created files that are significantly more flexible and fatigue resistant than the older designs. CBCT imaging gives us accurate 3D modeling of the tooth, which improves our mental picture for more accurate accesses, and the scope allows us to visualize through a smaller opening that was traditionally recommended. These tools allow us to replace our legacy access designs, with their convenience form and wider occlusal opening, with ones that conserve critical peri-cervical dentin. The result is a more nuanced access preparation with safer, more root-form-appropriate shaping in the upper part of the canal system. These efforts significantly increase tooth strength and help reduce the incidence of fracture.

It’s the intersection of all these technologies that allows us to gracefully do this.

I look back on all these developments with the joy of discovery because the challenges have been interesting and engaging.

Most changes have been evolutionary — some disruptive, like NiTi files, the microscope, and CBCT imaging. But I look at the issues that are being discussed now and what is on the horizon, and I can’t help but feel the changes are going to accelerate and could be revolutionary in nature.

People are questioning our disease model, and what radiographic findings really mean.

Our traditional plantonic bacterial model is now a biofilm discussion, a much different “animal.” We see cases all the time that do not match our disease model. We see 30-year-old silver point treated molars with missed MB2s that are functional and in solid bone. There are cases that were never obturated that healed. There are cases that are open to the oral environment that healed.

Our legacy research and legacy treatment protocols are coming into question more than ever before. And there are disruptive technologies like Sonendo® on the horizon.

What does it all mean? I’m not sure, but it’s going to be fun to watch. I hope I am around in another 40 years to find out. EP Volume 7 Number 6

T

he American Association of Endodontists’ Board of Directors has selected Peter S. Weber, MS, CAE, as its new executive director. An innovative and collaborative leader, Weber brings nearly 28 years of experience in professional association management to the AAE. “After an extensive, nationwide search, the AAE Board is pleased to announce Peter as our new executive director,” said AAE President Dr. Robert S. Roda. “Peter brings a wealth of experience in association management and has demonstrated success in membership growth and satisfaction, support for professional development, and public policy advocacy. With him, we look forward to growing the AAE in innovative ways to benefit members and patients.”

Weber comes to the AAE from the Illinois State Veterinary Medical Association (ISVMA), where he served as executive director since 2003. Under his leadership, the association experienced 250% membership growth and 500% financial growth. He helped develop the Illinois Veterinary Medical Foundation and the country’s largest and most comprehensive veterinary heritage museum, demonstrated vision and skill in outreach efforts to veterinary students and young professionals, and improved the ISVMA’s continuing education and communications programs.

Legislatively, Weber ensured that the veterinary profession has the most prominent voice in the Illinois State Capitol on animal health and welfare issues. He developed the ISVMA Legislative Action Center, created a successful grassroots advocacy program, implemented a Lobby Day, and wrote and assisted with the passage of significant laws that affect veterinary medicine.

“I came here because I believe AAE has a very talented and hardworking staff and volunteer leaders committed to the organization’s mission,” said Weber. “My goal is to empower and motivate every person at AAE to do magnificent things with our united vision and combined work ethic. Our efforts will ultimately improve the endodontic profession. I am inspired by what you have already accomplished and strongly believe that, together, we will continue to make a tremendous difference.”

Weber received his bachelor’s degree in political science from Knox College and Volume 7 Number 6

earned a master’s in educational administration from the University of Illinois at UrbanaChampaign. A certified association executive, Weber is an active volunteer in the American Society of Association Executives and the Illinois Society of Association Executives, and frequently lectures and writes about association management issues. He also serves on or has recently served on the boards of directors of the ASAE, American Society of Veterinary Medical Association Executives, Illinois Ornithological Society, and the Ovarian Cancer Symptom Awareness Organization.

His interests include ornithology, wildlife photography, mountain hiking, and sports.

About the American Association of Endodontists The American Association of Endodontists, headquartered in Chicago, Illinois, represents more than 7,600 members worldwide. The AAE, founded in 1943, is dedicated to excellence in the art and science of endodontics and to the highest standard of patient care. The Association inspires its members to pursue professional advancement and personal fulfillment through education, research, advocacy, leadership, communication, and service. For more information about the AAE, visit the Association’s website at www.aae.org. EP Endodontic practice 35

AAE NEWS

American Association of Endodontists names Peter S. Weber new Executive Director

CONTINUING EDUCATION

The rationale for the suggested use of fiber post segments in composite core buildups for endodontically treated teeth Drs. Leendert Boksman and Gary Glassman discuss the choices and challenges involved in certain restorations

T

he restoration of teeth utilizing composites still presents a myriad of clinical challenges for the dental clinician. This is especially true for extensively broken down teeth as well as those teeth that have been accessed endodontically. Fiber posts — such as the quartz Macro-Lock® Post® Illusion® X-RO® (RTD, St. Egreve, France); UniCore® Fiber post (Ultradent); and D.T. Light-Post® (RTD, St. Egreve, France) — are now the posts of choice for a direct one-appointment restoration of the severely compromised endodontically treated tooth. Current research supports the use of an etch and rinse bonding protocol, with a compatible bonding agent, utilizing a dual-cured composite cement that can be utilized for the core as well (CosmeCore™, Cosmedent®; CoreCem®, RTD, St. Egreve, France; Zircules™, Clinician’s Choice Dental Products, Inc.) for best results.1,2 Traditionally, minimally accessed endodontically treated teeth that are not extensively compromised by caries or fracture have been restored solely with a composite core, without the placement of a post. This decision must be based on the amount of tooth structure left and if a full coverage restoration is to be placed now or in the future. The width and height of the remaining ferrule are critical to restorative success (Figures 1A and 1B). Also,3-6 the number of tooth walls left and post

Educational aims and objectives

This clinical article aims to discuss the rationale for the suggested use of fiber post segments in composite core buildups for endodontically treated teeth.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 41 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some posts available for a direct one-appointment restoration of the severely compromised endodontically treated tooth.

• Recognize the many different types of composites that are now available to the practitioner.

• Realize some effects of possible polymerization contraction of the composite resin and contraction stress.

• Read about some suggested modifications of restorative techniques for placing a core in an endodontically treated tooth.

• See some relationship between immediate high-intensity light polymerization and polymerization stress.

preparation significantly affect the long-term restorative outcome (Figure 2).6,7,8 In a review of 41 articles published between 1969 and 1999 (the majority from

the 1990s), Heling states that “the literature suggests that the prognosis of root canaltreated teeth can be improved by sealing the canal and minimizing the leakage of

Figure 1A: Schematic diagram of a molar with conservative access opening, which when restored with a core only, will leave sufficient width and height of dentin to act as a ferrule resisting failure

Figure 1B: The same tooth with a widely divergent access opening, restored with Macro-Lock posts and composite core, when prepared for a full coverage restoration will not leave sufficient dentin (no ferrule), resulting in a stand-alone core, which will drastically influence failure rate

Leendert (Len) Boksman, DDS, BSc, FADI, FICD, graduated from the Faculty of Dentistry, University of Western Ontario with a DDS in 1972. He practiced dentistry for 7 years, then joined the Faculty of Dentistry at Western in 1979. In 1987, he returned to full-time private practice. Dr. Boksman lectures nationally and internationally, and is widely published. He is a part-time paid consultant to several dental manufacturers. He can be reached at lenpat28@gmail.com Gary Glassman, DDS, FRCD(C), is the author of numerous publications and lectures globally on endodontics. He is on staff at the University of Toronto, Faculty of Dentistry in the graduate department of endodontics, and is Adjunct Professor of Dentistry and Director of Endodontic Programming for the University of Technology, Kingston, Jamaica. He can be reached at gary@rootcanals.ca.

36 Endodontic practice

Volume 7 Number 6

Polymerization contraction (shrinkage) Many different types of composites are now available to the practitioner, including microfills, macrofills, hybrids, and small particle hybrids, nanofills, nanohybrids, or microhybrids.13 Even though the formulations can be adjusted in handling to make these composites “packable,” “flowable,” or “sculptable,” polymerization shrinkage or contraction stress is still the most important clinical challenge or problem associated with their use.14,15 This shrinkage or contraction and the stress created vary from composite

Figure 2: Schematic diagram of the molar in Figure 1A, but with Macro-Lock Fiber Post segments as inserts to decrease composite volume and increase polymerization factors

Volume 7 Number 6

to composite and can be affected by the following: • Its filler type and loading content • The resin matrix and its molecular weight • The shade and opacity • The cavity preparation shape (C-Factor) width and depth • The composite thickness • The elastic modulus of the composite and tooth • The irradiance level and curing time • The spectral output of the curing light • The curing light placement • Bulk or incremental fill • The rate of force development (highirradiance lights) • The initiator system used • The degree of conversion16-25 In published studies, shrinkage values for various composites have been reported from 2.00 to 5.63 vol. percent26, and 1.67 to 5.68 percent,27 with flowables demonstrating the highest shrinkage with contraction stress measurements ranging from 3.3 to 23.5 MPa.26 Not all composites advertised as low shrinkage actually have reduced polymerization shrinkage measurements. When evaluating seven low-shrink BisGMA-based composites, Aelite™ LS Posterior (Bisco, Inc.) and N’Durance® (Septodont) presented relatively high-shrinkage values.28 The polymerization contraction of the composite resin and contraction stress created, as discussed before, can produce tensile forces on the tooth structure and the bonding system that may not only disrupt the bond to the cavity walls29,30 but also fracture enamel along the prisms (white line margins).31 This failure can lead to caries, sensitivity in vital teeth, and microleakage, allowing the penetration of bacteria, fluids, and toxins, which can negatively affect the success of endodontic treatment (coronal leakage).32 Braga, et al., state that “shrinkage stress development must be considered a multi-factorial phenomenon” and that “the volume of the shrinking composite becomes a variable to be considered.”33 Unterbrink and Liebenberg in their publication state that shrinkage stress increases with increasing C-Factor and that the size of the restored cavity is an important factor when bulk filling.34 Their study35 also shows that incremental filling lowers the C-Factor and that it is better than bulk cure because of better adaptation to the cavity wall, decreasing microleakage and increasing the degree of conversion. In a study looking at microleakage and cavity dimensions, it was found

that microleakage seemed to be related to a restoration’s volume, but not to its C-Factor.36 With bulk filling techniques, the hardness or conversion of composites are significantly lower than those of the same material placed with the incremental technique.37 Watts, et al.,38 recommend that the restorative mass must be equally considered when translating shrinkage science into specific clinical recommendations.

