Endodontic Practice US - January/February 2015 Issue - Vol8.1 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING

EXCELLENCE

Frequency of postoperative pain in oneversus two-visit endodontic treatment

Drs. Jorge Paredes Vieyra, Francisco Javier Jimenez Enriquez, and Fabián Ocampo Acosta

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January/February 2015 – Vol 8 No 1

ENDODONTICS Adhesive restoration of the root-filled tooth Dr. Bob Philpott

Implementing the GentleWave™ System by Sonendo®

Management of a tooth with a large radiolucency: Part 2

Dr. Robert Seidberg

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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 GENERAL MANAGER | Adrienne Good Email: agood@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 | Kimberly Burke Email: kimberly@medmarkaz.com

No turning back from 3D to 2D imaging

ne of my top priorities when opening my endodontic practice was to integrate cone beam computed tomography (CBCT). The technology has changed the way we as endodontists are able to incorporate our knowledge of the root canal system into the true three dimensions the tooth encompasses. The benefits of CBCT imaging have immeasurable advantages in endodontics, as well as all other aspects of dentistry. Like many advances that have benefited endodontic imaging, the CBCT gives us the ability to help diagnose complex endodontic cases. With 2D imaging, a substantial amount of anatomy and pathology is overlaid by the osseous structures of the maxilla and mandible. This makes complex diagnosis difficult in situations such as lesions that have not perforated the cortical plates or superimposition of the maxillary sinus over the apices of the maxillary posterior teeth inhibiting our ability to accurately visualize this region. Cracked teeth can now be visualized by the associated vertical bone loss adjacent to the tooth possibly not detected clinically. Resorptive lesions can be more completely diagnosed because the location, extent, and missed anatomy in retreatment cases can all be seen in the third dimension. The patient experience is greatly improved using the CBCT as well. Visualization is key to proper discussion in endodontic treatment planning. Having the CBCT image provides this platform that allows patients not only to understand what the practitioner is relaying to them but also to make better informed treatment decisions. The CBCT is also the ideal diagnostic solution for patients for whom 2D imaging is especially difficult. They include those with limited ability to open, but also children and patients who are phobic or prone to gagging. Because it is extraoral, CBCT is much more comfortable for all patients. CBCT technology enables you to navigate these challenging situations in a much more efficient fashion by providing a map through the tooth’s anatomy prior to accessing. Therefore, because we can see exactly what is going on, we are able to go into treatment with a game plan. This enables us to complete procedures more effectively because we have a majority of the information at our disposable preoperatively from the scan. We chose the Sirona ORTHOPHOS XG 3D in particular based not just on its technology, which combines small and medium volume acquisitions and 100-micron slices, but also the reputation of the company. Dentists and dental specialists request scans for implant placement and TMJ imaging. The ORTHOPHOS XG 3D integration with CEREC allows compatible offices to plan implant placements, mill surgical guides, and fabricate crowns from the acquired CBCT image, thus allowing us to enhance the patient experience for our referring offices. As I see it, there’s no turning back from what this technology has to offer in terms of imaging for the dental world, especially endodontics. For me, practicing without the CBCT would be like reading a book with half the pages removed. Dr. Andrew Wiswall

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Volume 8 Number 1

Andrew Wiswall, DDS, received his dental degree at the University of Nebraska Medical Center in Lincoln, Nebraska, and then completed 1-year advanced education in the general dentistry program at the University of Missouri-Kansas City. Following his time in Kansas City, Dr. Wiswall completed a 26-month postgraduate residency in endodontics at the University of Minnesota School of Dentistry in Minneapolis, Minnesota. After earning his specialty certificate and a master’s degree, he returned home to Sioux Falls to establish Wiswall Endodontics. Dr. Wiswall is board-eligible by the American Board of Endodontics.

Endodontic practice 1

INTRODUCTION

January/February 2015 - Volume 8 Number 1

TABLE OF CONTENTS

Practice profile

Bruce Seidberg, DDS, MScD, JD

Reflections on 51 years in practice

Case study Post or no post?

Dr. Marcelo Balsamo presents a case report demonstrating direct adhesive post luting and core buildup in one appointment....................................18

Clinical

Irrigation in endodontics

Case study

Management of a tooth with a large radiolucency: Part 2

Drs. Peet J. van der Vyver and Heinrich Dippenaar explore activation devices for root canal irrigation solutions.........................................22

Dr. Nishan Odabashian discusses treating teeth with failing previous root canal treatment exhibiting large radiographic lucencies less invasively

ON THE COVER Cover photo courtesy of Dr. Randy Garland. Article begins on page 48.

2 Endodontic practice

Volume 8 Number 1

TABLE OF CONTENTS

Continuing education

Frequency of postoperative pain in oneversus two-visit endodontic treatment Drs. Jorge Paredes Vieyra, Francisco Javier Jimenez Enriquez, and Fabián Ocampo Acosta evaluate the incidence of postoperative pain in oneversus two-visit root canal treatment of necrotic teeth with apical periodontitis after a 1-year healing period............34

Legal matters

Continuing education

Adhesive restoration of the root-filled tooth

Dr. Bob Philpott looks at the developments in adhesive systems and endodontics

Risk management concepts for dentists Dr. Bruce H. Seidberg discusses three main factors that will reduce risk of legal issues .....................................42

Materials & equipment ........................54 Industry news ..............55 Technology

Implementing the GentleWave™ System by Sonendo® Endodontists speak about the ins and outs of successful new tech integration.......................................48

4 Endodontic practice

Product profile

Your loved one needs a root canal … Which result would you want them to have? Conservation matters......................52

Endospective

Seven clinical practice truths Dr. Rich Mounce offers some advice on the pursuit of endodontic happiness.......................................56

Volume 8 Number 1

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

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PRACTICE PROFILE

Bruce Seidberg, DDS, MScD, JD Reflections on 51 years in practice

Dr. Seidberg reviewing an X-ray (DEXIS™ system)

Dr. Seidberg shared the following history and accomplishments with Endodontic Practice US.

Dr. Seidberg with his JEDMED microscope 6 Endodontic practice

Dr. Bruce Seidberg was born in Syracuse, New York. His mother was a bookkeeper in a department store and his father, a barber — both survivors of the WWII depression era and who recognized the importance of education. Throughout primary and secondary school, they always encouraged him to pursue a professional career path. In high school, he was active in the band (a drummer), the cross-country track team, and as the manager of the basketball team. He entered dental school after 3 years of undergraduate school at the University of Buffalo.

He and his wife, Judy, have three children: Neal, Chairman of the Pediatric ICU at Golisano Children’s Hospital; Dan, an Attorney and CEO of Iamresponding.com, and Allison, an event planner and a healthcare administrator; they have six grandchildren and a Bichon Frise, Callie. He received his DDS from SUNY Buffalo and served in the Navy and, after a year at the Boston Naval Shipyard, was asked to be the base’s endodontist. He later received his Certificate of Proficiency and Master’s (MScD) degree in Endodontics from the Boston University School of Graduate Dentistry. Fast-forward, he has maintained active participation in the dental profession and has been in leadership roles in just Volume 8 Number 1

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PRACTICE PROFILE

Office: Dental Assistant Val preparing to take an X-ray

about every organization he is a member of. He is a Diplomate of the American Board of Endodontics and the American Board of Medical Malpractice, a Fellow of the American College of Dentists, the American Association of Hospital Dentistry, the Pierre Fauchard Academy, and the American College of Legal Medicine. He is a member of the American Dental Association, American Association of Endodontists, American Association of Dental Editors, Alpha Omega International Fraternity, New York State Endodontic Association, NYS Dental Association, NYS Board of Dentistry, and the American Association of Dental Boards, as well as other local dental societies. Dr. Seidberg is a former Associate Professor of Endodontics at SUNY at Buffalo and Chair of the Postgraduate Endodontic Program that he and Dr. Jim Guttuso started in 1967. He was also the former Director of a General Dentistry Residency Program that he was a co-founder of at the St. Joseph’s Hospital Health Center in Syracuse. He is currently Chief of Dentistry at Crouse Hospital in Syracuse, New York, Chairman of the American Board of Medical Malpractice, and Secretary of the ACLM Foundation. Dr. Seidberg has contributed many articles to the dental literature and a chapter in the dental text Dentistry for the Special Patient, the legal text Legal Medicine, and the 6th edition of Ingle’s Endodontics. Dr. Seidberg served as Associate Editor of the Fifth District Dental Society Bulletin (NYS), Editor of the Boston University School of Graduate Dentistry Endodontic publications (Quarterly, Newsletter, and Journal) for 25 years, on the Scientific Advisory Panel for the Journal 8 Endodontic practice

of Endodontics, Managing Dr. Bruce Seidberg and Judy Seidberg Editor of the ACLM Communiqué, and Editor-in-Chief of participates in the NERBS organization and the AAE District II Endodontic Forum; and he is currently serving as Vice Chairman of the served a 4-year term on the American Dental NYS Board of Dentistry. Association Council on Communications. Outside of the dental profession, he is a He has lectured at national and interPast Commander of the JWV Post 131 and is national meetings about the fields of the Central New York Director of the Special dentistry and law. He has served two terms Olympics Special Smiles Program. on the AAE Foundation Board, including a term as secretary-treasurer, vice chairman of Dr. Seidberg, is your practice limited the American Dental Association Council on to endodontics? Communications, and two terms each on the Yes, my practice is limited 100% to Board of Governors of the American College the traditional school of endodontics using of Legal Medicine and the Board of Directors the improved technology with the basic of the American Association of EndodonSchilderian principles and without the allowtics. He was awarded the President’s Award able expanded services offered within the last from the AAE in 2001, becoming just the decade such as periodontal modifications, second individual to receive that honor in restorative buildup efforts, and implants. the 54-year history of the organization. He was also presented with a President’s Award Why did you decide to focus on for Service from ACLM in 1992, 1993, and endodontics? 1994 and the ACLM Gold Medal in 2013 Dentistry is that part of medicine where for excellence and participation on behalf patients need teeth to eat and speak propof dentistry and law. He has completed two erly. Endodontics is the one exciting phase of terms as President of the New York State dentistry that enables patients to save their Association of Endodontists, represented teeth that would otherwise be extracted. It the State Endodontists on the New York is rewarding to be able to save a tooth, even State Dental Association Board of Goverif it has to be done heroically. It’s generally a nors, and served 2 years as chairman of feeling akin to that of an obstetrician bringing the NYS Section of the Pierre Fauchard life into the world; we are giving extended Academy. Dr. Seidberg is a Past President of life to teeth and bringing smiles to people, the Syracuse chapter of Alpha Omega, the and that’s a great feeling to be able to help BU Endodontic Alumni Association, and the people and to improve their health. As Dr. Cayuga County and the Onondaga County Dental Societies. He was the 48th President Herb Schilder always said, the best implant is of the American College of Legal Medicine, a natural tooth, and in endodontics, we can the only dentist to serve in that capacity. He usually preserve that natural tooth. Volume 8 Number 1

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PRACTICE PROFILE How long have you been practicing, and what systems do you use? I’ve been in practice for 51 years, starting as the base’s endodontist in 1964 at the Boston Naval Shipyard, and then returned to school and graduated from the Boston University School of Graduate Dentistry and finally the private practice of endodontics in Syracuse, New York since 1967. I still have a strong passion for the specialty and helping patients of all ages. I use a combination of systems, but primarily using the Dentsply Tulsa Dental Specialties armamentaria, continuing the use of hand instrumentation, and incorporating rotary systems. I also use the DEXIS™ digital radiography system and JEDMED and Seiler microscopes.