So where does this lead us in a suggested modification of our restorative technique for placing a core in an endodontically treated tooth? Currently, when there are enough walls and tooth structure left, many clinicians insert a bulk fill, dual-cure composite resin into the endodontic access opening (the same material as that used for cementing the fiber post) and then cure it all at once with an LED curing light. As mentioned previously, this bulk fill not only creates a challenge for proper depth of cure and maximum physical properties on polymerization, which will be addressed later in this article, but the large volume/amount of composite inserted negatively affects the integrity of adhesion and increases microleakage. The typical access opening, which is essentially a very deep Class I cavity preparation, not only requires a large amount of composite, but as well, places the composite in the highest C-factor cavity preparation configuration of five. Only when utilizing a composite deep in the prepared root canal has the C-Factor claimed to be higher at 200 to infinity.39 The suggested solution to the high polymerization and contraction stress caused by bulk filling the access opening is to reduce the mass or bulk of composite by placing multiple Fiber Post Segments into the composite mass before curing with the LED light. It has been conclusively shown that even when the C-Factor is at 200 or more in a prepared root canal, minimizing the thickness of the composite (the mass), results in less contraction stress (S-Factor), which increases the patency of the bond to the root canal walls decreasing microleakage.40-43 Of course, the placement of inserts into composite is not a new idea.

Glass ceramic inserts and beta quartz have been used to decrease composite volume, and later silica glass and ceramics were introduced as a method for post-composite insertion bulk reduction.44-46 These techniques demonstrated increased marginal patency and less microleakage, but the inserts were difficult to contour and polish with adhesion between the inserts and the composite being a challenge.47,48 Composite Endodontic practice 37

CONTINUING EDUCATION

oral fluids and bacteria into the periradicular areas as soon as possible after completion of root canal therapy.”9 A similar review by Saunders, et al., also concluded that coronal leakage of root canals is a major cause of root canal failure.10 Sritharan states, “it has been suggested that apical leakage may not be the most important factor leading to the failure of endodontic treatment — but that coronal leakage is far more likely to be the major determinant of clinical success or failure.”11 Coronal microleakage can occur due to a deficient final restoration (due to resultant microleakage from polymerization contraction, cement wash out, poor full coverage, flex, etc.), and resultant secondary caries.12

CONTINUING EDUCATION megafillers were introduced later, as these were essentially the same as the matrix of the bulk filled composite, eliminating the inherent chemical differences between the materials.49,50 The authors suggest the insertion of multiple high-quality, high-capacity, light-conducting fiber post segments. (Not all fiber posts conduct light efficiently.51,52) This is not only to reduce the composite volume, thereby minimizing the potential for microleakage, but is also equally as critical to use the light conductance of the fiber post segments to significantly increase the degree of polymerization of the dual-cure composite resin cements/core materials deep in the access opening, thereby increasing their physical properties.53 In their review of polymerization shrinkage, Cakir, et al., discuss the attenuation of light, which means that the deeper layers of composite resin are less cured with reduced mechanical properties, and that bulk filling shows significantly less hardness.54 Others have also shown that bulk placement and increased cavity depth result in a significant decrease in the effectiveness of polymerization, regardless of the exposure time.55 The ADA Professional Product review on Restorative Materials evaluated the depth of cure of 38 restoratives with ranges of 1.2 mm to 5 mm with a core material CompCore™ AF SyringeMix™ (Premier Dental Products Co.) (W) being the lowest depth of cure at 1.2 mm. Included in the study were measurements of maximum polymerization shrinkage stress showing that LuxaCore® Dual Smartmix™ (DMG America) (W) was the highest in stress MPa of the core materials tested, with Clearfil™ Photo Core (Kuraray America, Inc.) (T) showing the highest development of shrinkage stress rate.56 Dual cure composite materials show the best physical properties and best polymerization with sufficient light exposure, even though they are claimed to polymerize in the absence of light,57-61 and “there is no

evidence for a substantial chemically induced polymerization of dual cure resins that occurs after light exposure is completed.”62 This reality is especially critical for dual-cure selfadhesive resin cements Maxcem™ and RelyX™ Unicem (3M ESPE), which show a better degree of conversion when they are light activated, with a lack of light activation decreasing the monomer conversion by 25% to 40%63; and even in their dual cure mode, the degree of cure at best among the self-etch adhesives is only 41.52%.64-66 Thus, the placement of a bulk filled dual cure composite into the endodontic access opening, followed by the placement of multiple fiber post segments that carry sufficient light energy to the depth of the occlusal floor of the access preparation, will increase the polymerization conversion, resulting in a composite that demonstrates superior physical properties.

As a final comment, it has been proven that immediate high-intensity light polymerization creates the greatest polymerization stress. Ilie, et al., state that “fast contraction force development, high contraction stress, and an early start of the stress build-up cause tension in the material with possible subsequent distortion of the bond to the tooth structure.”67 This finding has been collaborated by many others in the scientific literature with resultant recommendations for a soft-start or lower energy over a longer period of time.68,69 Miller states that “manufacturers continue to make outlandish claims of their curing capabilities, most of which fall into the “too good to be true” category,70 and Swift concludes that “the curing times recommended by a manufacturer might not deliver the amount of energy required to adequately cure composite, even under the ideal laboratory conditions,” that “very short curing times are not a good idea in most clinical situations,” and that “longer curing times are required.”71 As well, Swift states that “instead of obtaining a boost, the

Figure 3: Radiographic presentation of a patient with pain in the lower left second molar which has been minimally restored

Figure 4: The clinical presentation of the second molar which would demonstrate sufficient tooth structure remaining after root canal treatment so that a fiber post and core is not required

38 Endodontic practice

‘turbo’ tip actually will reduce the amount of light reaching the composite to initiate the polymerization process.”72

Clinical Case A 64-year-old female presented to the endodontic office with an uneventful medical history. She complained of spontaneous pain on the lower left side of 1 week’s duration, which radiated up the ramus of the jaw and was causing headaches. She also complained of hot and cold sensitivity with pain on biting.

Clinical tests revealed pain to cold, which lingered for 5 minutes, and a sharp electriclike pain when a Tooth Slooth® (Professional Results, Inc.) was placed over the DL cusp tip. A distal crack was visualized. There was no periodontal pocketing. All other mandibular left and maxillary left teeth tested vital and asymptomatic. The radiograph revealed a small shallow minimally invasive amalgam restoration (Figure 3). The diagnosis was Cracked Tooth Syndrome with an irreversibly inflamed pulp. The patient was advised of the questionable long-term prognosis with cracked teeth yet decided to try and retain it, understanding that if the crack extended in the root proper and a periodontal pocket developed, then extraction with an implant replacement would be a viable solution.

Due to the minimal invasiveness of the restoration, it was anticipated that after endodontic treatment, there would be enough coronal tooth structure left to allow for the preparation of a full-coverage restoration with a fully circumferential ferrule of at least 2+ mm in height, as well as width (Figure 4). Figure 5 is a magnified view of the distal vertical crack, with the wear facet on the lingual cusp indicating a working side contact interference. Endodontic therapy was initiated under the microscope, and after a thorough debridement and shaping of the root canal spaces (Figure 6), the roots were obturated with gutta percha using a continuous wave of condensation technique

Figure 5: Magnified view of the distal ridge of the second molar demonstrating a vertical crack

Volume 7 Number 6

Figure 7: The root canals have been obturated with gutta percha, a couple of mm below the level of the pulpal floor

Figure 8: After placement of the phosphoric acid (Ultra-Etch, Ultradent) a microbrush is used to agitate the acid to clean the dentin, rinsed, and lightly dried

Figure 9: MPa bonding agent is applied to a microbrush and agitated into the tubules, followed by evaporation of the solvent with an air-only line

Figure 10: The bonding agent is cured for 10 seconds with a Valo curing unit (Ultradent)

Figure 11: Multiple Macro-Lock X-RO (Clinician’s Choice Dental Products) fiber post segments (covered with a bonding agent which is first light cured) are verified for fit into the distal and two mesial canals

Figure 12: The CosmeCore A2 is injected into the bottom of the pulpal area filling to one half of the crown height, followed by the placement of the Macro-Lock X-RO segments at the canal orifices

Figure 13: Occlusal view of the CosmeCore placed half way up the coronal tooth structure with the three segments placed.

This first layer was light cured and followed with the completion of the final CosmeCore layer cured for 20 seconds

Figure 14: Postoperative radiograph of the completed restoration

to a level 2 mm below the pulpal floor (Figure 7). Phosphoric acid etching was initiated with the placement of Ultra-Etch® Etchant (Ultradent), followed by micro-brush agitation to work the etchant into the dentin, a thorough rinse, and light air drying (Figure 8). Figure 9 shows the application of MPa bonding agent (Clinician’s Choice Dental Products) with a micro-brush, which again was followed by agitation to facilitate deeper penetration of the bonding agent, followed by evaporation of the solvent for 10 seconds. The bonding agent was cured with a Valo® curing light (Ultradent) for 10 seconds utilizing a Valo Proxiball Lens (Figure 10). The Macro-Lock

X-RO segments were verified for fit over the three canal orifices, and then coated with MPa bonding agent, which was cured for 10 seconds (Figure 11). CosmeCore A2 was injected into the pulp chamber one-half way up the occlusal height of the clinical crown (Figure 12). The Macro-Lock X-RO segments were inserted into the CosmeCore followed by a 10-second cure with the Valo (Figure 13). The rest of the occlusal access opening is filled with the CosmeCore and thoroughly cured with the Valo for 20 seconds. Figure 14 is the final postoperative radiograph showing the placement of the fiber segments into the core. The final restoration of the occlusal

Volume 7 Number 6

Figure 15: Occlusal view of the final restoration, trimmed, and adjusted to the occlusion. The tooth is now ready for a full coverage crown or onlay to protect the clinical crack

access opening is shown in Figure 15 after trimming and occlusal adjustment. The endodontically treated tooth is now ready for a final restoration.

Endodontic practice 39

CONTINUING EDUCATION

Figure 6: Completion of the debridement of the canals after rubber dam isolation with a better view of the extent of the distal crack line

CONTINUING EDUCATION This article has recommended restoring the teeth that meet the criteria for not needing the placement of fiber posts because of sufficient remaining tooth structure with the use of multiple fiber post segments placed into the dual-cure composite cores of endodontically treated teeth based on the preceding evidence. This will decrease the overall polymerization contraction and stress formation, thereby reducing occlusal microleakage, while at the same time, driving the dual-cure composite to a better overall cure or conversion for better physical properties. EP Acknowledgments

The authors wish to thank Mrs. Laura Delellis for her work in creating the figures used in this article.

This article was reprinted with permission from Oral Health, Canada’s leading dental journal.

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28. Boaro LC, Goncalvas F, Guimaraes TC, Ferracane JL, Versluis A, Braga RR. Polymerization stress, shrinkage, and elastic modulus of current low-shrinkage restorative composites. Dent Mater. 2010;26(12):1144-1150.

29. Rosin M, Urban AD, Gartner C, Bernhardt O, Splieth C, Meyer G. Polymerization shrinkage-strain and microleakage in dentin-bordered cavities of chemically and light-cured restorative materials. Dent Mater. 2002;18(7):521-528.

30. Irie M, Suzuki K, Watts DC. Marginal gap formation of light-activated restorative materials: effects of immediate setting shrinkage and bond strength. Dent Mater.

2002;18(3):203-210.

53. Taneja S, Kumari M, Gupta A. Evaluation of light transmission through different esthetic posts and its influence on the degree of polymerization of a dual cure resin cement. J Conserv Dent 2013;16(1):32-35.

54. Cakir D, Sergent R, Burgess JO. Polymerization shrinkage – a clinical review. Inside Dentistry. 2007;3(8):84-87.

55. Yap AU. Effectiveness of polymerization in composite restoratives claiming bulk placement: impact of cavity depth and exposure time. Oper Dent. 2000;25(2):113-120.

56. Council on Scientific Affairs. ADA Professional Product Review – Restorative materials. Spring 2010;5(2):1-16.

57. Peutzfeldt A. Dual cure resin cements. In vitro wear and effect of quantity of remaining double bonds, filler volume, and light curing. Acta Odontol Scand. 1995;53(1):29-34.

31. Pensak T. Clinical Showcase – Get in the groove. JCDA Feb 2004;70(2):118-119.

58. El-Badrawy WA, El-Mowafy OM. Chemical versus dual curing of resin inlay cements. J Prosthet Dent.

1995;73(6):515-524.

32. Davidson CL, de Gee AJ, Feilzer A. The competition between the composite-dentin bond strength and the polymerization contraction stress. J Dent Res. 1984;63(12):1396-1399.

59. Yan YL, Kim YK, Kim KH, Kwon TY. Changes in degree of conversion and microhardness of dental resin cements.

Oper Dent. 2010;35(2):203-210.

33. Braga RR, Ballester RY, Ferracane JL. Factors involved in the development of polymerization shrinkage stress in resin-composites: a systematic review. Dent Mater.

2005;21(10):962-970.

60. Mendes LC, Matos IC, Miranda MS, Benzi MR. Dual-curing, self adhesive cement: influence of the polymerization modes on the degree of conversion and micro-hardness. Mat Res. 2010;13(2):171-176.

34. Unterbrink GL, Liebenberg WH. Flowable resin composites as “filled adhesives”: literature review and clinical recommendations. Quintessence Int. 1999;30(4):249-257.

61. Braga RR, Cesar PF, Gonzaga CC. Mechanical properties of resin cements with different activation modes. J Oral Rehabil. 2002;29(3):257-262.

35. Yamazaki PC, Bedran-Russo AK, Pereira PN, Swift EJ Jr. Microleakage evaluation of a new low-shrinkage composite restorative material. Oper Dent. 2006;31(6):670-676.

62. Rueggeberg FA, Caughman WF. The influence of light exposure on polymerization of dual-cure resin cements. Oper Dent. 1993;18(2):48-55.

36. Braga RR, Boaro LC, Kuroe T, Azevedo CL, Singer JM. Influence of cavity dimensions and their derivatives (volume and ‘C’ factor) on shrinkage stress development and microleakage of composite restorations. Dent Mater.

2006;22(9):818-823.

63. Cadenaro M, Navarra CO, Antoniolli F, Mazzoni A, Di Lenarda R, Rueggeberg FA, Breschi L. The effect of curing mode on extent of polymerization and microhardness of dual-cured, self-adhesive resin cements. Am J Dent. 2010;23(1):14-18.

37. Campdonico CE, Tantbirojn D, Olin PS, Versluis A. Cuspal deflection and depth of cure in resin-based composite restorations filled by using bulk, incremental and transtooth-illumination techniques. J Am Dent Assoc.

2011;142(10):1176-1182.

38. Watts DC, Satterthwaite JD. Axial shrinkage-stress depends upon both C-factor and composite mass. Dent Mater.

2008;24(1):1-8.

39. Breschi L, Mazzoni A, De Stefano DE, Ferrari M. Adhesion to intraradicular dentin: a review. J Adhes Sci Technol.

2009;23(7-8):1053-1083.

40. Di Francescantonio M, Aquiar TR, Arrais CA, Cavalcanti AN, Davanzo CU, Giannini M. Influence of viscosity and curing mode on degree of conversion of dual-cured resin cements.

Eur J Dent. 2013;7(1):81-85.

41. Tay FR, Loushine RJ, Lambrechts P, Weller RN, Pashley DH. Geometric factors affecting dentin bonding in root canals: a theoretical modeling approach. J Endod.

2005;31(8):584-589.

42. Okuma M, Nakajima M, Hosaka K, Itoh S, Ikeda M, Foxton RM, Tagami J. Effect of composite post placement on bonding to root canal dentin using 1-step self-etch dualcure adhesive with chemical activation mode. Dent Mat J. 2010;29(6):642-648.

43. Egilmez F, Ergun G, Cekic-Nagas I, Vallittu PK, Lassila LV. Influence of cement thickness on the bond strength of

64. Vrochari AD, Eliades G, Hellwig E, Wrbas KT. Curing efficiency of four self-etching, self-adhesive resin cements.

Dent Mater. 2009;25(9):1104-1108.

65. Moraes RR, Boscato N, Jardim PS, Schneider LF. Dual and self-curing potential of self-adhesive resin cements as thin films. Oper Dent. 2011;36(6):635-642.

66. Aguiar TR, Francescantonio M, Arrais CA, Ambrosano GM, Davanzo C, Giannini M. Influence of curing mode and time on degree of conversion of one conventional and two selfadhesive resin cements. Oper Dent. 2010;35(3):295-299.

67. Ilie N, Felten K, Trixner K, Hickel R, Kunzelmann KH. Shrinkage behavior of a resin-based composite irradiated with modern curing units. Dent Mater. 2005;21(5):483-489.

68. Feilzer AJ, Dooren LH, de Gee AJ, Davidson CL. Influence of light intensity on polymerization shrinkage and integrity of restoration-cavity interface. Eur J Oral Sci. 1995;103(5):322-326.

69. Lu H, Stansbury JW, Bowman CN. Impact of curing protocol on conversion and shrinkage stress. J Dent Res. 2005;84(9):822-826.