What training have you undertaken? My dental degree is from the State University of New York at Buffalo. While in the Navy in Boston, I was sent to a series of courses at the Boston University School of Graduate Dentistry under the tutorship of Dr. Herb Schilder, where I later studied and received my Certificate of Proficiency and Master of Science Degree in Endodontics. I continue to attend numerous continuing education courses through the AAE and other dental organizations and study clubs.

Staff: Val, Hope, and Faith

Who has inspired you professionally? Dr. Herbert Schilder was most inspiring and certainly most influential in my professional practice of endodontics, as a teacher and as a friend. Drs. Harold Levin and Seymour Melnick exemplified the characteristics of a professional and were influential in my development of a practice. Dr. Michael Fallon inspired me as a professional leader with his philosophy of affability, availability, and ability that remain the basis of my professional character. Drs. Cyril Wecht, Stuart Reuter, Phil Shelton, and Robert Buckman (to name just a few) were inspirational in the legal aspect of my profession.

What is the most satisfying aspect about your practice? The respect I receive from my colleagues, staff, and patients. As one of my colleagues, Dr. Dan Orr, has said: “What better a vocation is there that affords the daily opportunity to relieve pain and suffering while restoring function.” I could not agree more. Every day is satisfying when patients can be helped. Not one day is more satisfying than another, and that’s what makes it so exciting to be an endodontist!

What has been your biggest challenge? My biggest challenge is to fit all that I 10 Endodontic practice

Grandchildren: Meghan, Ashley, Cody, Ethan, Jennie, and Hali

want to do into a day in the office, spend quality time with my family, and be able to take enough time off to “smell the roses.”

What would you have become if you had not become a dentist? Although my college advisor told me to be an accountant, I’ve wanted to be a dentist

all of my life; and it was a close friend’s father, Dr. Joseph Watson, a general dentist, who was the constant dental professional encouraging his son, Jeff, and me to apply to dental school. Of course, my parents were always encouraging me to pursue my goal, and then my wife, Judy, encouraged me to specialize. I never had a second choice. Volume 8 Number 1

The future is very bright for both the specialty of endodontics and the profession of dentistry. The constant advances in technology have contributed to being able to do better dentistry. Recognize that technology only enhances treatment; it does not replace the basic principles of treatment. Each advance brings more excitement to the practitioner, and that should be a reflection in the growth of each practice. I’d like to see it easier for dentists to cross state lines to practice, especially after being in practice for a few years. There is no logic for patients to be able to be treated on each coast but for dentists to be limited by licensure in one (or more) locations. If I can treat a Floridian visiting in New York State, why can’t I treat that same person in Florida as a specialist without having to take a general dentistry exam? But that’s a whole other issue involving states’ rights, and that is slowly being resolved. Nevertheless, there is pride to being a dentist, and the rewards of relieving the pain and helping patients are overwhelming. There are alternatives in treatment when a tooth must be removed, but you can’t beat the feeling of saving teeth and making patients healthy and happy.

Top 10 pieces of advice 10. 9. 8. 7. 6. 5. 4. 3. 2. 1.

Be happy with what you do. Continue to learn. Be active in your profession. Recognize your limitations. Be honest with your patients and yourself. Do the very best you can do with every case. Treat your staff professionally. Treat your patients with respect. Spend quality time with your family. Be moral, ethical, and protect your integrity.

Top 10 favorites 10. Watching basketball and soccer 9. Participating in dental/legal organizations 8. Using the microscope 7. Working in my office saving teeth 6. Listening to classical music 5. Boating and kayaking 4. Vacationing 3. Photography 2. Attend grandchildren’s activities 1. Spend quality family time

Volume 8 Number 1

Grandchildren: Meghan, Ashley, Cody, Ethan, Jennie, and Hali with pets Abby, Callie, and Baxter

Judy Seidberg

What are your top tips for maintaining a successful practice? Treat your staff and patients with respect. Be an understanding and caring person. Maintain a professional attitude in and outside of your office.

What advice would you give to budding endodontists? Whether you are a budding endodontist or a new dental practitioner, you must practice with integrity, morality, ethics, and sensitivity. Be honest with your patients and recognize your limitations. Don’t be afraid to refer to a colleague or to seek help. You cannot treat the entire world; there are enough patients for everyone. You cannot please everyone, but you can certainly try. Every treatment you perform will not be successful as hard as you might try. You have to look in the mirror every night and every morning, and you should be able to do that without remorse.

What are your hobbies, and what do you like to do in your spare time? I like to spend my spare time with my grandchildren and attend as many of their activities that I can; there I put my photography hobby to work photographing them playing sports, in their concerts, or just in general. I’ve been taking photographs for many years and have won a number of awards. I also enjoy kayaking, boating, and vacationing but, most of all, spending time with my family.

Why did you decide to pursue law in addition to endodontics? I was chairman of my local dental society mediation committee for nearly a decade, and each case brought its own

Dr. Seidberg with his mother, Fannie, on her 100th birthday. (Today she is 105.)

unique set of issues. I wanted to be fair but remain within legal boundaries and decided that it would be interesting to study law. Most things we do in dentistry have a legal twist. After law school, I became a member of the American College of Legal Medicine, an organization of dual-degree doctors (MD/ JD and DDS/DMD/JD). I decided that my passion was for endodontics and that I was not going to change my professional focus, so my practice of law concentrated on risk management lectures, helping colleagues avoid legal entanglements, and reviewing alleged dental malpractice cases around the country. I’ve had chapters published in several legal and dental texts and papers published in several journals. My legal ventures and leadership abilities were highlighted when I became the first dentist to be elected President of the prestigious premier legal organization, the American College of Legal Medicine, and to receive its highest award, the Gold Medal. EP Endodontic practice 11

PRACTICE PROFILE

What is the future of endodontics and dentistry?

CASE STUDY

Management of a tooth with a large radiolucency: Part 2 Dr. Nishan Odabashian discusses treating teeth with failing previous root canal treatment exhibiting large radiographic lucencies less invasively Introduction A healthy 22-year-old male presented to our office on March 1, 2011, after his mother, a previous patient, insisted that he obtain a second opinion. He was referred to an oral surgeon by his general dentist and was advised that he would need extensive surgery in his lower right mandibular molar area which would include removal of the first and second molars.

Clinical and radiographic examination Clinical findings The patient had a crown on tooth No. 30. He had an occlusal amalgam restoration on tooth No. 31. He had visible slightto-moderate intraoral and extraoral swelling in the lower left molar area (Figure 7). He had moderate-to-severe pain on palpation and percussion of tooth No. 30, slight pain to percussion on tooth No. 31, and neither palpation nor percussion sensitivity on tooth No. 29. Both teeth No. 29 and No. 31 responded normally to cold sensitivity testing. Radiographic findings Panoramic, periapical, bitewing, as well as 3D imaging pointed to a large unilocular lucency apical to tooth No. 30 and tooth No. 31. The lucency extended almost the entire corono-apical length of the mandible (Figure 2). Tooth No. 30 had a previous root canal treatment (longer than 10 years ago, according to the patient). The tooth had a screw-type post, a PFM crown, with apical resorption apparent in both mesial and distal roots of both tooth No. 30 and tooth No. 31.

Diagnosis

• Pulpal: Pulpless — previously treated root canal • Periapical: Symptomatic periradicular abscess

Differential diagnosis • Lesion of endodontic origin • PA Cyst • Keratocystic Odontogenic Tumor (KCOT) formerly Odontogenic Keratocyst (OKC) • Central Giant Cell Granuloma • Ameloblastoma • Other Immediate treatment plan • Incision and drainage (I&D) • Initiate retreatment, and based on results, send for biopsy or continue with endodontic retreatment.

Treatment Retreatment was initiated by isolating with a rubber dam, accessing the crown, removing the core and the screw post from the distal canal, as well as the removal of gutta percha from all canals. A sero-sanguinous exudate rushed into the chamber, (Figure 5), which was flushed with copious

Figure 1: Preoperative PA radiograph

Figure 2: Preoperative panoramic radiograph

Medical history Non-contributory. Slight fever and swelling on the right molar area upon presentation. Nishan Odabashian, DMD, is a graduate of Tufts University School of Dental Medicine. After 8 years of practicing restorative dentistry, he pursued his specialty training in endodontics at Loma Linda University School of Dentistry (LLUSD), Department of Graduate Endodontics. He is part-time faculty at LLUSD and practices microscope-aided restorative endodontics in Glendale, California.

Figure 3: Clinical photograph of post and core removal 12 Endodontic practice

Figure 4: Clinical photograph of chamber after post and core removal Volume 8 Number 1

CASE STUDY

amounts of sodium hypochlorite. The tooth was left to drain for approximately 30 minutes. The canals were then irrigated, dried, and dressed with calcium hydroxide (Figure 6). The tooth was temporized with Cavitâ&#x201E;˘ (3M ESPE). This was followed by an I&D of the buccal swelling. The patient was prescribed clindamycin 300mg, 2 tabs immediately, and 1 tab 3 times a day for 5 days. Patient presented 5 days later, and his facial as well as buccal swelling (Figure 9)

Figure 5: Clinical photograph of sero-sanguinous exudate

Figure 6: Clinical photograph of calcium hydoxide placement

Figure 7: Clinical photograph of preoperative intraoral buccal swelling

Figure 8: Calcium hydroxide PA radiograph

Figure 9: Clinical photograph 9 days post I&D

Figure 10: PA radiograph of calcium hydroxide â&#x20AC;&#x201D; 2 months intertreatment

Figure 11: Clinical photograph of MTA obturation of distal canals Volume 8 Number 1

Figure 12: Clinical photograph of MTA obturation of mesial canals

Figure 13: Clinical photograph of amalgam buildup Endodontic practice 13

CASE STUDY was considerably better. His symptoms had become tolerable, and retreatment was planned to continue. Patient was seen monthly with further cleaning of the canals and replacement of the calcium hydroxide paste. The tooth was obturated with MTA, on August 17, 2011, and apical surgery was planned to remove the thin gutta-percha points, which extruded into the periapical area during retreatment (Figure 14) at the next scheduled appointment.

This case shows the capacity of the body to heal if and when the offending insults are removed. It shows the result of patience and taking the time to perform the most conservative dental treatment possible.

The patient missed his surgery appointment due to his college classes. He rescheduled in December 2011 during his Christmas break. He presented in December but did not

want to have surgery during his Christmas break, and said that he has been asymptomatic since April. He asked if surgery was absolutely necessary and was advised that it would be best if he had the surgery, but was not absolutely necessary. He was given a follow-up during spring break, and he was still asymptomatic and asked if the surgery could be delayed until the summer.

Figure 14: Postoperative PA radiograph, 8/17/2011

Figure 15: 2-month recall panoramic radiograph

Figure 16: 4-month recall PA radiograph of tooth No. 30

Figure 17: 4-month recall PA radiograph of tooth No. 30 showing reduction in the size of lucency

Follow-up

14 Endodontic practice

Follow-ups continued every 3 months with the patient declining surgery each time. The radiographic presentations (see below) show continued healing of the periapical area. Tooth No. 31 shows complete osseous healing and normal response to temperature testing. Tooth No. 30 shows almost complete osseous resolution of

Figure 18: 4-month recall PA radiograph of tooth No. 31 showing reduction in the size of lucency Volume 8 Number 1

CASE STUDY

Figure 19: 9-month recall PA radiograph of tooth No. 31 showing continued healing

Figure 20: 2-year recall PA radiograph of tooth No. 31 showing continued healing

Figure 21: 3-year recall PA radiograph of tooth No. 31 showing osseous healing of the large PA lucency on both teeth Nos. 30 and 31

the large radiolucent area, and the patient continues to be asymptomatic.