70. Miller MB. Curing lights: what you should know before buying one. Oral Health. December 2009:48-56.

71. Swift EJ Jr. Critical appraisal. Visible light-curing. J Esthet Restor Dent. 2011;23(3):191-196.

72. Corciolani G, Vichi A, Swift EJ Jr. Turbo Tips. J Esthet Restor Dent. 2011;23(5):294-295.

Volume 7 Number 6

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The rationale for the suggested use of fiber post segments in composite core buildups for endodontically treated teeth BOKSMAN-GLASSMAN

1. Traditionally, minimally accessed endodontically treated teeth that are not extensively compromised by _____ have been restored solely with a composite core, without the placement of a post. a. caries b. fracture c. bone resorption d. both a and b 2. The width and height of the remaining ferrule ________ restorative success. a. have no effect on b. are only peripheral to c. are critical to d. double 3. Also, the _______ significantly affect the long-term restorative outcome. a. coronal fluids b. number of tooth walls left c. post preparation d. both b and c 4. ______ can occur due to a deficient final restoration (due to resultant microleakage from polymerization contraction, cement wash out, poor full coverage, flex, etc.), and resultant secondary caries. a. Ferrule compromise b. Etching

Volume 7 Number 6

c. Coronal microleakage d. Thickness of the elastic modulus 5. Watts, et al., recommend that the _______ must be equally considered when translating shrinkage science into specific clinical recommendations. a. restorative mass b. coronal expansion c. polymerization d. high radiance

8. In their review of polymerization shrinkage, Cakir, et al., discuss the ______, which means that the deeper layers of composite resin are less cured with reduced mechanical properties, and that bulk filling shows significantly less hardness. a. contraction of light b. attenuation of light c. prisimization of light d. distalization of light

6. The suggested solution to the high polymerization and contraction stress caused by bulk filling the access opening is _____________ the mass or bulk of composite by placing multiple Fiber Post Segments into the composite mass before curing with the LED light. a. to increase b. to reduce c. to totally extract d. to wash out

9. Thus, the placement of a bulk filled dual cure composite into the endodontic access opening, followed by the placement of multiple fiber post segments that carry sufficient light energy to the depth of the occlusal floor of the access preparation, will _________ the polymerization conversion, resulting in a composite that demonstrates superior physical properties. a. neutralize b. decrease c. increase d. eliminate

7. The authors suggest the insertion of multiple _________ fiber post segments. (Not all fiber posts conduct light efficiently.) a. high-quality b. high-capacity c. light-conducting d. all of the above

10. As a final comment, it has been proven that immediate high-intensity light polymerization creates _____ polymerization stress. a. the greatest b. the least c. no d. significantly less

Endodontic practice 41

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

ProGlider™: clinical protocol Using clinical case reports, Dr. Peet J. van der Vyver outlines the clinical protocol for the use of the ProGlider™, a single file glide path rotary instrument to facilitate glide path enlargement before canal preparation

D

espite the fact that nickel-titanium manual and rotary instruments have revolutionized the field of endodontics (Kubde, et al., 2012), there is still a risk of instrument fracture as a result of cyclic or torsional fatigue (Sattapan, et al., 2000; Serene, Adams, Saxena, 1995; Ullmann, Peters, 2005; Plotino, et al., 2009). The preparation of a glide path prior to the introduction of rotary nickel-titanium instruments became a standard adjunct to ensure more safety during the use of these instruments (Mounce, 2004). According to West (2006, 2010, 2011a), a glide path can be defined as a smooth radicular tunnel from the canal orifice of the canal to the physiologic terminus of the root canal. In other words, the clinician should ensure that there is an uninterrupted pathway (glide path) for the first rotary instrument to passively follow the root canal up to the canal terminus.

Some clinicians advocate that a glide path can either be created with hand files (manual glide path) or by using small rotary files (mechanical glide path). However, it is very important to realize that the initial phase of a glide path can only be discovered or created by using small stainless steel hand files (sizes 06-10 in a sequential manner) and not by the use of rotary “glide path” instruments (Nahmias, Cassim, Glassman, 2013).

According to West (2011b), it is very important that clinicians understand the following observations regarding root canal anatomy: 1. Most root canal foramina are at least the diameter of a No.15 hand instrument.

2. All root canal systems are different.

3. Many root canal systems are already essentially smooth-walled tunnels, albeit some of them are much narrower than a No.10 hand file.

Dr. Peet J. van der Vyver is extraordinary professor at the Department of Odontology, School of Dentistry, University of Pretoria. His private practice is limited to endodontics in Sandton, South Africa. (Visit www.studio4endo.com for more information.)

42 Endodontic practice

Educational aims and objectives

This clinical article aims to outline the clinical protocol for the use of the ProGlider, a single file glide path rotary instrument, to facilitate glide path enlargement before canal preparation with ProTaper® Next instruments by means of clinical case reports.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 48 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize clinical protocol for the use of the single file glide path rotary instrument, ProGlider.

• Realize that certain types of root canal anatomy will affect the glide path and the file needed.

• Identify how to secure a reproducible glide path in certain situations.

4. After restorative procedures or a traumatic incident, the dental pulp responds by either becoming necrotic or calcific (from the crown toward the apex).

Clinically, the author observed that between 20% and 40% of root canals present with an irregular type of glide path in the apical third of root canal systems (Figure 1). This means that when we try to negotiate these types of canals with a small endodontic file, it can often hang up on one of the root canal wall irregularities (Figures 2A-2C). To complete canal negotiation, it often requires pre-bending of the tip of the hand instrument, followed by meticulous small negotiation steps until the file reaches the apical terminus (Figure 2D) or passes through the apical foramina (patency). In other words, the pre-bent, stainless steel K-file is used to scout and negotiate the root canal up to patency in order to discover the glide path.

During this phase, the clinician is made

Figure 1: Irregular canal path in apical part of a root canal system

Figures 2A-2D: A-C. Small endodontic file that hangs up on root canal’s wall irregularities (arrows) on different levels of the system. D. After several meticulous small negotiation steps with a small pre-bent file, it was able to follow the canal path up to the apical foramen Volume 7 Number 6

Figure 5: ProGlider, single file rotary glide path instrument

aware of the canal size, possible obstructions, calcifications or bifurcations, and presence of sharp canal curvatures.

Clinicians often feel proud when they manage to negotiate a canal to patency.

However, this is often followed by frustration when they discover that, when the file is pulled back from the canal, it is impossible to push it back in order to follow the previously discovered canal path. The reason for this is that the canal path is not a reproducible path, and the tip of the file hangs up against the irregularities or obstructions in the root canal system (Figures 3A-3C). Failure to make the canal path reproducible at this early stage of treatment often results in ledge formation, fracture of instruments, inadequate irrigation, and obturation.

So, how do we secure a reproducible glide path in these situations? Once you have managed with a small file (06, 08, or 10 K-file) to follow through all the irregularities in the root canal up to your selected working length, it is very important not to pull the file back or out of the root canal. This instrument must be used to smooth some of the irregularities on the canal walls (Figure 4A) and, at the same time, used to remove some restrictive dentin in certain areas of the root canal.

The file is moved manually in short amplitude vertical strokes until the file feels loose at this length. According to West (2010), this can mean half a dozen or 100 manual strokes — whatever it takes to get the file loose at this position.

The amplitude is then increased in 1 mm increments until the file feels loose up to 4 mm from the working length. If the first file was a 06 K-file, then the same procedure should be followed with a 08 and then a 10 Volume 7 Number 6

K-file. If the first file was a 08 K-file, then the same procedure should be followed with a 10 K-file. The end goal should be that a size 10 K-file can be pushed with light finger pressure from 4-5 mm short of working length up to patency of the root canal system, without any interference or obstruction. This will confirm a reproducible glide path (Figure 4B).

It is recommended that the minimal size of a glide path should be a “super loose” size 10 K-file (West, 2010).

Only after establishment of a reproducible glide path up to a size 10 K-file can it be enlarged manually with a size 15-20 K-file or mechanically by means of rotary nickeltitanium glide path instruments (such as PathFiles® (Dentsply Tulsa Dental Specialties). In general, a size 15 K-file will not easily follow the glide path that was prepared with a size 10 K-file because of the fact that the tip of this instrument is 50% wider in diameter compared to the tip size of a size 10 K-file (West, 2011b).

West (2011b) warns that a size 15 K-file is one of the most dangerous instruments that can be used for glide path enlargement, because it often results in ledges, blocks, and even canal transportation. The only way to safely and predictably enlarge the glide path manually up to a size 15 or 20 K-file is to make use of the “balance manual motion” technique (West, Roane, 1998; West, 2006; West, 2008). The easiest and most predictable method to enlarge the glide path is to use rotary path enlargement files.

The PathFile rotary system consists of three nickel-titanium 02 tapered rotary instruments that can be used to increase the glide path diameter. PathFile No.1 (purple ring) has an ISO 013 tip size, PathFile No. 2 (white ring)

Figures 6A-B: A. ProGlider is used to enlarge the reproducible glide path. B. Final shape of the reproducible glide path. Note that all the canal irregularities and obstructions are removed.

This glide path will accept the first rotary preparation instrument, providing an uninterrupted pathway for the instrument to passively follow the root canal up to the canal terminus

has an ISO 016 tip size, and PathFile No.3 (yellow ring) has an ISO 019 tip size.

Several studies advocate glide path preparation to a minimum of 0.20 mm before the use of rotary nickel-titanium instruments (Berutti, et al., 2004; Varela Pantino, et al., 2005). Berutti, et al. (2004), also suggest that the canal diameter after glide path preparation should be at least one size larger than the tip of the first rotary instrument.

Recently, the ProGlider™ (Dentsply Tulsa Dental Specialties) (Figure 5), a single file rotary glide path instrument, was introduced to increase the glide path diameter, as an alternative to using a series of three PathFiles. This instrument has the following characteristics: • Semi-active tip, size ISO 016 with a 2% taper • Progressive taper from 2% (D0) to 8.5% over the 18 mm active cutting zone • Centered, square cross section with variable helical angles • Available in 21, 25, and 31 mm length • Used in continuous rotation of 300rpm and a torque of 2-4Ncm • Manufactured from M-Wire nickeltitanium alloy Endodontic practice 43

CONTINUING EDUCATION

Figures 3A-3C: As the file is pulled back, it often hangs up on different levels of wall irregularities (arrows). This makes it difficult to push the file back to WL. This confirms the absence of a reproducible glide path

Figures 4A-4B: A. Indication of where canal wall irregularities and restrictive dentin should be removed (dotted lines) in certain areas of the root canal with small manual instruments.

B. A reproducible glide path — smooth radicular tunnel from the canal orifice of the canal to the physiologic terminus of the root canal

CONTINUING EDUCATION

Figure 7: Preoperative radiograph showing the presence of a large composite restoration and widening of the periodontal ligament around the apex of the mesial root of the left mandibular first molar. Note that the root canals appear calcified in the midroot and apical portion of the mesial root and in the apical part of the distal root

Figure 8: Access cavity preparation ensuring straight-line access into all the root canal systems. Four root canal orifices were located

Figure 9: Coronal restrictive dentin was removed from the canal orifices with a SX instrument from the ProTaper Universal system, using it in a backstroke cutting motion

As mentioned before, the final step after a reproducible glide path has been secured will be to enlarge the glide path to approximately the same or one size larger as the tip of the first rotary instrument. The ProGlider single file rotary glide path instrument (Figure 6A) creates an ideal size glide path (Figure 6B) to accept the ProTaper NextÂŽ X1 rotary instrument for canal preparation.

Case report 1 The patient, a 42-year-old female, presented with spontaneous pain on her mandibular left first molar. Clinical examination revealed that the tooth was restored with a large composite restoration. Radiographic examination confirmed the presence of a large composite restoration and widening of the periodontal ligament around the apex of the mesial root. It was also noted that the root canals appeared calcified in the midroot and apical portion of the mesial root and in the apical part of the distal root (Figure 7).

After the administration of local anesthetic, an access cavity, ensuring straightline access into all the root canal systems, was prepared. Four root canal orifices were located (Figure 8), and canal negotiation was initiated with a size 10 K-file. It was found that the size 10 K-file could travel only approximately 8 mm down the mesial root canal systems and 14 mm down the distal root canal systems before complete resistance was met.

Coronal restrictive dentin was removed from the canal orifices (Figure 9) with an SX instrument from the ProTaper Universal system, using it in a backstroke cutting 44 Endodontic practice

Figure 10: Using an alternating combination of size 08 C+ and size 08 K-files, the canals were negotiated to working length as determined by a ProPex PiXi apex locator

motion. Using an alternating combination of size 08 C+ and size 08 K-files, the canals were negotiated to patency. A ProPex PiXiâ&#x201E;˘ (Dentsply Maillefer) apex locator was used to establish working lengths for the four root canal systems and confirmed radiographically (Figure 10).

Initial glide paths were established by moving the size 08 K-file in short amplitude vertical strokes of 0.5-1 mm from working length, ensuring removal of restrictive dentin by withdrawing or carving in a clockwise direction as proposed by West (2010). This

Figure 11: Initial glide path was established by moving the size 08 K-file in short amplitude vertical strokes of 0.5-1 mm from WL, ensuring removal of restrictive dentin by withdrawing or carving in a clockwise direction. This process was repeated until the file felt loose. The procedure was repeated by withdrawing the file 2 mm, 3 mm, and 4 mm from the WL, ensuring that the file felt loose in the canal

process was repeated in each canal until the file felt loose at this distance. The same procedure was repeated by withdrawing the file 2 mm, 3 mm, and 4 mm from the working length, ensuring that the file felt loose in the canals (Figure 11). The same protocol was followed with a size 10 K-file. A reproducible glide path was confirmed in each canal, by ensuring that the size 10 K-file could travel freely from 4-5 mm from working length to patency, using light finger pressure (Figure 12).

A ProGlider single glide path instrument, operating at 300rpm and a torque Volume 7 Number 6

Figure 13: The ProGlider single file rotary glide path instrument was used to enlarge the reproducible glide path that was secured with hand instruments

Figure 15A: Four size X2 GuttaCore verifiers were placed up to the working length in each of the prepared root canals

of 2Ncm, was introduced. The file was allowed to progress and enlarge the secured glide paths up to working length in the distobuccal and distolingual root canal systems (Figure 13). The ProGlider file only progressed two-thirds down the mesiobuccal and mesiolingual root canal systems before marked resistance was observed.

A deliberate backstroke brushing motion was incorporated at this level in order to create more coronal flare in the canals. This allowed the ProGlider instrument to progress to full working length. The ProGlider Volume 7 Number 6

Figures 14A and 14B: ProTaper Next X1 and X2 instruments were used to complete root canal preparation

Figure 15B: The fit of the GuttaCore verifiers was confirmed radiographically

instrument enlarged the glide paths to a continuous progressive tapered preparation from the radiographic apices up to the canal orifices.

ProTaper Next X1 and X2 instruments (Figures 14A-14B) were used according to the technique outlined by Van der Vyver and Scianamblo (2013) to complete root canal preparation. Adequate canal preparation was confirmed when a size 25 nickeltitanium hand file fitted snug at working length in all four root canal systems. Four size X2 GuttaCore速 (Dentsply Tulsa Dental

Figure 16: Postoperative obturation result. Note the apical curvature in the distolingual root canal system that was maintained during glide path preparation and root canal preparation with ProGlider and two ProTaper Next instruments

Specialties) verifiers were placed up to the working length in each of the prepared root canals (Figure 15A), and the fit was confirmed radiographically (Figure 15B). The four root canal systems were obturated using AH Plus速 root canal cement and size X2 GuttaCore crosslinked gutta-percha obturators.

Figure 16 shows the final result after obturation. Note the apical curvature in the distolingual root canal system that was maintained during glide path preparation and root canal preparation with the ProGlider and two ProTaper Next instruments.

Endodontic practice 45

CONTINUING EDUCATION

Figure 12: The same protocol was followed with a size 10 K-file. A reproducible glide path was confirmed by ensuring that the size 10 K-file could travel freely from 4-5 mm from working length to patency (arrow), using light finger pressure

CONTINUING EDUCATION

Figure 17: Preoperative radiograph of non-vital mandibular left first molar. Note the large periapical and an intraradicular lesion

Figure 18: Sagittal view of a CBCT scan confirmed the presence of a large intraradicular lesion connected to the periapical lesion around the mesial and distal root canal systems

Figure 19: Axial view of CBCT scan at the level of the furcation revealed the presence of two mesial and two distal root canals (white arrows), intraradicular bone loss extending through the buccal cortical plate (yellow arrow)

Case report 2 The patient, a 25-year-old female, presented with a non-vital mandibular left first molar. A periapical radiograph revealed a large periapical and an intraradicular lesion (Figure 17). The sagittal view of a cone beam computed tomography (CBCT) scan confirmed the presence of a large intraradicular lesion connected to the periapical lesion around the mesial and distal root canal systems (Figure 18). The axial view at the level of the furcation revealed the presence of two mesial and two distal root canals, intraradicular bone loss extending through the buccal cortical plate (Figure 19).

Four root canal orifices were located and the canals negotiated to patency using size 08 C+ and K-files. Length determination was done with a ProPex PiXi apex locator and confirmed radiographically (Figure 20).

Reproducible glide paths were prepared up to a size 10 K-file before a ProGlider instrument was used to enlarge the glide paths.

AH Temp™ calcium hydroxide-based root canal dressing (Dentsply Maillefer) was dispensed into the coronal aspect of each root canal and moved apically to 1 mm short of working length with a ProGlider instrument driven by an X-Smart® Plus motor (Dentsply Tulsa Dental Specialties) on the WaveOne® setting. The reciprocal action of the file moved the calcium hydroxide material slowly and predictably to the desired depth. The access cavity was closed with Poly-F® Plus (Dentsply Maillefer), and the tooth was left with the AH Temp dressing for three weeks.

At the second visit, root canal preparation was done with ProTaper Next X1 and 46 Endodontic practice

Figure 20: Length determination radiograph

Figure 21: Four months postoperative radiograph showing healing of the intraradicular and periapical pathology

X2. The prepared root canals were irrigated with Topclear (Dental Discounts), a mixture of 17% EDTA and 0.2% cetrimide, to facilitate smear layer removal. The EDTA solution was activated for approximately 30 seconds in each root canal system using the EndoActivator® (Dentsply Tulsa Dental Specialties).

The final stage of irrigation was achieved by using 3.5% sodium hypochlorite (heated to approximately 40°C) with the EndoVac® system (SybronEndo). The EndoVac system is an apical negative pressure irrigation system. Instead of applying pressure, it uses suction to pull the irrigant down the root canal, then up and away into the highvacuum suction unit. There is also no risk of pushing sodium hypochlorite beyond the apical foramen.

A macrocannula is used to remove coarse debris inside the coronal two-thirds of the root canal followed by using a microcannula that is taken into the apical third of the root canal. The microcannula is a 28-gauge needle with 12 laser-drilled, microscopic evacuation holes. The root canal systems were obturated by using AH Plus root canal cement in combination with size 25 GuttaCore obturators for the two mesial root canal systems. Two size 25 ProTaper Next guttapercha cones using the continuous wave of condensation obturation technique with the Calamus® dual obturation unit (Dentsply Tulsa Dental Specialties) was the method of choice for the two distal root canal systems.

Figure 21 depicts a periapical radiograph that was taken 4 months postoperatively, Volume 7 Number 6

4. Nahmias Y, Cassim I, Glassman G. Own the canal – the importance of a reproducible glide path. Oral Health.

2013;May:74-82.

5. Patiño PV, Biedma BM, Liébana CR, Cantatore G, Bahillo JG. The influence of manual glide path on the separation rate of NiTi rotary instruments. J Endod. 2005;31(2): 114-116.

6. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini, G. A review of cyclic fatigue testing of nickel-titanium rotary instruments. J Endod. 2009;35(11):1469-1476.

7. Sattapan B, Nervo GJ, Palamara JE, Messer HH. Defects in rotary nickel titanium files after clinical use. J Endod.

2000;26(3):161-165.

8. Serene TP, Adams JD, Saxena A. Nickel Titanium Instruments. Applications in Endodontics. St Louis, MO: Ishiyaku EuroAmerica Inc; 1995.

9. Ullmann CJ, Peters OA. Effect of cyclic fatigue on static fracture loads in ProTaper nickel-titanium rotary instruments. J Endod. 2005;31(3):183-186.