Discussion This case presentation is the second in a series of teeth exhibiting large periradicular lucencies associated with failing root canal treatments. (The first article in the series appeared in Endodontic Practice US, May/ June 2014, Volume 7, No. 3.) As mentioned in the previous report, treatment of teeth 16 Endodontic practice

with large lucencies requires more than the garden-variety retreatment or surgery. It requires time, patience, proper follow-up, sound restorative treatment, proper diagnosis, and involvement of other specialists as necessary. In this instance, the 22-year-old male patient was slated to go through an extensive surgery with the loss of two molar teeth. And although neither the general dentist nor the oral surgeon can be faulted for the treatment

that was about to be rendered, it helps to take a step back and think the treatment through given the clinical presentation. The fact that there was an intraoral and extraoral swelling associated with a previous root canal treatment pointed this clinician to a diagnosis of lesion of endodontic origin. Also, the titrated-type treatment that was rendered, allowed us to “throw in the towel” if the signs and symptoms were not improved. At such time, some type of biopsy would have been performed to render the appropriate treatment for the condition. This case also shows the capacity of the body to heal if and when the offending insults are removed. It shows the result of patience and taking the time to perform the most conservative dental treatment possible. It would have been much easier to “just extract” and, after extensive surgery and grafting, to place two implants and implantsupported crowns. It was much more timeconsuming for this clinician, but also much more rewarding. The treatment rendered was much less invasive, much less expensive, and much less morbid.

Summary This case shows what is possible with endodontic treatment/retreatment as far as osseous healing of large periradicular lucencies. This case also shows the benefit of multi-visit endodontic retreatment. Titrated treatment, a term that was coined by Dr. Gary Carr, is very useful in these types of cases. It allows for re-evaluation of the results (or lack thereof) during the course of treatment. EP Volume 8 Number 1

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1. K. Bentley, S. Janyavula, D. Cakir, P. Beck, L.C. Ramp, J.O. Burgess. "Mechanical and Physical Properties of Vital Pulp Materials". School of Dentistry, University of Alabama at Birmingham, Birmingham, AL. 2. A. Atmeh, F. Festy, A. Banerjee, F. Mannocci, T. F. Watson. "Mineral Interaction Zone; A Chemo-morphological Chracterization of The Dentine-Biodentine Interface". 2012. King's College London Dental Institute, Biomaterials, Biomimetrics and Biophotonics, London, UK.

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CASE STUDY

Post or no post? Dr. Marcelo Balsamo presents a case report demonstrating direct adhesive post luting and core buildup in one appointment

he question about whether to use a post or not is essentially one of substance lost. A large amount of substance loss in the clinical crown area is an argument for anchoring and reinforcing the core buildup with a post. For small defects, anchoring the buildup on the surrounding tooth substance is often sufficient. Post solutions made from different materials (metal, high-strength ceramic, glass, and quartz fiber) are now available. Quartz and glass fiber posts are characterized by tooth-like elasticity modulus and thus limit the risk of root fracture from shear loads. In the case discussed in this article, the patient presented with considerable substance loss on tooth LL5 (Figures 1-3). The barrel ring preparation necessary for a poured post buildup further weakened the tooth substance. A purely retentive post anchoring, according to the traditional pattern, appeared insufficient due to the anticipated stress to the core. Preference was therefore given here to the direct post buildup in the adhesive technique. Utilization of a system based on the adhesive technique also facilitates a minimally invasive procedure, which preserves tooth substance and benefits the adhesive bond. For this case, a post build-up system was chosen that provided an adhesive bond, root-posts, cement-post build-up material (Rebilda Post System, Voco). With this system, the build-up material simultaneously provides post luting, which allows post cementation and core buildup in one step. The system contains posts in three sizes as well as the matching bur and a reamer for pre-drilling (Figure 4).

Figure 1: Initial situation on tooth LL5

Figure 2: Substantial substance loss on tooth LL5 in a visible area

Figure 3: Initial situation on tooth LL5 from coronal

Case details After removing the remainder of the old filling (Figure 5), the length of the root canal was determined to establish the drilling depth

Dr. Marcelo Balsamo is a dentist and professor with the S찾o Paulo Association of Surgical Dentists (APCD) in S창o Paulo, Brazil.

Figure 4: Posts and burs 18 Endodontic practice

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CASE STUDY

(Figure 6). Care must be given that approximately 4 mm of root canal filling remains apically to provide an apical seal. A rubber dam or gingival barrier is used to isolate the tooth during the restoration (Figure 7). The root canal filling material was removed to the determined depth with the bur, and the canal thus concomitantly prepared to the correct diameter (Figure 8). An X-ray was used to verify the fitting accuracy of the post. The post is clearly visible on the X-ray (Figure 9). It was subsequently shortened to the required length with a diamond. Figure 10 shows the canal after preparation but before the bonding step. A self-etching, dual-curing bond (Futurabond, Voco) was then applied on the adhesive surfaces around the canal access, but not yet light-cured (Figure 11). This guarantees that the excess material expelled from the canal during insertion of the post also provides a good adhesive bond to the tooth. The employed bond contains a special

Figure 5: After removing the remaining old filling

Figure 6: Determining the length

Figure 7: Gingival barrier

Figure 8: Preparing the canal

Figure 9: Fitting accuracy of the post

Figure 10: Prepared canal

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Figure 11: Bonding the tooth surfaces Endodontic practice 19

CASE STUDY

Figure 12: Bonding the canal

Figure 13: The bond is dried

Figure 14: Silanising the post

catalyst and can also be used for self- or dual-curing composites. The application of the bond in the root canal (Figure 12) was carried out with an endo-applicator (Endo Tim, Voco). The bond was still not light-cured but thoroughly dried with oil-free air (Figure 13). After silanising the post (Figure 14), the core build-up material (Rebilda DC速, Voco) was applied directly in the root canal (Figure 15) with an endo-application tip for post luting. The post was then inserted into the root canal with a light twisting motion immediately after application of the core build-up material (Figure 16). Only now can light-curing be

Figure 16: Inserting the post 20 Endodontic practice

Figure 15: Applying the core build-up material in the canal

Figure 17: Light-curing the post, core build-up material and bond Volume 8 Number 1

CASE STUDY

Figure 18: Further core buildup

Figure 19: Light-curing the core buildup

Figure 20: Core buildup before grinding

Figure 21: Grinding the core buildup

carried out. The post is fixed in the core buildup material with this action (Figure 17). This permits further buildup immediately afterward, without having to wait for the duration of the setting time. The core was then further constructed around the core with the direct application of Rebilda DC (Figure 18) and lightcured (Figure 19). The core buildup can be further processed immediately afterward (Figure 20). The gingival barrier was removed at this point and the core ground. The core buildup material exhibited a surface hardness comparable to dentin. It can be ground precisely, especially in the areas that change over to dentin (Figure 21). Figure 22 shows the completed crown core. EP

Figure 22: Prepared core Volume 8 Number 1

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CLINICAL

Irrigation in endodontics Drs. Peet J. van der Vyver and Heinrich Dippenaar explore activation devices for root canal irrigation solutions Irrigant agitation techniques and devices According to Gopikrishna, et al. (2014), the three most important characteristics for an endodontic irrigant are tissue dissolution, anti-microbicity, and the ability to remove the smear layer. Most irrigation protocols advocate the use of a combination of irrigation solutions such as NaOCl with EDTA or chlorhexidine (Gu, et al., 2009) to achieve this goal and to complement the shortcomings that are associated with the use of a single irrigant. According to Zehnder (2006), irrigants should be brought into direct contact with all canal wall surfaces for effective action, particularly for the apical portions of small root canal systems. Studies have indicated that after root canal preparation with nickel-titanium instruments, there are still untouched areas that can harbor tissue debris, microbes, and their byproducts (Peters, 2004; Schäfer, Zapke, 2000) (Figures 1 and 2), resulting in persistent periradicular inflammation (Naidorf, 1974). Different irrigant delivery systems and agitation systems for root canal irrigation have been proposed (Gu, et al., 2009). The systems can be divided into two broad categories: manual agitation techniques and machine-assisted agitation devices.

Manual agitation techniques Manual agitation techniques include: • Syringe irrigation with end-venting or side-venting needles • Brushes for debridement of the canal walls or for agitation of the irrigant inside the root canal (e.g., NaviTip® FX®, Ultradent Products Inc.) • Manual-dynamic agitation irrigation technique where apically fitting guttapercha cones are used in an up-anddown motion to activate the irrigation solution

Figure 1: Remnant of vital pulp tissue (white arrows) visible under 10x microscope magnification in the midroot area of a distobuccal root canal of a mandibular first molar, after root canal preparation with NiTi rotary instrumentation and sodium hypochlorite syringe irrigation with a side-vent needle

Machine-assisted agitation devices Machine-assisted agitation systems include: • Rotary brushes (e.g., canal brush operating at 600rpm in contra-angle handpiece to facilitate debris and smear layer removal) • Sonic irrigation devices (e.g., EndoActivator®, Dentsply Maillefer, Dentsply Tulsa Dental Specialties, and Vibringe®, Vibringe BV) • Ultrasonic irrigation devices (e.g., ProUltra PiezoFlow™, Dentsply Maillefer, Dentsply Tulsa Dental Specialties, and EndoUltra™, Vista™ Dental Products) • Pressure alternation devices (e.g., EndoVac, SybronEndo, and EndoSafe™, Vista Dental Products)

Passive irrigation Passive irrigation is achieved by slowly injecting an irrigation solution into the root canal system using different gauged and flexible cannulas (Figure 3). The smaller the cannula gauge, the deeper it can be placed into the root canal system. The cannula must fit loosely into the root canal to ensure reflux and coronal movement of the debris during

Dr. Peet J. van der Vyver is an extraordinary professor at the Department of Odontology, School of Dentistry, University of Pretoria, South Africa. He is in private practice limited to endodontics in Sandton, South Africa. (Visit www.studio4endo.com for more details.) Dr. Heinrich Dippenaar is guest lecturer at the Department of Odontology, School of Dentistry, University of Pretoria. He is a dentist in private practice, Welkom, South Africa.

22 Endodontic practice

Figure 2: Magnified cross-section view of a mesial root canal system in an extracted root canal-treated molar after preparation with rotary NiTi instruments, syringe irrigation with a side-vent needle using 17% EDTA and 3.5% sodium hypochlorite and warm vertical condensation. Note the remnants of debris not removed with conventional irrigation

Figure 3: Passive irrigation is achieved by slowly injecting an irrigation solution into the root canal system using different gauged and flexible cannulas

irrigation. If the operator slowly injects the solution in combination with continuous hand movements, it can potentially eliminate NaOCl accidents. The main limitation of passive irrigation is that a static reservoir of irrigant restricts the potential for any reagent to penetrate, circulate, and clean all aspects of root canal systems. Senia, et al. (1971), demonstrated that NaOCl does not extend any closer than 3 mm from working length during irrigation, even if the root apex is enlarged up to a size 30. The first reason is because of air entrapment by an advancing liquid front in closed-end micro-channels (Migun, Azuni, 1996; Migun, Shnip, 2002), called the vapor Volume 8 Number 1

Manual dynamic agitation irrigation technique The manual dynamic agitation irrigation technique involves gently moving a well-fitting gutta-percha master cone up and down (Figure 5) in short 2 mm-3 mm strokes, within an instrumented root canal (Gu, et al., 2009). Studies have confirmed that this technique can produce an effective hydrodynamic effect and significantly improve the displacement and exchange of any given irrigant (McGill, et al., 2008; Huang, Gulabivala, Ng, 2008). Several factors contribute to the positive results of this activation technique: • The push-pull motion of a well-fitting gutta-percha cone in the root canal generates high intracanal pressure changes during the pushing movement, ensuring more effective delivery of irrigation solution to the unprepared root canal surfaces (McGill, et al., 2008). • The push-pull motion also ensures better mixing of fresh unreacted irrigation solution with the spent, reacted irrigant (Wiggins, Ottino, 2004). The manual dynamic agitation irrigation technique often produces a cloud of debris

Figure 4: Scanning electron microscopy images of a mesiobuccal root canal wall of an upper first molar after instrumentation up to a size F3 (30/09) ProTaper Universal instrument. The root canal was irrigated with 3.5% NaOCl followed by 17% EDTA, using a 30-gauge Max-i-Probe irrigation needle. In the coronal-midroot aspect of the root canal, most of the smear layer was removed, and in the midroot-apical portion of the root canal, the smear layer was partially removed. Note the inability of the irrigation solutions to remove the smear layer in the apical 2 mm of the root canal, probably due to the vapor lock effect

Figure 6A: Access cavity of a maxillary first molar flooded with 3.5% sodium hypochlorite Volume 8 Number 1

Figure 6B: Size 30 gutta-percha point is used to manually agitate the irrigation solution

that can be observed within the fluid-filled pulp chamber that indicates the effectiveness of this technique (Figures 6A-6C). It is a very cost-effective and simplistic method that can be used for agitation of irrigation solutions. However, the laborious nature of the hand movement involved in this technique creates favor toward the new automated devices.