Figure 22: Sagittal view of a follow-up CBCT scan confirmed good healing of intraradicular and periapical pathology

showing healing of the intraradicular and periapical pathology. A sagittal view of a follow-up CBCT scan also confirmed good healing (Figure 22). The axial view at the level of the furcation revealed healing of the intraradicular bone and the buccal cortical plate (Figure 23). EP

Volume 7 Number 6

Figure 23: Axial view of a follow-up CBCT scan at the level of the furcation revealed healing of the intraradicular bone and the buccal cortical plate (arrow)

REFERENCES 1. Berutti E, Negro AR, Lendini M, Pasqualini D. Influence of manual preflaring and torque on failure rate of the ProTaper rotary instruments. J Endod. 2004;30(4):228-230.

2. Kubde R, Saxena A, Chandak M, Bhede R, Sundarkar P. Creating endodontic glide path: A short review. Int J Dent Clinics. 2012;4(1)40-41.

3. Mounce R. An excellent glide path, the road to smoother endodontics. Oral Health Group Web site. http://www.oralhealthgroup.com/news/an-excellent-glide-path-the-road-

10. Van der Vyver PJ, Scianamblo MJ. Clinical guidelines for the use of ProTaper Next instruments: part one. Endodontic Practice. 2013;16(4):33-40.

11. West J. Endodontic Update 2006. J Endod. 2006;18(5): 280-300.

12. West J. Endodontic predictability - restore or remove: How do I choose? In: Cohen M, ed. Interdisciplinary Treatment Planning: Principles, Design, Implementation. Chicago, IL: Quintessence Publishing Co; 2008:123-164.

13. West JD. The endodontic Glidepath: Secret to rotary safety.

Dent Today. 2010;29(9):86-93.

14. West J. Glidepath implementation: “return to the beginning”.

Dent Today. 2011a;30(4):92-97.

15. West J. Manual versus mechanical endodontic glide path.

Dent Today. 2011b;30(1):136-140.

16. West J, Roane J. Cleaning and shaping the root canal system. In: Cohen S, Burns RC, eds. Pathways of the Pulp.

7th ed. St Louis, MO: Mosby; 1998: 203-257.

Endodontic practice 47

CONTINUING EDUCATION

to-smoother-endodontics/1000141940/?&er=NA. Published March 1, 2014.

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: EP V7.6 VAN DER VYVER

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ProGliderâ&#x201E;˘: clinical protocol VAN DER VYVER

1. Despite the fact that nickel-titanium manual and rotary instruments have revolutionized the field of endodontics, there is still a risk of instrument fracture as a result of _________. a. cyclic fatigue b. torsional fatigue c. canal wall regularities d. both a and b 2.

According to West, it is very important that clinicians understand the following observations regarding root canal anatomy: 1. Most root canal foramina are at least the diameter of a ______ hand instrument. a. No. 10 b. No. 15 c. No. 20 d. No. 25

3. Many root canal systems are already essentially smooth-walled tunnels, albeit some of them are much narrower than a _____ hand file. a. No. 5 b. No. 10 c. No. 15 d. No. 20 4.

Clinically, the author observed that between _______ of root canals present with an irregular type of glide path in the apical third of root canal systems.

48 Endodontic practice

a. b. c. d.

5% and 10% 15% and 18% 20% and 40% 65% and 70%

5. To complete canal negotiation, it often requires prebending of the tip of the hand instrument, followed by ______ until the file reaches the apical terminus or passes through the apical foramina (patency). a. meticulous large negotiation steps b. re-bending of the instrument c. pushing heavily into the canal d. meticulous small negotiation steps 6. â&#x20AC;ŚWhen the file is pulled back from the canal, it is impossible to push it back in order to follow the previously discovered canal path. The reason for this is that the canal path is _________, and the tip of the file hangs up against the irregularities or obstructions in the root canal system. a. a reproducible path b. not a reproducible path c. is necrotic d. is calcific 7. Failure to make the canal path reproducible at this early stage of treatment often results in ________, and obturation. a. ledge formation

b. fracture of instruments c. inadequate irrigation d. all of the above 8. In general, a size 15 K-file will not easily follow the glide path that was prepared with a size 10 K-file because of the fact that the tip of this instrument is _______ in diameter compared to the tip size of a size 10 K-file. a. 15% wider b. 25% wider c. 40% wider d. 50% wider 9. Several studies advocate glide path preparation to a ______ before the use of rotary nickel-titanium instruments. a. minimum of 0.20 mm b. maximum of 0.20 mm c. maximum of 0.10 mm d. maximum of 0.15 mm 10. Berutti, et al. (2004), also suggest that the canal diameter after glide path preparation should be at least _____ than the tip of the first rotary instrument. a. one size smaller b. half-size smaller c. one size larger d. half-size larger

Volume 7 Number 6

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Endodontic practice 49

STEP-BY-STEP

GentleWave™: Root canals cleaned at the speed of sound The GentleWave™ System is capable of removing all tissue; smear layer, biofilm, and bacteria from the tubules to a very deep level that is not typically seen in traditional endodontic treatment.

Dr. Rich Mounce reviews the steps to using the GentleWave™ System

C

urrent methods of endodontic cleaning and shaping are limited, as no current cleaning and shaping technique is able to predictably remove bacteria, biofilm, and tissue from canal systems. In addition, no current instrumentation system touches all canal walls. As a result, bacteria are commonly entombed in the dentinal tubules and isthmuses after endodontic treatment.

Today’s “state of the art” is techniquesensitive, operator-sensitive, and greatly affected by anatomic complexity and patient cooperation.1,2 Sonendo® has provided an innovative and unrivaled method designed to create “ultraclean” canals in order to overcome current limitations and challenges.

The GentleWave™ System is capable of removing all tissue, smear layer, biofilm, and bacteria from the tubules to a very deep level that is not typically seen in traditional endodontic treatment.3 The GentleWave™ System gives the clinician options. It can be used either as an adjunct to traditional treatment protocols or as the primary treatment method with “minimum shaping.” Regardless of shaping protocol, the obturation method is performed with the clinician’s preferred technique. Treatment can be simpler, faster, and performed with less iatrogenic potential

Rich Mounce, DDS, is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. Dr. Mounce is a clinical consultant for Sonendo and receives an honorarium for this work. Dr. Mounce is entirely responsible for the contents of this article. The opinions, statements, and clinical recommendations contained in this article are his alone.

He can be reached at RichardMounce@MounceEndo.com, MounceEndo.com. Twitter: @MounceEndo

50 Endodontic practice

as GentleWave™ instrumentation protocols can be greatly simplified relative to existing instrumentation concepts. Minimal shaping protocols remove less tooth structure, which could possibly reduce the chance of vertical root fracture while cleaning canals to a degree never before possible. Because it is less technique sensitive, the GentleWave™ System can contribute to a treatment that may be less stressful and less invasive for the patient.

Sonendo’s GentleWave™ technology is provided by a handpiece connected to a freestanding, ergonomic, mobile console containing a reservoir of sodium hypochlorite, EDTA, and distilled water. The device has

a user-friendly interactive screen that guides the clinician through each step sequentially.

The GentleWave™ System automatically cycles the treatment fluids through the device and into the entire canal system in a closed loop environment. As the fluids move through the treatment tip and into the canals, multisonic energy is created. This sonic energy presents in the form of specific wide spectrum wavelengths using different frequencies, aiding greatly in tissue and debris dissolution and removal as well as disinfection of root canals system. Aside from a preoperative system leakage test, at present, the total treatment time is less than 10 minutes.

Volume 7 Number 6

Step 1: Preparatory steps The rubber dam is applied. All caries is removed. Endodontic access is made. All canals are located, orifices negotiated and patency established, and working length determined.

The GentleWave™ System gives the clinician options. It can be used either as an adjunct to traditional treatment protocols or as the primary treatment method with “minimum shaping.”

Step 4: Application of the GentleWave™ The handpiece is placed into its holder on the Sonendo console. A self-guided menu takes the clinician through the steps needed to prepare the system prior to use. Once the system is calibrated, during the treatment, an on-screen display illustrates the progress of the treatment.

Step 2: Shaping technique Effective GentleWave™ ultracleaning is compatible with a minimal shaping protocol.

In essence, the clinician determines the smallest taper and apical diameter (minimal shaping) appropriate to the canal being ultracleaned and obturated. After ultracleaning, obturation is performed using the clinician’s preferred method.

Step 3: Creating a closed loop system A closed loop system is prepared that connects the Sonendo handpiece to the tooth being cleaned. If 1 mm of coronal tooth structure is present above the CEJ, then no rebuilding of the coronal tooth structure is required. Less coronal tooth structure requires rebuilding the tooth to facilitate the connection between the handpiece and the tooth. Sonendo has proprietary aids and techniques available to rebuild the tooth and create a closed loop system.

Step 4: The GentleWave™ System console, intuitive display, and touchscreen interface

Step 3: The GentleWave™ handpiece connected to the tooth to create a closed system Volume 7 Number 6

Sonendo has grown from a concept in 2006 to its limited commercial release today. The device is FDA cleared. Located in Laguna Hills, California, Sonendo currently employs more than 80 engineering, marketing, and research professionals. For more information, contact Sonendo at info@Sonendo.com. EP

REFERENCES 1. Del Carpio-Perochena AE, Bramante CM, Duarte MA, Cavenago BC, Villas-Boas MH, Graeff MS, Bernardineli N, de Andrade FB, Ordinola-Zapata R. Biofilm dissolution and cleaning ability of different solutions on intraorally infected dentin. J Endod. 2011;37(8):1134-1138.

2. Paqué, F, Balmer M, Attin T, Peters OA. Preparation of oval-shaped root canals in mandibular molars using nickeltitanium rotary instruments: a micro-computed tomography study. J Endod. 2010;36(4):703–707.

3. Haapasalo, M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour M. Tissue dissolution by a novel multisonic ultracleaning system and sodium hypochlorite. J Endod.

2014;40(8):1178-1181.

Endodontic practice 51

STEP-BY-STEP

The GentleWave™ causes energized fluid to move first across the pulp chamber floor and circulate gently throughout the entire root canal system to the apex. The design goal of GentleWave™ is a neutral to negative apical pressure providing complete fluid control with simultaneous canal cleaning. The GentleWave™ is able to reach all the previously inaccessible areas of the root canal system, including isthmuses, fins, cul de sacs, anastomoses, and other complexities.

PRACTICE MANAGEMENT

Effortless, fun, and profitable endodontics In part 2 of his series, Dr. Ace Goerig suggests ways to reduce stress in the practice

A

lmost all endodontists could be completely out of debt and on the way to financial freedom within 5 to 7 years if they only knew the secret. But the secret is counterintuitive, and here it is: By changing your mind-set and systems in your office, it is a lot easier and less stressful to complete six cases a day instead of the average four cases. Also, the quality of the six cases you complete will be even better.

These additional two cases will give you an additional $1,925,000 over the next seven years to pay off all debts and begin your path to financial freedom. It is just a numbers game. If you work 200 days a year, and your root canal fee is $1,000, two

Dr. Ace Goerig co-founded Endo Mastery in 1996, a coaching company designed specifically for endodontists. He has worked with 20% of all endodontists in the country to understand the business of dentistry, become debt-free, and learn how to love their practice. He graduated from Case Western Reserve University School of Dental Medicine in 1971, entered the Army, and retired as a colonel in 1991. He is a Diplomate of the American Board of Endodontists and owns one of the most successful endodontic practices in the country.

Dr. Goerig co-authored a book with Kendrick Mercer entitled Time and Money: Your Guide to Economic Freedom to teach doctors and their teams the secrets of becoming personally and financially free. He and his wife, Nancy, have five children and were married in 1969.

52 Endodontic practice

more cases a day will give you $400,000 in net profit. After taxes, you will have an additional $275,000 for debt reduction; $275,000 times 7 years is $1,925,000.

Over my 17 years of coaching endodontists throughout Canada and the United States, I have found a common encoding among many them. They believe to obtain high-quality endodontic results, it must take time and has to be hard. Many people are imprinted from childhood in the belief that life has to be hard. I was just talking with a 55-year-old endodontist, who for the past 20 years has worked 5 days a week with only 2 weeks off for vacation and takes home $325,000 a year. While on the other hand, I show endodontists that I work with how it is possible to work only 3 days a week and take 8 to 12 weeks off a year for vacation and net 2 to 3 times as much as the previous endodontist. Most of these dentists are now debt-free and well on their way to financial freedom. More importantly, they now have personal freedom. In this philosophy, doctors never have to change their clinical technique or treatment philosophy while providing the highest quality of endodontic excellence. This is called the “retire in practice philosophy” that I have personally practiced for the last 20 years.

Recently, I worked with a 63-year-old endodontist who within 6 months was able to increase his daily completed cases from three or four cases (which he had done for the past 36 years) to seven or eight cases a day, easier than when he was doing three or four. He could have learned this system when he was younger and enjoyed the “retire in practice” model for over 30 years instead of working 5 days a week with only a few weeks off for vacation each year.

Bringing in the right associate is an essential part of this philosophy, which will be addressed in a future article. It should be noted that you cannot bring in an associate successfully until you are completing an average of six cases per day, or you will be sharing your net profit with the associate and reduce your personal income significantly.

After reviewing the practice numbers of 20% of all endodontists in the country, I have found the average endodontist completes three to four cases in a 9-hour workday.

When I spoke to this group about the possibilities of treating more cases and being more profitable, many say, “I don’t want to work any harder, and I will never compromise quality.” The problem is they only know what they know, and don’t know what they don’t know. I then asked them, “How long does Volume 7 Number 6

Why are endodontists so inefficient?

The reason is most endodontists waste 3 to 4 hours each day in nonproductive time, i.e., piddledontics, non-treatment cases, doctor and team inefficiency, and the doctor talking too much. Because of these inefficiencies and lack of office systems, both the doctor and team struggle through the day. This is not a fun, profitable, or effortless practice model. Sometimes there is a disruptive team member who “stirs the pot” and does not like change. Many doctors think it is about improving technique to become more efficient, but this rarely affects the number of cases completed in the day. Some doctors subconsciously believe they are not worthy of success and feel everything in the office has to be hard. Some doctors are not open to new possibilities such as doing one-appointment endodontics. When your ego always has to be right, it will be very difficult to find peace, happiness, and freedom in your life.

8 necessary steps for a fun, profitable, and effortless career

Step 1: Write an empowered vision of how you want your practice. You can have it any way you want it to include all the right team members, all the best referring doctors, and the best patients. Part of your vision may read “Our office has a reputation of being so gentle, safe, and caring that we draw the best patients from all of the best doctors in our area. We enjoy every day to the fullest but live in each moment. Our office flows effortlessly and is filled with pride, a sense of ease, and a calmness that allows us to provide excellence in endodontic treatment that is unsurpassed.” Your vision becomes the compass for your practice and sends you in the right direction as well as a magnet to bring all the right people into your practice, including the right associate. The vision sets the tone of the practice culture.

Step 2: Write out specific goals for your practice. Some examples follow: “I will spend 98% of my time in direct patient care,” or “Within 6 months (date) I will be completing two more cases per day.” When goals are Volume 7 Number 6

Your vision becomes the compass for your practice and sends you in the right direction as well as a magnet to bring all the right people into your practice, including the right associate. written down, they are much more likely to be accomplished.

Step 3: Change your systems. Office systems that are not working cannot be fixed and need to be replaced. Bring in a practice management consultant that has your same personal philosophy and the reputation of getting results with his/her clients.

You probably have already tried to improve your office, but nothing seems to change. An outside observer can see what you cannot see and implement systems that work for your specific situation.

Step 4: Become the leader of your practice and empower your team to run the office and the schedule. Many doctors are afraid to give up control, but in reality, you’re just giving up the stress of control.

When you know you have the right team and office manager, the office will run better than when you were trying to do it all. The job of a practice consultant should be to train team leaders to run the practice allowing the doctor to focus on treatment.

Step 5: Eliminate the drama in your office. If your office does not run smoothly and is filled with drama, there is always someone who stirs the pot, back stabs, gossips, or comes in late. Many times this may be one of your best employees that you would hate to lose and because he/she is good, he/she feels that he/she can get away with bad behavior. Sometimes it is difficult to identify who is stirring the pot, but there are ways to find out. Once you identify the employee, these infractions need to be documented. From my personal experience, these types of employees will never improve, and as soon as you set them free from your office, the dark cloud will go away.

Step 6: Effective marketing results in easier cases. There is an old phrase in marketing that states, “Those who need to market should not, and those that do not need to market should.” This statement means that if you need patients, there is something you are doing in your office that turns them away. This is also true with the referring offices. It may be a negative lady at the front desk; it may be you are booked out too far and can’t get patients in immediately,

plus many other reasons. Before you market, make sure you have addressed all the concerns of the referring offices. It’s a good idea to send out a referring office survey to find out what is important to them. Marketing is all about the development of personal relationships. I also believe that every endodontic office needs a marketing coordinator to run a marketing program that has multiple strategies that are changed over the years.

Depending on the size of the practice, it could be a 15- to 40-hour per week job.

Step 7: Efficient and predictable technique. Over the past 25 years, there has been a revolution with new technology and instrumentation in endodontics. With the new engine files, microscopes, digital radiography, CBCT scans, apex locators, etc., endodontics has become simplified and more predictable than when we just had hand files. One of the big philosophy changes is one-appointment endodontics. I have been doing oneappointment endodontics for over 40 years in the majority of my cases and have extremely high success rates with little postoperative problems. There are very few contraindications to not doing single visit endodontics.

Your patients want it; your referring doctors want it, therefore, making it one of the strongest marketing strategies you can implement.

If you find all the canals and instrument up to at least size 40 in every canal, your success rate should be close to 100%.

Step 8: Get out of debt. As described in part 1 and in the above paragraphs, eliminating debt should only take 3 to 7 years.

When debt is eliminated, so are the stresses associated with being in debt. You will find yourself much more relaxed and much more peaceful in your practice and your life. You are now really going to work because you want to, not because you have to. What is surprising is that more abundance seems to flow into your life more easily and without effort when you are debt-free. For the specific step-by-step plan on how to get out of debt, go to free resources on the www.endomastery.com website.

In part 3 of this series, I will discuss many of the ideas and secrets to obtaining personal freedom, peace, and abundance in your life while always enjoying the process. EP Endodontic practice 53

PRACTICE MANAGEMENT

it take you to complete a quality molar root canal?” The more experienced endodontist will say about 1 hour. My next question is, “If you are working a 9-hour day, why are you only completing four cases instead of nine?” The good news is that it’s not about the doctor’s technique; it’s about the doctor’s mind-set, office systems such as scheduling, team training, flow of the office, and focus of the doctor.

ENDOSPECTIVE

Implants for the endodontist: to place or not to place?

Dr. Rich Mounce shares his evolving view on implants

E

ndodontists want to save teeth.

It’s exciting, fulfilling, creative, and rewarding to relieve pain, help people, and be good at your craft. I believe it’s in our genes to solve the many clinical challenges we face on a daily basis. Removing teeth with the goal of placing implants is not in our nature, whether that nature was ingrained and trained into us as residents and/or developed in most of us through daily practice. More than one implant surgeon has told me that placing implants is easy; endodontics is hard. My suspicion is that we enjoy the tinkering and mastering the difficulties we face.