Sonic irrigation Tronstad, et al. (1985), were the first to show the effectiveness and safety of a sonic vibratory endodontic instrument. Sonic irrigation operates at low frequencies (1-6kHz), produces small shear stresses (Ahmad, Pitt Ford, Crum, 1987; Gu, et al., 2009),

Figure 5: Manual dynamic agitation irrigation technique — a well-fitting gutta-percha master cone is moved up and down in short 2 mm-3 mm strokes, within an instrumented root canal

Figure 6C: Cloudy appearance of the irrigation solution after the agitation technique loosened debris from the root canal systems Endodontic practice 23

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lock effect in endodontic literature (Gu, et al., 2009). These micro-channels can be flooded with the liquid, but it can take hours to days (Pesse, Warrier, Dhir, 2005). This physical phenomenon has practical implications for clinicians when they deliver irrigation solutions with syringe needles from the coronal to the middle third of the root canal. Generally, root canal irrigation is performed within a time frame of minutes; air entrapment in the apical portion of the root canal often precludes this region from contact by the irrigation solutions (Gu, et al., 2009) (Figure 4). Secondly, when NaOCl reacts with organic material in the root canal system, it can form micro-gas bubbles at the apical termination that coalesce into a vapor lock effect (Schoeffel, 2008). Huang, Gulabivala, and Ng (2008) suggested that the vapor lock might be disrupted via the use of a hand-activated well-fitting root filling material (e.g., a size 30, 0.06 taper gutta-percha point) that is introduced to working length after instrumentation. This will eliminate the vapor lock because the root filling material, carrying with it a film of irrigant to the working length, replaces the space previously occupied by air.

CLINICAL

Figure 7: EndoActivator

Figure 8: Small, medium, and large polymer tips

Figure 9: The vibrating tip of the EndoActivator is moved up and down in short, 2 mm-3 mm vertical strokes to synergistically optimize a powerful hydrodynamic phenomenon

Figure 10A: Magnified view of the isthmus area between two mesial root canal systems in a mandibular first molar after root canal preparation and conventional syringe irrigation with a side-vent needle. Note the isthmus area is still filled with cutting debris and remnants of pulp tissue

Figure 10B: After a fresh solution of sodium hypochlorite was activated with the EndoActivator for 45 seconds in each canal, most of this tissue dissolved due to the activation of the irrigation solution

and generates significantly high amplitudes (back-and-forth tip movement). Sonic irrigation has been shown to be efficient for root canal debridement (Walmsley, Williams, 1989). However, some studies report that sonic instruments may contribute toward canal cleanliness but still leave residual debris on the canal walls in hard-to-reach locations (Stamos, et al., 1987; Jensen et al., 1999). Sonically driven canal irrigation systems currently available are the EndoActivator system and the Vibringe system.

Operations of 10,000, 6,000, and 2,000 cycles per minute can be selected by depressing a switch on the handpiece. The tips, made from a medical-grade polymer, have an easy snap-on/snap-off design and are color-coded yellow, red, and blue, corresponding to small, medium, and large (Figure 8). In prepared root canals, a tip is selected to fit loosely in the root canal to approximately 2 mm short of the working length. The vibrating tip is moved up and down in short, 2 mm-3 mm vertical strokes (Figure 9) to synergistically optimize a powerful hydrodynamic phenomenon (Ruddle, 2002). According to the manufacturer, this device is intended to provide the clinician with a safer, better, and faster method to disinfect root canal systems. Initial research has shown that the EndoActivator system

EndoActivator The EndoActivator system comprises a cordless contra-angled handpiece, which activates the strong flexible polymer tips with a three-speed sonic motor (Figure 7). 24 Endodontic practice

is able to debride completely into the deep lateral anatomy, remove the smear layer, and dislodge biofilm clumps within curved canals of molar teeth (Caron, 2007; Gu, et al., 2009). The hydrodynamic activation serves to improve penetration, circulation, and flow of irrigation solution into the more inaccessible regions of the root canal (Gu, et al., 2009). Figure 10A illustrates a magnified view of the isthmus area between two mesial root canal systems in a mandibular first molar after root canal preparation and conventional syringe irrigation with a sidevent needle. Note that the isthmus area is still filled with cutting debris and remnants of pulp tissue. After a fresh solution of sodium hypochlorite was activated for 45 seconds with the EndoActivator in each canal, most of this tissue dissolved due the activation of the irrigation solution (Figure 10B). However, a study performed by Klyn, Kirkpatrick, and Rutledge (2010) demonstrated that there was no statistically significant difference in canal isthmus cleanliness when the EndoActivator was used as an adjunct to aid in canal debridement compared to irrigation alone. Huffaker, et al. (2010), also demonstrated that there was no significant difference in the ability of the EndoActivator and a standard irrigation group to eliminate cultivable bacteria from root canals. Mancini, et al. (2013), evaluated the smear layer removal and canal cleanliness using the EndoActivator, EndoVac, and passive ultrasonic irrigation by means of a field emission-scanning electron microscopic evaluation. The results of the study showed Volume 8 Number 1

CLINICAL

that none of the activation/delivery systems completely removed the smear layer from the endodontic dentin walls. The EndoActivator demonstrated the best results at 3 mm, 5 mm, and 8 mm compared to the EndoVac system, which showed the best results at 1 mm, 3 mm, 5 mm, and 8 mm from the apex. Vibringe Vibringe is a system that combines manual delivery and sonic activation of the irrigation solution. The Vibringe is a cordless device that fits in a special disposable 10ml LuerLock syringe, which is compatible with most conventional irrigation needles (Figure 11). RĂśdig, et al. (2010), compared the efficiency of Vibringe, syringe irrigation, and passive ultrasonic irrigation (PUI) in the removal of debris from simulated root canal irregularities. The results of the study indicated that ultrasonic irrigation removed debris significantly better from the artificial canalsâ&#x20AC;&#x2122; irregularities than the Vibringe system and syringe irrigation. The Vibringe system demonstrated significantly better results compared to syringe irrigation in the apical part of the root canal.

Ultrasonic irrigation Ultrasound was introduced for canal debridement by Richman in 1957. Ultrasonic energy is different from sonic energy in that it operates at a higher frequency (25-30kHz) and produces low amplitudes when compared to sonic energy (Walmsley, Williams, 1989). There are two types of ultrasonic irrigation. The first type is a combination of simultaneous ultrasonic instrumentation and irrigation (UI) and the second type is passive ultrasonic irrigation, which operates without instrumentation (Gu, et al., 2009). With PUI, the energy is transmitted from an oscillating file or smooth wire to the irrigant

Figure 12: EndoUltra (Vista Dental) Volume 8 Number 1

Figure 11: Vibringe (Vibringe VB)

in the prepared root canal by means of ultrasonic waves that induces acoustic streaming and cavitation of the irrigant (Ahmad, Pitt Ford, Crum, 1987; Ahmad, et al., 1988). Acoustic streaming and cavitation contribute to the cleaning efficiency of root canal irrigation. Acoustic streaming can be defined as a rapid movement of fluid in a circular or vortex-like motion around a vibrating file (Walmsley, Williams, 1989). The shear stresses produced by acoustic streaming are capable of disrupting biological cells and removal of debris. Cavitation can be defined as the creation of vapor bubbles or the expansion, contraction, or distortion of pre-existing bubbles (so-called cavitation nuclei) in a liquid. The process is linked to acoustic energy (Leighton, 1995). The first application of PUI can be a continuous flush of fresh irrigant from an ultrasonic handpiece. Nusstein (2005) developed a needle-holding adapter attached to an ultrasonic handpiece. This device allows the irrigation needle to be simultaneously activated by the ultrasonic handpiece, while the irrigant is delivered from an intravenous tubing connected via a Luer-Lock to an irrigation delivering syringe (Gu, et al., 2009). A study demonstrated that 1 minute of continuous ultrasonic irrigation with this device produced significantly cleaner canals

and isthmi in both vital and necrotic teeth (Burleson, et al., 2007). The second application is an intermittent flush technique by using syringe delivery of the irrigant. The irrigant is injected into the root canal with a syringe and replenished several times after each ultrasonic activation cycle (Cameron, 1988). There is a general consensus in the literature that PUI is more effective than conventional needle irrigation in removing pulpal tissue remnants and dentin debris (Sabins, Johnson, and Hellstein, 2003; Metzler, Montgomery, 1989). According to Sabins, Johnson, and Hellstein (2003), the ultrasonic irrigation technique is more capable of removing debris compared to sonic irrigation. Several studies have also demonstrated that the use of PUI after hand or rotary instrumentation results in a significant reduction in the number of bacteria in root canals (DeNunzio, Hicks, Peleu, 1989; Siqueira, et al., 1997). EndoUltra EndoUltra is a cordless, handheld ultrasonic device for use in endodontics (Figure 12). The unit is capable of generating a tip frequency of 40,000Hz, which is required to create sufficient acoustical streaming and cavitation necessary to effectively clean, penetrate, and remove vapor lock. The EndoUltra kit includes six autoclavable stainless steel activator tips (size 15/02) that resonate down the entire length of the tip. According to the manufacturer, these ultrasonic tips will not engage or remove tooth structure (one of the disadvantages of ultrasonic cleaning). The EndoUltra has a LED light at the tip for improved visibility and an LED battery indicator at the back to show the remaining battery power. It is recommended to move the activated activator tip up and down using small (2 mm-3 mm) vertical motions, maintaining a distance of 2 mm from working length. At the time of publication, no studies on the EndoUltra system could be found on Medline. Endodontic practice 25

CLINICAL Figure 13A shows a preoperative periapical radiograph of a mandibular right second premolar. A reproducible glide path was established with the size 10 K-file before the glide path was enlarged with size 15 and 20 K-files. Root canal preparation was performed with ProTaper NextÂŽ X1, X2, and X3 (Dentsply Maillefer, Dentsply Tulsa Dental Specialties). After root canal preparation, the smear layer was removed by using a 17% EDTA solution, followed by irrigation with heated 3.5% sodium hypochlorite, and activated with the EndoUltra for 2 minutes. Final irrigation was done with SmearOFFâ&#x201E;˘ (Vista Dental) and activated with the EndoUltra for 1 minute. Figure 13B shows the postoperative result after root canal obturation. Note a few lateral canals that were obturated in the apical part of the root canal system.