Personally, having been an endodontist in full-time private practice since 1991, it is a pleasure to study the literature, take classes, give classes, and exchange information with colleagues. Like many of you, I eat, drink, and sleep endodontics. As the quote goes, “Endodontics is a big issue about a little tissue,” and truer words were never spoken.

Hard to believe we as endodontists devote our professional lives to cleaning a very small and complex space that we never truly see.

Coming up on 25 years as an endodontist, I know a lot less now than I did when I graduated from residency.

All of this leads us to implants. Would, could, and should we place them?

For some endodontists who say yes, the motivation may be financial, especially if their practices are not as busy as they want.

For others, the many possible reasons might include patient service and convenience, general practitioner service, and optimized

Rich Mounce, DDS, is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty.

He owns MounceEndo, an endodontic supply company also based in Rapid City, South Dakota (605-791-7000). Dr. Mounce has no commercial interest in any of the products or companies mentioned in this article.

He can be reached at RichardMounce@MounceEndo.com, MounceEndo.com. Twitter: @MounceEndo.

54 Endodontic practice

continuity of care in select circumstances, and affection for surgery.

Reasons for not placing implants are myriad and stretch from busyness with purely endodontic cases, resistance to change, the expense of training and materials, and needed staffing systems changes. And of course, removing teeth and placing implants is not what we signed on for.

Whether we place implants or not, my sense is that endodontists are frustrated with the arbitrary removal of many teeth by nonendodontists that otherwise could be treated and/or retreated. A significant number of treatable teeth appear to be extracted for financial gain rather than the clinical benefit of patients.

I do not speak for the AAE or the endodontic community at large, and yet, from my single viewpoint, some patients are not being given all the endodontic options they should be. Calling endodontic therapy “pre-implant treatment” or giving teeth one poor attempt at endodontic therapy followed by extraction cheapens all of our reputation as dental care providers and reduces the public’s trust. The same could be said about indiscriminant endodontic surgery that is poorly treatment planned or carried out to cover for poor orthograde technique.

There clearly is a limit of “when to say when.”

But, in my view, the pendulum has swung to extraction in cases where endodontic therapy is viable, predictable, and the best natural implant.

Up to this point, I have resisted placing implants and getting trained. My reasons might be slightly different than those above in that I have spent much of my out-ofoffice professional life teaching and writing in endodontics. To be frank, I never thought much about learning to place implants or the art and science behind the discipline.

And yet recently, I watched a recorded lecture on endodontic surgery where the endodontist stated that he went to many implant courses knowing that 98% of what was being taught was irrelevant to endodontics, but going made him a better endodontic surgeon if he adapted what was relevant.

That struck a chord with me. This alone seems reason enough to become fluent in implant placement, and it is a journey I will slowly begin.

Will I ever become an implantologist?

No. Will implants ever capture my heart like endodontics? No. But I believe it can make me a better endodontist and a more effective surgeon, and as such, it’s a journey worth embarking on. I welcome your feedback. EP Volume 7 Number 6

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Air Techniques introduces the all new ProVecta S-Pan panoramic X-ray Air Techniques, Inc., has announced its latest solution for digital radiography with the all new ProVecta S-Pan Panoramic X-ray.

ProVecta S-Pan brings a new level of image sharpness in dental radiography paving the way to faster and more precise therapy. A full adult panoramic X-ray is available in just 7 seconds and offers 17 image programs. Among these 17 programs there are four specifically designed for children, offering a reduced radiation exposure. The heart of the S-Pan image technology starts with the patient specific path that the Csl sensor follows and continues as 20 layers of images are collected, sliced into 20,000 image segments, and then one amazingly sharp image is automatically constructed from the best selections. Patient comfort is accommodated by height adjustment and outward facing orientation and assured positioning with three laser guides.

Practitioners’ needs are also addressed with a large, menu-driven touchscreen control and optional voice commands.

For more information, visit www.airtechniques.com.

Ultradent introduces Ultrawave™ and the Ultrawave™ XS Piezo ultrasonic units Ultradent Products, Inc., introduced Ultrawave™ and Ultrawave™ XS — a new line of piezo ultrasonic devices for the clinician seeking a power scaler that is gentle to the tooth surface while also powerful enough to remove the toughest calculus. The Ultrawave line of piezoelectric devices allows for a variety of uses — from the workhorse of your hygiene operatory to restorative, perio, or endodontic treatments. Thanks to intuitive Reflex™ technology, both Ultrawave and Ultrawave XS offer optimized performance, reduced chair time, and more comfort for patients.

These devices are reliable and efficient. Their ultrasonic piezoelectric linear motion moves back and forth, in contrast to the ellipse of magnetostrictive competitive devices, providing more complete scaling with less effort.

The linear motion provides greater consistency and faster performance while treating the tooth more gently.

To learn more, call 800-552-5512, or visit ultradent.com.

56 Endodontic practice

i-CAT™ launches a new 3D cone beam system i-CAT™, a brand member of the KaVo Kerr Group, has launched of the newest member of the award-winning family of cone beam 3D imaging products, the i-CAT™ FLX MV (medium field-of-view) for general dentists and specialists who place and restore implants, perform oral surgery, periodontics, prosthodontics, endodontics, and oral surgery with greater confidence and lower radiation. The innovative features of the i-CAT FLX MV will deliver greater clarity, ease-of-use, and control for those clinicians who need a medium field-of-view and a range of image sizes to fit a variety of needs.

From Scan to Plan to Treat, i-CAT FLX MV offers these features to seamlessly provide information and control: • Medium field-of-view captures up to both arches and the temporomandibular joints in 3D • Visual iQuity™ advanced image technology provides i-CAT’s clearest 3D and 2D images • Provides lower dose scan options, including QuickScan+ • Easy-to-use SmartScan STUDIO™ touchscreen allows for selection of the appropriate scan for each patient • Capture traditional 2D panoramic images with i-PAN • Integration with CAD/CAM programs To learn more, visit www.i-cat.com.

LED Dental’s new digital intraoral camera features advanced touch-capture functionality LED Dental, a wholly owned subsidiary of LED Medical Diagnostics Inc., has introduced a new intraoral camera, the LED IC200, designed to acquire high-resolution intraoral and extraoral images with auto-focus and a large depth of field.

• Image resolution of 768 x 494 pixels for crisp, clear images • Eight LED lights for uniform illumination and an increased 105-degree angle of view for improved observation of distal areas • Aspheric lens prevents image distortion • Touch capture capability helps prevent camera movement allowing the LEDIC200 to stay completely focused • Direct USB plug-in • Ergonomic design • Open architecture workflow For more information, call 844-952-7327 or visit www. leddental.com.

Volume 7 Number 6

Highly Calcified Canals?

No problem.

C+ Files from Maillefer can withstand up to 300% more pressure than a standard K-File without buckling. They have the strength a clinician needs to cut through tough calcification while allowing them to confidently negotiate the canal.

• Easier location of canal orifices • Easier access to apical third • Better tactile feel

A superior performance using C +Files A superior performance using C +Files • Buckling forceBuckling Force 4.0

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• Easier location of canal orifices • Easier access to apical third • Better negotiation • Easier location of calcifications of canal orifices • Easier access to apical third• Better tactile feel • Better negotiation + of calcifications C Files K-Files 008 010 015 • Better tactile feel ISO diameter

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• Makes it easier to determine the working length when working with X-rays • Easier positioning of the silicone stop at working length • Makes it easier to determine the working length when working with X-rays Special offer • Easier positioning of the silicone stop at working length

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• Pyramid-shaped Promo Code MCV tip Ø • Easier penetration during catheterization • Pyramid-shaped tip • Polished instruments • Easier penetration during catheterization • Better removal of debris • Polished instruments • Smoother insertion of the instrument in the canal Ø

• Better removal of debris • Square section DENTSPLY MaiLLEfEr / T: 1-800-924-7393 / f: 1-800-924-7389 / MaiLLEfEr.DENTSPLY.coM • Smoother insertion of the instrument in the canal • Better resistance to distortion • Consistent cutting sensation across the whole range of instruments • Square section • Increased safety *TO REDEEM YOUR FREE GOODS: Mail your invoice noting the promo code and free product(s) desired to: DENTSPLY Maillefer, 5100 East Skelly Drive, Suite 300, Tulsa OK, 74135 or (toll free) fax • Better resistance to or distortion to 1-800-924-7389 email+to mailleferusa@dentsply.com. Offer is valid October 1, 2014 through December 31, 2014. Purchase must be made on ONE (1) invoice. Limit 5 redemptions of each • Cmust Range offer per Doctor. be received no later range than January 31, 2015 to claim free goods. These offers may not be combined with any other DENTSPLY offers. All free goods fulfilled through • Consistent cuttingInvoices sensation across the whole of instruments DENTSPLY. Allow 4-6 weeks for delivery. Offer valid in the 50 United States only. Free goods must be of equal or lesser value than those purchased.

• Increased safety • Two available lengths, 21mm and 25mm allow optimal efficiency in all clinical cases + • C Range ©2014 DENTSPLY International, Inc., DENTSPLY Maillefer. All rights reserved. For Dental Use Only Rx Only ADMAIC+ Rev. 0 07/14 REF A 012X REF A 012X 900 om .c ly p ts n • Two available lengths, 21mm and 25mm allowle optimal in all clinical cases fe r. d eefficiency 006

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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 or call 800.944.6365 © Carestream Health, Inc. 2014. 11141 EN CS 8100 3D AD 1114