There are three clinical steps involved when using this system. Step one involves gross debris evacuation with the master delivery tip (MDT) during and between root canal instrumentation. This tip siphons off the excess irrigant to prevent overflow from the pulp chamber. This action ensures frequent and continuous flow of irrigant at a constant level in the pulp chamber (Figure 14). Step two makes use of a macro-cannula in a titanium handpiece (attached to a highspeed suction device) to pull the freshly delivered irrigant from the MDT, down the root canal, into the plastic cannula, and

out through the suction hose (Figure 15). This action will remove coarse debris from the root canal. It is recommended that the macro-cannula is moved up and down in each canal within a few millimeters of the apical foramen. Step three utilizes a micro-cannula mounted on a small titanium finger piece to evacuate microscopic debris from the apical part of the root canal. The EndoVac microcannula is a 30-gauge needle with 12 laserdrilled, microscopic evacuation holes, placed at the end of the needle. The MDT is again used to deliver fresh irrigant while the fluid is

Figure 13A: Preoperative periapical radiograph of a mandibular right second premolar

Figure 13B: Periapical radiograph of the postoperative obturation result. Note a few lateral canals that were obturated in the apical part of the root canal system

Figure 15: A plastic macro-cannula in a titanium handpiece (attached to a high-speed suction device) is used to pull the freshly delivered irrigant from the MDT, down the root canal (white arrows), into the plastic cannula, and out through the suction hose (red arrows)

Figure 16: The EndoVac micro-cannula is mounted on a small titanium finger piece to evacuate microscopic debris from the apical part of the root canal. The MDT delivers fresh irrigant while the fluid is drawn toward the apical region of the root canal (white arrows). Debris is evacuated through the holes in the micro-cannula from full WL (red arrows)

Negative pressure or vacuum devices An example of this technique is an irrigation system called EndoVac (SybronEndo). This system enables safe irrigation up to the apical terminus with an abundance of fresh and continuous amounts of irrigation solution. Unlike passive irrigation (positive pressure), which uses cannulas to deliver irrigation solutions into the root canal, the EndoVac system is a true apical negative pressure system that draws fluid apically by way of evacuation. Studies have also demonstrated that apical negative pressure helps to overcome the issue of vapor lock (Nielsen, Baumgartner, 2007; Shin, et al., 2010).

Figure 14: Gross debris evacuation with the master delivery tip (MDT). Irrigant is delivered with a needle into the pulp chamber (white arrows) while the surrounding evacuation device siphons off the excess irrigant (red arrows) to prevent overflow from the pulp chamber. This ensures frequent and continuous flow of irrigant at a constant level in the pulp chamber 26 Endodontic practice

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before the glide path was enlarged with a ProGlider™ instrument (Dentsply Maillefer, Dentsply Tulsa Dental Specialties). Root canal preparation was done with ProTaper Next X1 and X2. After root canal preparation, the smear layer was removed by using a 18% EDTA root canal irrigation solution followed by irrigation with heated, 3.5% sodium

hypochlorite using the EndoVac system (Figures 18A-18C). Final irrigation was done with SmearOFF. Figure 19 shows the final result after obturation using the Calamus® DUAL obturation unit (Dentsply Maillefer, Dentsply Tulsa Dental Specialties) in conjunction with a ProTaper Next X2 gutta-percha point and Pulp Canal Sealer (SybronEndo).

Figure 18A: Master delivery tip. Root canal irrigation done with the EndoVac system using 3.5% heated sodium hypochlorite after the smear layer was removed

Figure 17: Periapical radiograph of a mandibular left second premolar with a sharp apical curvature in the last few millimeters of the root. Note the position where the size 10 K-file exits the root canal system after canal negotiation

Figure 18B: Macro-cannula. Root canal irrigation done with the EndoVac system using 3.5% heated sodium hypochlorite after the smear layer was removed

Figure 19: Postoperative periapical radiograph after obturation. Note the lateral canal that branched off from the main root canal at a 90-degree angle, following the apical curved part of the root and another lateral canal on the distal aspect of the root, approximately 6 mm from WL

Figure 18C: Micro-cannula. Root canal irrigation done with the EndoVac system using 3.5% heated sodium hypochlorite after the smear layer was removed Endodontic practice 27

CLINICAL

drawn toward the apical region of the root canal. Microscopic debris is then evacuated through the holes in the micro-cannula from full working length (Desia, Himmel, 2009) (Figure 16). The EndoVac system ensures a constant flow of fresh irrigant and safe and efficient delivery of irrigation solution up to the working length by using apical negative pressure (Glassman, 2013). Nielsen and Baumgartner (2007) showed that the volume of irrigant delivered by the EndoVac system was significantly higher than the volume delivered by conventional syringe irrigation in the same time period. They also showed significantly better debridement at 1 mm from working length by using the EndoVac compared to needle irrigation. At the 3-mm level from working length, there was no significant difference between the groups. Several studies also showed that the EndoVac was the only system capable of cleaning 100% of isthmus areas compared to EndoActivator, manual dynamic Max-i-Probe®, passive and pressure ultrasonics (Gutarts, et al., 2005; Klyn, Kirkpatrick, Rutledge, 2010; Susin, et al., 2010). Brito, et al. (2009), compared the effectiveness of NaviTip needles (Ultradent), EndoActivator and the EndoVac system in reducing intracanal Enterococcus faecalis populations. The study concluded that there was no antibacterial superiority between these techniques. A similar study showed that there were fewer colony-forming units of E. faecalis bacteria when using the EndoVac compared to a 30-gauge side-vented needle for irrigation. However, the results were not statistically significant. Postoperative pain after endodontic treatment can range from 3% to 58% (Sathorn, Parashos, Messer, 2008). One of the factors that can cause postoperative pain can be irritation of the periapical tissues from sodium hypochlorite during irrigation (Seltzer, 1986). In a well-controlled study, the EndoVac irrigation system was compared to needle irrigation (Gondim, et al., 2010). The study concluded that negative apical pressure irrigation with the EndoVac system resulted in significantly less postoperative pain and necessity for analgesic medication than conventional needle irrigation. Figure 17 shows a periapical radiograph of a mandibular left second premolar with a sharp apical curvature in the last few millimeters of the root. Note the position where the size 10 K-file exits the root canal system after canal negotiation. A reproducible glide path was established with the size 10 K-file

CLINICAL It is important to note how effective this irrigation protocol was in the apical part of this complex root canal system. There was a lateral canal that branched off from the main root canal at a 90-degree angle, following the apical curved part of the root. In addition, another lateral canal was obturated on the distal aspect of the root, approximately 6 mm from working length. Endo-Safe The EndoSafeâ&#x201E;˘ (Vista Dental Products) (Figure 20) is a negative pressure device comparable to the EndoVac. A very thin needle with a side porthole of exit is connected to a ratchet-type syringe, which allows for a tactile and audible signal when used for irrigation. On the side of the syringe is a small suction tube that connects to a high suction tip on one end, and the other end slides over the thin needle in front of the syringe. The needle is placed in a root canal, and the soft flexible suction tube is placed in the pulp chamber, creating negative pressure.

Every click of the ratchet syringe extrudes 0.20ml of irrigation liquid. As the irrigation liquid is extruded at the needle tip inside a root canal, the irrigation liquid gets sucked back by the rubber tube over the needle in the pulp chamber. This creates a constant flow and exchange of clean irrigation liquid inside a root canal and eliminates positive pressure buildup inside the root canal.

The EndoSafe ensures safe and efficient irrigation (Figures 21A and 21B). At the time of publication, no studies on the EndoSafe system could be found on Medline.

Safety of irrigation devices One of the main concerns of passive irrigation with a needle is that the closer the needle tip is positioned to the apical tissue,

Figure 20: EndoSafe

Figure 21B: Clinical use of the EndoSafe system for root canal irrigation in a mandibular first molar

The most important and significant advancement that can be made in endodontics in the future will be the development of irrigating solutions and new devices to promote complete three-dimensional cleaning of root canal systems. Figure 21A: Diagram illustrating the flow of the irrigant through the root canal system (arrows) with the EndoSafe 28 Endodontic practice

Volume 8 Number 1

Conclusion The most important and significant advancement that can be made in endodontics in the future will be the development of irrigating solutions and new devices to promote complete three-dimensional cleaning of root canal systems. This will enable endodontists Volume 8 Number 1

to achieve the biological goal of complete debridement and disinfection of root canal systems prior to obturation. EP REFERENCES 1.

Van der Vyver References

Ahmad M, Pitt Ford TR, Crum LA. Ultrasonic debridement of root canals: an insight into mechanisms involved. J Endod. 1987;13(3):93-101.

Ahmad M, Pitt Ford TR, Crum LA, Walton AJ. Ultrasonic debridement of root canals: acoustic cavitation and its relevance. J Endod. 1988;14(10):486-493.

Bither R, Bither S. Accidental extrusion of sodium hypochlorite during endodontic treatment: A case report. J Dent Oral Hyg. 2013;5(3):21-24.

Bradford CE, Eleazer PD, Downs KE, Scheetz JP. Apical pressures developed by needles for canal irrigation. J Endod. 2002;28(4):333-335.

Brito PR, Souza LC, Machado de Oliveira JC, Alves FR, De-Deus G, Lopes HP, Siqueira JF Jr. Comparison of the effectiveness of three irrigating techniques in reducing intracanal Enterococcus faecalis populations:an in vitro study. J Endod. 2009;35(10):1422-1427.

Boutsioukis C, Lambrianidis T, Kastrinakis E, Bekiaroglou P. Measurement of pressure and flow rates during irrigation of a root canal ex vivo with three endodontic needles. Int Endod J. 2007;40(7):504-513.

Burleson A, Nusstein J, Reader A, Beck M. The in vivo evaluation of hand/rotary/ultrasound instrumentation in necrotic, human mandibular molars. J Endod. 2007;33(7):782-787.

Cameron JA. The use of ultrasound for the removal of the smear layer. The effect of sodium hypochlorite concentration; SEM study. Aust Dent J. 1988;33(3):193-200.

10. Caron G. Cleaning Efficiency of The Apical Millimetres of Curved Canals Using Three Different Modalities of Irrigant Activation: An SEM Study [master’s thesis]. Paris, France: Paris VII University; 2007. 11. DeNunzio MS, Hicks ML, Pelleu GB Jr, Kingman A, Sauber JJ. Bacteriological comparison of ultrasonic and hand instrumentation of root canals in dogs. J Endod. 1989;15(7):290-293. 12. Desai P, Himel V. Comparative safety of various intracanal irrigation systems. J Endod. 2009;35(4):545-549. 13. Glassman G. Endodontic irrigants and irrigant delivery systems. Roots. 2013;1:30-37. 14. Gondim E Jr, Setzer FC, Dos Carmo CB, Kim S. Postoperative pain after the application of two different irrigation devices in a prospective randomized clinical trial. J Endod. 2010;36(8):1295-1301. 15. Gopikrishna V, Ashok P, Kumar AP, Narayanan LL. Influence of temperature and concentration on the dynamic viscosity of sodium hypochlorite in comparison with 17% EDTA and 2% chlorhexidine gluconate: An in vitro study. J Conserv Dent. 2014;17(1):57-60. 16. Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR. Review of contemporary irrigant agitation techniques and devices. J Endod. 2009;35(6):791-804. 17. Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod. 2005;31(3):166-170. 18. Huang TY, Gulabivala K, Ng YL. A bio-molecular film ex-vivo model to evaluate the influence of canal dimensions and irrigation variables on the efficacy of irrigation. Int Endod J. 2008;41(1):60-71. 19. Huffaker SK, Safavi K, Spangberg LS, Kaufman B. Influence of a passive sonic irrigation system on the elimination of bacteria from root canal systems: a clinical study. J Endod. 2010;36(8):1315-1318. 20. Hülsmann M, Rödig T, Nordmeyer S. Complications during root canal treatment. Endod Topics. 2007;16(1):27-63. 21. Jensen SA, Walker TL, Hutter JW, Nicoll BK. Comparison of the cleaning efficacy of passive sonic activation and passive ultrasonic activation after hand instrumentation in molar root canals. J Endod. 1999;25(11):735-738. 22. Klyn SL, Kirkpatrick TC, Rutledge RE. In vitro comparisons of debris removal of the EndoActivator system, the F-File, ultrasonic irrigation, and NaOCl irrigation alone after hand-rotary instrumentation in human mandibular molars. J Endod. 2010;36(8):1367-1371. 23. Leighton TG. Bubble population phenomena in acoustic cavitation. Ultrason Sonochem. 1995;2(2):S123-S136. 24. Mancini M, Cerroni L, Iorio L, Armellin E, Conte G, Cianconi L. Smear layer removal and canal cleanliness using different irrigation systems (EndoActivator, EndoVac, and

passive ultrasonic irrigation): field emission scanning electron microscopic evaluation in an in vitro study. J Endod. 2013;39(11):1456-1460. 25. McGill S, Gulabivala K, Mordan N, Ng YL. The efficacy of dynamic irrigation using a commercially available system (RinsEndo) determined by removal of a collagen ‘bio-molecular film’ from an ex vivo model. Int Endod J. 2008;41(7):602-608 26. Metzler RS, Montgomery S. Effectiveness of ultrasonics and calcium hydroxide for the debridement of human mandibular molars. J Endod. 1989;15(8):373-378. 27. Migoun NP, Azuni MA. Filling of one-side-closed capillaries immersed in liquids. J Colloid Interface Sci. 1996;181(1):337-340. 28. Migun NP, Shnip AI. Model of film flow in a dead-end conic capillary. Journal of Engineering Physics and Thermophysics. 2002;75(6):1422-1428. 29. Mitchell RP, Baumgartner JC, Sedgley CM. Apical extrusion of sodium hypochlorite using different root canal irrigation systems. J Endod. 2011;37(12):1677-1681. 30. Naidorf IJ. Clinical microbiology in endodontics. Dent Clin North Am. 1974;18(2):329-344. 31. Nielsen BA, Baumgartner JC. Comparison of the Endovac system to needle irrigation in root canals. J Endod. 2007;33(5):611-615. 32. Nusstein J, inventor. Ultrasonic dental device. US patent 6,948,935. 2005. 33. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review. J Endod. 2004;30(8):559-567. 34. Pesse AV, Warrier GR, Dhir VK. An experimental study of the gas entrapment process in closed-end microchannels. Int J Heat Mass Transf. 2005;48(25-26):5150-5165. 35. Richman RJ. The use of ultrasonics in root canal therapy and root resection. Med Dent J. 1957;12:12-18. 36. Rödig T, Bozkurt M, Konietschke F, Hülsmann M. Comparison of Vibringe system with syringe and passive ultrasonic irrigation in removing debris from simulated root canal irregularities. J Endod. 2010;36(8):1410-1413. 37. Ruddle CJ. Chapter 8.Cleaning and shaping root canal systems. In: Cohen S, Burns RC, eds. Pathways of the Pulp. 8th ed. St Louis, MO: Mosby; 2002: 231. 38. Sabins RA, Johnson JD, Hellstein JW. A comparison of the cleaning efficacy of short-term sonic and ultrasonic passive irrigation after hand instrumentation in molar root canals. J Endod. 2003;29(10):674-678. 39. Sathorn C, Parashos P, Messer H. The prevalence of postoperative pain and flare-up in single- and multiple-visit endodontic treatment: a systematic review. Int Endod J. 2008;41(2):91-99. 40. Schäfer E, Zapke K. A comparative scanning electron microscopic investigation of the efficacy of manual and automated instrumentation of root canals. J Endod. 2000;26(11):660-664. 41. Seltzer S. Pain in endodontics. J Endod. 2004;30(7):501-503. 42. Senia ES, Marshall FJ, Rosen S. The solvent action of sodium hypochlorite on pulp tissue extracted teeth. Oral Surg Oral Med Oral Pathol. 1971;31(1):96-103. 43. Shin SJ, Kim HK, Jung IY, Lee CY, Lee SJ, Kim E. Comparison of the cleaning efficacy of a new apical negative pressure irrigating system with conventional irrigation needles in the root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(3):479-484. 44. Schoeffel GJ. The EndoVac method of endodontic irrigation, part 2 – efficacy. Dent Today. 2008;27(1): 82, 84, 86-87. 45. Siqueira JF Jr, Machado AG, Silveira RM, Lopes HP, de Uzeda M. Evaluation of the effectiveness of sodium hypochlorite used with three irrigation methods in the elimination of Enterococcus faecalis from the root canal, in vitro. Int Endod J. 1997;30(4):279-282. 46. Stamos DE, Sadeghi EM, Haasch GC, Gerstein H. An in vitro comparison study to quantitate the debridement ability of hand, sonic, and ultrasonic instrumentation. J Endod. 1987;13(9):434-440. 47. Susin L, Liu Y, Yoon JC, Parente JM, Loushine RJ, Ricucci D, Bryan T, Weller RN, Pashley DH, Tay FR. Canal and isthmus debridement efficacies of two irrigant agitation techniques in a closed system. Int Endod J. 2010;43(12):1077-1190. 48. Tronstad L, Barnett F, Schwartzben L, Frasca P. Effectiveness and safety of a sonic vibratory endodontic instrument. Endod Dent Traumatol. 1985;1(2):69-76. 49. Wiggins S, Ottino JM. Foundations of chaotic mixing. Philos Trans A Math Phys Eng Sci. 2004;15;362(1818):937-970. 50. Walmsley AD, Williams AR. Effects of constraints on oscillatory pattern of endosonic files. J Endod. 1989;15(5):189-194. 51. Zehnder M. Root canal irrigants. J Endod. 2006;32(5): 389-398.

Endodontic practice 29

CLINICAL

the greater the chance of extrusion of the irrigant (Boutsioukis, et al., 2007; Bradford, et al., 2002). The cytotoxic effects of NaOCl on vital tissue are well established (Hülsmann, Rödig, Nordmeyer, 2009) and include acute inflammation, cellular destruction in all tissues except heavily keratinized epithelium, followed by necrosis of the tissues concerned, immediate swelling, and profuse bleeding (Bither, Bither, 2013). The associated sequelae of a NaOCl extrusion have been reported to include life-threatening airway obstruction, facial disfigurement requiring multiple corrective surgical procedures, and permanent paresthesia with loss of facial muscle control (Glassman, 2013). Because there is no alternative root canal irrigation solution that is able to fulfil the vital role of NaOCl, emphasis should be placed on how to deliver this irrigant safely into root canals. The first study to compare the safety of some of the modern irrigation devices was conducted by Desai and Himmel in 2009. The devices that were tested included EndoVac micro- and macro-cannula, EndoActivator, manual irrigation with the Max-i-Probe needle, ultrasonic needle irrigation and Rinsendo (Air Techniques Inc.) that utilizes pressure-suction technology. The results of the study showed that the EndoVac did not extrude irrigant after deep intracanal delivery and suctioning the irrigant from the chamber to full working length. EndoActivator showed a minimal amount of irrigant extruded out of the apex when delivering irrigant into the pulp chamber and root canal, although statistically insignificant. Manual, ultrasonic, and Rinsendo groups had significantly greater amount of extrusion compared with EndoVac and the EndoActivator. Mitchell, Baumgartner, and Sedgley (2011) conducted a similar study comparing the apical extrusion of sodium hypochlorite in extracted teeth. The EndoActivator, EndoVac, Rispisonic/Micro Mega 1500, passive ultrasonic irrigation, and syringe irrigation with a slot-tipped needle were compared. Significantly less extrusion occurred using the EndoVac system compared with positive pressure irrigation with the slotted-needle.

CONTINUING EDUCATION

Adhesive restoration of the root-filled tooth Dr. Bob Philpott looks at the developments in adhesive systems and endodontics

he use of composite in the restoration of root-filled teeth has become more common, with the need for esthetic dentistry in general increasing due to patient demands, the increased simplicity of the available systems, and the marketing of the products. Endodontically treated teeth, however, pose different problems. They are often badly broken down with little residual dentin remaining; have altered biological and chemical properties (Sim, et al., 2008; Grigoratos, et al., 2001) due to the effects of treatment procedures on them (Reeh, et al., 1989); and a question has always remained regarding the ability to bond to the altered dentin on the pulp chamber floor and within the root canal (Schüpbach, Krejci, Lutz, 1997; Ferrari, et al., 2000). The predominance of in vitro over in vivo studies on the topic has done little to assist in addressing these concerns. Studies have shown that the quality of the final coronal restoration is a prognostic factor in the outcome of root canal treatment (Ray, Trope, 1995; Hommez, Coppens, De Moor, 2002; Ng, Mann, Gulabivala, 2011). Studies have also previously compared various materials, their placement (direct versus indirect), microleakage, and performance over time. In the case of composite, concerns have been raised especially about the hydrolytic degradation of the dentin bond over time (Söderholm, et al., 1984; Drummond, 2008). Placement of composite restorations is technique-sensitive, involving a number of interconnected steps. Studies have shown that adequate isolation, a three-step bonding technique (Foxton, Mannocci, Melo, 2006), incremental placement, and correct Bob Philpott, BDS, MFDS, RCSI, RCSEng, MClinDent (UCL), MRD (RCSEd), graduated from University College Cork in 2003. Following 2 years in general practice in London, he completed his senior house officer (SHO) year at the University Hospital of Wales Dental Hospital, Cardiff. He completed his specialist training pathway in endodontology at the Eastman Dental Hospital with distinction and gained a membership in restorative dentistry from the Royal College of Surgeons of Edinburgh in 2009. Since then, he has had a variety of private practice and teaching roles in the United Kingdom, Ireland, Australia, and New Zealand. In June 2014, he was appointed as a senior clinical lecturer in endodontics/honorary consultant at Edinburgh Dental Institute and is due to take up a position in private practice at Edinburgh Dental Specialists in February 2015.

30 Endodontic practice

Educational aims and objectives

This clinical article aims to explore the developments in adhesive systems.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • See the developments in adhesive systems. • Identify systems that offer endodontists greater choices. • Recognize systems that offer more reliability and better outcomes for patients. • Realize some techniques for preparation of the access cavity. • Identify some concerns regarding the ability to bond effectively within the depths of the root canal due to the altered dentin and the practical difficulties in bonding there.

finishing are all important in the optimization of outcomes. In the case of endodontically treated teeth, there are additional concerns — the altered structure both physically and chemically, the need to protect the root filling, and the performance of direct restorations in badly broken down teeth over time. There are also further technical issues to be considered: • What is the protocol to clean the access cavity following obturation? • What is the best material to seal the canal orifices? • What matrix system is best to aid placement? • How do direct composites perform in comparison to indirect cuspal coverage restorations? • What role do adhesive post systems have to play?

Preparation of the access cavity Depending on the technique used, there are varying amounts of obturation material in the access cavity on completion. Studies have shown that residual eugenol can have a negative effect on the polymerization of composite resin (Millstein, Nathanson, 1983). Meticulous cleaning of the access cavity is essential. Remnants of root filling material must first be removed using either an ultrasonic scaler or an excavator. The cavity walls should be wiped clean using a cotton pellet soaked in chloroform, the most effective solvent of gutta percha available. The cavity should then be cleaned using a cotton pellet soaked in isopropyl alcohol. This should remove all visible remnants of obturation material, and although concerns have been

expressed about eugenol residues remaining in the dentinal tubules, this does not appear to be clinically significant. Three-step bonding techniques appear to offer better outcomes. The protocol used in the cases below involved etching with 37% phosphoric acid for 20 seconds followed by washing and drying (with care taken to avoid dessication of dentin). Following application of primer, the bonding agent is applied in a thin layer and cured. It is important to avoid pooling of the bonding agent by applying compressed air due to the effects it may have on the final restoration margins.

Sealing of the root canal orifices A number of materials have been used to seal the root canal orifices following obturation. These include amalgam, glass ionomer cement, IRM, and other zinc oxide and eugenol-based cements, Cavit™ (3M™ ESPE™), and various types of composite resin (Belli, et al., 2001; Galvan, et al., 2002). Unfortunately, leakage studies have many drawbacks and do not accurately represent the clinical scenario. Comparisons between the various materials have also been inconclusive, with a variety of materials all shown to be effective barriers. Another critical factor in relation to this stage of treatment is the ease of placement. Difficulties are often encountered in the placement of a material like GIC into the coronal portion of the obturated root canal. Incorrect placement of the material can often result in a void between the obturation material and the orifice sealer with potential implications for the prognosis of the treatment. Concerns have previously been voiced about the use of a flowable composite to Volume 8 Number 1

focused on the advantages of placement of indirect cuspal coverage restorations on root-filled teeth. In 2002, Aquilino and Caplan concluded that endodontically treated teeth not crowned after treatment were lost at a 6 times greater rate. Tickle, et al. (2008), in a study on the outcome of NHS endodontic treatment, agreed that placement of a cast cuspal coverage restoration had a positive effect on outcome, although success criteria were not stringent. The basis of this is due to the fact that endodontically treated teeth are often badly broken down, have altered properties due to treatment processes, and have lost their proprioceptive capability (Reeh, Messer, Douglas, 1989). As a result, these teeth appear to be more susceptible to catastrophic fracture and benefit greatly from coverage of the remaining unsupported cusps. The reality is, however, that cuspal coverage can also be provided directly.

Studies comparing both approaches have shown that they are comparable in terms of longevity (Mannocci, Ferrari, Watson, 2001; Mannocci, et al., 2002). More regular followup of such cases may be necessary if they are used as long-term restorations, and a question may remain over the effects of saliva on the dentin bond over time. In the current economic climate, these direct multi-surface composite and amalgam restorations afford both the patient and the clinician the luxury of a tooth protected from fracture, thereby allowing a period of review to establish healing prior to possible placement of a crown. This may be particularly relevant in a tooth of questionable prognosis. Access through existing cast restorations is also a common scenario encountered during endodontic treatment, assuming satisfactory margins both clinically and radiographically. The protocol for composite restoration placement in these teeth is different.

Matrix systems Systems such as AutoMatrix® (Dentsply) have been used effectively for many years, especially in the placement of amalgam restorations in root-filled teeth. The importance of the coronal restoration in the outcome of endodontic treatment has been established although this relates primarily to the prevention of ingress of bacteria toward the root filling (Ng, Mann, Gulabivala, 2011). The importance of establishing a correct and cleansable contact area between rootfilled and adjacent teeth holds particular significance when placing direct cuspal coverage restorations. Again, root-filled teeth pose particular problems. The lack of buccal and/or lingual walls often precludes correct placement of a non-sectional matrix, ultimately resulting in large open contact areas. The patient’s inability to maintain correct oral hygiene measures then has obvious implications for the periodontal health of the region. Secondly, depending on the extent of the previous restoration or caries, clinicians may often encounter deep mesial or distal proximal boxes. Sectional matrices, such as the Palodent® and Palodent® Plus systems (Dentsply), have simplified the process. These systems consist of pre-curved metal strips of varying width and design, a metal V-ring to adapt the margins of the band to tooth tissue, and easy placement wedges of various sizes.

Direct versus indirect restorations Much of the endodontic literature has Volume 8 Number 1

Figures 1A and 1B: Access cavities following cleaning using outlined protocol prior to restoration placement. Note orifices sealed with IRM Endodontic practice 31

CONTINUING EDUCATION

circumvent this problem. Studies have shown that these materials are as effective (Belli, et al., 2001) as many of the alternatives, and due to their flow properties, correct placement becomes less technique-sensitive. Often, longer 23g and 25g hypodermic needle tips can be used in order to aid visibility during placement when working within the confines of the coronal portions of the canal and pulp chamber. Newer materials such as Dentsply Smart Dentin Replacement (SDR®) have simplified the process even further. This material’s flow characteristics allow it to spread into the available space due to its self-leveling capability. The material has also been marketed as a bulk fill flowable resin, with the option to place it in increments of up to 4 mm due to decreased shrinkage stresses during polymerization (Ilie, Hickel, 2011). These two special properties are especially practical in the restoration of the root-filled tooth in dealing with the anatomical irregularities of the pulp chamber and the necessity for large amounts of restorative material (Figures 1A and 1B).

CONTINUING EDUCATION

Figures 2A and 2B: Restoration of tooth UL6 using adhesive gold onlay (note cementation under rubber dam)

Longer etching times using hydrofluoric acid and bonding techniques incorporating silane in the protocol are essential in the optimization of outcomes.

Posts: yes or no? The decision on whether a post is necessary in the restoration of a root-filled tooth is often a difficult one. Restorability of teeth, despite various attempts to quantify it, is a subjective concept (McDonald, Setchell, 2005; Bandlish, McDonald, Setchell, 2006). It has been established that the longevity of such restorations is dependent on the presence of a ferrule of remaining dentin being present. Various figures have been proposed and a minimum of 1-1.5 mm of remaining supragingival tooth tissue seems to be necessary in achieving optimal outcomes. Traditionally, metal (both direct and indirect) post-and-core systems have been more popular and have been shown to perform well (Nanayakkara, McDonald, Setchell, 1999). Concerns have been raised about the esthetics, removal of tooth tissue, stress effects on remaining dentin (in the case of threaded active posts), and performance in function. More recently, esthetic post systems have become popular, citing improvements in esthetics, ease of manipulation, and functional advantages over metal systems due to their similar modulus of elasticity to dentin. Many studies, both in vitro and in vivo, have concluded that the systems are comparable (Mannocci, et al., 2002) while a systematic review on the subject (Theodosopoulou, Chochlidakis, 2009) concluded that carbon fiber posts in resin matrices appeared to outperform precious metal alloy dowels. Glass fiber posts also appeared to perform better than their metal screw counterparts. Concerns have been raised over the ability to bond effectively within the depths of the root canal due to the altered dentin and the practical difficulties in bonding there. Care must be taken to follow the correct cleaning 32 Endodontic practice

protocol as outlined, and evidence seems to support the use of dual-cure adhesives in these cases. It has also been suggested that application of hydrogen peroxide and silane to the posts may increase interfacial strengths of such systems in the root canal (Monticelli, et al., 2006). In following these guidelines, esthetic post systems may be particularly beneficial in the restoration of immature anterior teeth, offering the opportunity to reinforce the weakened cervical area.

Conclusion Developments in adhesive systems have simplified the life of the restorative dentist in recent years, with greater choice and more reliable systems leading to better outcomes for patients. Despite this, the same principles apply and composite restoration placement still remains a techniquesensitive process. Great care must be taken to adhere to strict technical and biological principles in its use. EP

REFERENCES 1. Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent. 2002;87(3):256-263. 2. Bandlish RB1, McDonald AV, Setchell DJ. Assessment of the amount of remaining coronal dentine in root-treated teeth. J Dent. 2006;34(9):699-708. 3. Belli S, Zhang Y, Pereira PN, Ozer F, Pashley DH. Regional bond strengths of adhesive resins to pulp chamber dentin. J Endod. 2001;27(8):527-532. 4. Drummond JL. Degradation, fatigue, and failure of resin dental composite materials. J Dent Res. 2008;87(8):710-719. 5. Ferrari M, Mannocci F, Vichi A, Goracci G. Bond strengths of a porcelain material to different abutment substrates. Oper Dent. 2000;25(4):299-305. 6. Foxton RM, Mannocci F, Melo L. Adhesive restoration of endodontically treated teeth-current research. Dent Update. 2006;33(8):500-502, 505-506. 7. Galvan RR Jr, West LA, Liewehr FR, Pashley DH. Coronal microleakage of five materials used to create an intracoronal seal in endodontically treated teeth. J Endod. 2002;28(2):59-61. 8. Grigoratos D, Knowles J, Ng YL, Gulabivala K. Effect of exposing dentine to sodium hypochlorite and calcium hydroxide on its flexural strength and elastic modulus. Int Endod J. 2001;34(2):113-119. 9. Hommez GM, Coppens CR, De Moor RJ. Periapical health related to the quality of coronal restorations and root fillings. Int Endod J. 2002;35(8):680-689. 10. Ilie N, Hickel R. Investigations on a methacrylate-based flowable composite based on the SDR™ technology. Dent Mater. 2011;27(4):348-355 11. Mannocci F, Ferrari M, Watson TF. Microleakage of endodontically treated teeth restored with fiber posts and composite cores after cyclic loading: a confocal microscopic study. J Prosthet Dent. 2001;85(3):284-291. 12. Mannocci F, Bertelli E, Sherriff M, Watson TF, Ford TR. Three-year clinical comparison of survival of endodontically treated teeth restored with either full cast coverage or with direct composite restoration. J Prosthed Dent. 2002;88(3):297-301. 13. McDonald A, Setchell D. Developing a tooth restorability index. Dent Update. 2005;32(6):343-344, 346-348. 14. Millstein PL, Nathanson D. Effect of eugenol and eugenol cements on cured composite resin. J Prosthet Dent. 1983;50(2):211-215. 15. Monticelli F, Osorio R, Toledano M, Goracci C, Tay FR, Ferrari M. Improving the quality of the quartz fiber postcore bond using sodium ethoxide etching and combined silane/adhesive coupling. J Endod. 2006;32(5):447-451. 16. Nanayakkara L, McDonald AV, Setchell DJ. Retrospective analysis of factors affecting the longevity of post crowns. J Dent Res. 1999;78:222. 17. Ng YL, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of nonsurgical root canal treatment: part 1: periapical health. Int Endod J. 2011;44(7):583-609. 18. Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J. 1995;28(1):12-18. 19. Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness as a result of endodontic and restorative procedures. J Endod. 1989;15(11):512-516. 20. Schüpbach P, Krejci I, Lutz F. Dentin bonding: effect of tubule orientation on hybrid-layer formation. Eur J Oral Sci. 1997;105(4):344-352. 21. Sim TP, Knowles JC, Ng YL, Shelton J, Gulabivala K. Effect of sodium hypochlorite on mechanical properties of dentine and tooth surface strain. Int Endod J. 2001;34(2):120-132. 22. Söderholm KJ, Zigan M, Ragan M, Fischlschweiger W, Bergman M. Hydrolytic degradation of dental composites. J Dent Res. 1984;63(10):1248-1254. 23. Theodosopoulou JN, Chochlidakis KM. A systematic review of dowel (post) and core materials and systems. J Prosthodont. 2009;18(6):464-472. 24. Tickle M, Milsom K, Qualtrough A, Blinkhorn F, Aggarwal VR. The failure rate of NHS funded molar endodontic treatment delivered in general dental practice. Brit Dent J. 2008;204(5): E8; 254-255.

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Adhesive restoration of the root-filled tooth PHILPOTT

1. Studies have shown that the quality of the final coronal restoration __________ in the outcome of root canal treatment. a. is a prognostic factor b. has a minor effect on c. is not a prognostic factor d. is the only important factor 2.

In the case of composite, concerns have been raised especially about the hydrolytic degradation of the ________ over time. a. amalgam b. dentin bond c. auto-matrix d. distal proximal box

3. Depending on the technique used, there ____ of obturation material in the access cavity on completion. a. are large amounts b. are small amounts c. are varying amounts d. is absolutely no amount 4. Studies have shown that residual eugenol can have ________ on the polymerization of composite resin. a. a negative effect b. a positive effect c. a healing effect d. no effect

Volume 8 Number 1

5. The importance of the coronal restoration in the outcome of endodontic treatment has been established although this relates primarily to the prevention of _________ toward the root filling. a. too much dentin left b. hydrogen peroxide leakage c. ingress of bacteria d. siloxane leakage 6.

Much of the endodontic literature has focused on the advantages of placement of indirect cuspal coverage restorations on root-filled teeth. In 2002, Aquilino and Caplan concluded that endodontically treated teeth not crowned after treatment were lost at a ________ greater rate. a. 3 times b. 6 times c. 20 times d. 26 times

7. Tickle, et al. (2008), in a study on the outcome of NHS endodontic treatment, agreed that placement of a cast cuspal coverage restoration had a positive effect on outcome, although success criteria were not stringent. The basis of this is due to the fact that endodontically treated teeth _________. a. are often badly broken down b. have altered properties due to treatment processes

c. have lost their proprioceptive capability d. all of the above 8. It has been established that the longevity of such restorations (in a root-filled tooth) _________ the presence of a ferrule of remaining dentin being present. a. is not dependent on b. has no relation to c. is dependent on d. are unlikely in 9.

Various figures have been proposed and a minimum of __________ of remaining supragingival tooth tissue seems to be necessary in achieving optimal outcomes. a. 0.5 mm b. 1-1.5 mm c. 2-2.5 mm d. 3-3.5 mm

10. More recently, esthetic post systems have become popular, citing _______ due to their similar modulus of elasticity to dentin. a. improvements in esthetics b. ease of manipulation c. functional advantages over metal systems d. all of the above

Endodontic practice 33

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Frequency of postoperative pain in oneversus two-visit endodontic treatment Drs. Jorge Paredes Vieyra, Francisco Javier Jimenez Enriquez, and Fabián Ocampo Acosta evaluate the incidence of postoperative pain in oneversus two-visit root canal treatment of necrotic teeth with apical periodontitis after a 1-year healing period

he goal of endodontic therapy is to prevent or eliminate apical periodontitis by means of cleaning, shaping, disinfecting and filling the root canal system. Since the vast majority of endodontic problems are microbial in origin, their removal is considered the most important step in root canal therapy (Hülsmann, Rümmelin, Schäfers, 1997). The success of endodontic treatment is directly related to the control of endodontic infection. When the pulp is vital, endodontic treatment in a single session is ideal if there is time for the accomplishment of the procedure. This treatment modality is based on the fact that the canal is free from bacteria. Since the aseptic chain has been maintained by the clinician, there is no reason for not finishing the procedure in the same session (Siqueira, et al., 1997). Little controversy exists that teeth diagnosed with irreversible pulpitis should be treated in one session. However, in cases of pulp necrosis with or without apical periodontitis, the literature is more controversial. Single- versus multiple-visit root canal treatment has been the subject of long-standing debate in the endodontic community (Abbott, Yu, 2007). In the case of necrotic teeth with visible periapical lesions on a radiograph, the biomechanical preparation and the immediate filling of the root canal raises doubts over the quality of canal disinfection due to the diffuse nature of the infection through the isthmuses, dentinal tubules, secondary and accessory canals, apical cementum, and areas of apical Dr. Jorge Paredes Vieyra works at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico. Francisco Javier Jimenez Enriquez works at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico. Dr Fabián Ocampo Acosta is a histopathologist, professor at the Universidad Autónoma de Baja California, Facultad de Odontologia Tijuana, México.

34 Endodontic practice

Educational aims and objectives

This clinical article aims to evaluate the incidence of postoperative pain in oneversus two-visit root canal treatment of necrotic teeth with apical periodontitis after a 1-year healing period.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 40 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify compelling evidence that indicates a significantly different incidence of postoperative pain/flare-up of either single- or multiple-visit root canal treatment is lacking. • See some of the reasons for the debate for either single- or multiple-visit root canal treatment. • Realize some possible causes and treatments for apical periodontitis. • Identify reasons for patient discomfort after an endodontic treatment. • Recognize how postoperative pain can be an argument either for or against one-visit root canal treatment.

cemental resorption (Abbott, Yu, 2007; Möller, et al., 1981; Kakehashi, Stanley, Fitzgerald, 1965). Possibly, some reports of refractory periapical lesions or many cases of partially healed radiolucencies are consequences of such remaining infection. It has been established that apical periodontitis is caused by bacteria within root canals (Kakehashi, Stanley, Fitzgerald, 1965). Logically, the treatment of apical periodontitis should be the removal of the cause of the disease. The reduction of the microbial load as well as the disruption of biofilms are achieved by a combination of mechanical instrumentation, irrigation with tissuedissolving and microbicidal solutions, and application of antimicrobial medicaments in the root canal between appointments. Soares, et al. (2001), have assessed the incidence of postoperative pain and periapical healing, following endodontic treatment in a single session in patients with necrotic pulps associated with radiolucent periapical lesions. After a 12-month period, endodontic treatment in a single session proved to be clinically successful in 100% of the cases, although radiographic success lagged far behind. However, the endodontic literature reports cases of treatment of teeth with necrotic pulps and apical periodontitis in a single session and sometimes within

a relatively short period (Berger, 1991; Coutinho Filho, Gurgel Filho, Diblasi, 1997; Walton, Fouad, 1992; Glennon, et al., 2004; Ng, et al., 2004), which had a good outcome. Pain and swelling are often indicators of an existing disease process associated with an offending tooth. Endodontic treatment aims to reverse the disease process and thereby eliminate the associated signs and symptoms (Berger, 1991; Coutinho Filho, Gurgel Filho, Diblasi, 1997). When the treatment itself appears to initiate the onset of pain and/or swelling, the result can be very distressing to both the patient and the operator. Patients might even consider postoperative pain and flare-up as a benchmark against which the clinician’s skills are measured. Incidence of postoperative pain or flare-up is, therefore, one of the influencing factors when making a clinical decision. Obviously, treatment with the lower incidence of postoperative pain is usually the treatment of choice. Even though postoperative pain in endodontics is not a particularly good outcome measure because it tends to be transient, it has been widely used as an argument either for or against one-visit root canal treatment (Walton, Fouad, 1992). Postoperative pain is defined as pain of any degree that happens after the initiation of root canal treatment, while an endodontic flare-up has been defined as the onset or Volume 8 Number 1

inadequate canal disinfection, bacterial recontamination of the root canal system because of unsatisfactory coronal seal, or host factors (Ng, et al., 2004). The idea of speeding up root canal disinfection while maintaining the same efficacy observed in two-visit treatment has been fuelled by some clinicians and researchers. The purpose of this randomized controlled trial was to compare the incidence of postoperative pain in oneversus two-visit root canal treatment of necrotic teeth with apical periodontitis after a 1-year healing period.

Materials and methods This study took place at the Autonomous University of Baja California, School of Dentistry in Tijuana, Mexico. The subjects review committee approved the study and all the participants were treated in accordance with the Helsinki Declaration (www.cirp.org/ library/ethics/helsinki). The study was developed between May 2013 and June 2014. The main inclusion criteria were radiographic evidence of apical periodontitis (minimum size ≥2.0 mm x 2.0 mm) and a diagnosis of pulpal necrosis confirmed by negative response to hot and cold tests. Thermal pulp testing was performed by the author, and radiographic interpretation was verified by two certified endodontists. Patient selection was based on the following criteria: 1. The aims and requirements of the study were freely accepted. 2. Treatment was limited to patients in good health.

3. All teeth had non-vital pulps and apical periodontitis, with or without a sinus tract. 4. A negative response to hot and cold pulp sensibility tests. 5. Presence of enough coronal tooth structure for rubber dam isolation. 6. No prior endodontic treatment on the involved tooth. 7. No analgesics or antibiotics were used before the clinical procedures began. Exclusion criteria were patients without inclusion requirements or failure to obtain patient’s authorization, patients younger than 16 years old, pregnant, those with a positive history of antibiotic use within the past month, diabetic, or if the tooth had been previously accessed or endodontically treated. Once eligibility was confirmed, the study was explained to the patients, and they were invited to participate. A financial incentive was offered for patients to return for followup clinical and radiographic examination. After explaining the clinical procedures and risks and clarifying all questions raised, each patient signed a written informed consent form, and the patient was randomly assigned to either the one-visit or two-visit group by using a block of random numbers generated by one of the investigators. Randomization was performed before the clinical examination using the minimization method described by Pocock (1983). Two randomization factors were considered: tooth group and pain as a clinical symptom (Tables 1 and 2). Sample size was

Table 1: Distribution of teeth by randomization factors (tooth group) Tooth group

Maxillary n=150 (%)

Mandibular n=150 (%)

One-visit n=75 (%)

One-visit follow-up n=72 (%)

Two-visit n=75 (%)

Two-visit follow-up n=71 (%)

Incisor

16 (10.66)

10 (6.66)

13 (17.33)

9 (12.5)

13 (17.33)

8 (11.26)

Canines

8 (5.33)

6 (4.0)

7 (9.33)

7 (9.72)

7 (9.33)

7 (9.85)

Premolar

28 (18.66)

17 (11.33)

22 (29.33)

19 (26.38)

23 (30.66)

18 (25.35)

Molar

36 (24)

29 (19.33)

33 (44)

37 (51.58)

32 (42.66)

38 (53.52)

Total

88 (58.66)

62 (41.33)

75 (100)

72 (100)

75 (100)

71 (100)

Table 2: Distribution of teeth by randomization factors (pain) Tooth group

Maxillary n=150 (%)

Mandibular n=150 (%)

One-visit n=75 (%)

One-visit follow-up n=72 (%)

Two-visit n=75 (%)

Two-visit follow-up n=71 (%)

With sinus tract

14 (9.33)

13 (8.66)

16 (21.33)

7 (9.72)

11 (14.66)

2 (2.81)

Without sinus tract

61 (40.66)

62 (41.33)

59 (80.64)

65 (90.27)

64 (85.33)

69 (97.18)

Total

75 (50.0)

75 (100)

72 (100)

75 (100)

71 (100)

Volume 8 Number 1

Endodontic practice 35

CONTINUING EDUCATION

continuation of pain and/or swelling after endodontic treatment that is of such severity that it disrupts the patient’s lifestyle enough so that the patient requires an unscheduled appointment where active treatment is undertaken (Walton, Fouad, 1992). Endodontic therapy can be followed by short-term and long-term complications. The former includes signs and symptoms of postoperative inflammation of the periradicular tissues, with discomfort being the most common short-term outcome of root canal treatment procedures (Glennon, et al., 2004). Discomfort after an endodontic treatment is thought to be related to a periapical inflammatory response caused by one or more of the following factors: • Instrumentation • Passage of medications or infected debris into the periapical tissues • Damage of vital neural or pulpal tissue • Central sensitization (Ng, et al., 2004) In previous studies, postoperative discomfort after non-surgical root canal treatment has been reported to range from approximately 3% to more than 50% (Roane, Dryden, Grimes, 1983; Ashkenaz, 1979). Postoperative discomfort can lead to increased analgesic usage or unscheduled dental visits. Another short-term adverse event is swelling, which could result from an exacerbation of a chronic periapical lesion or could occur without a detectable periapical lesion. Swelling is thought to be dependent on bacterial contamination of the periapical tissues caused by instrumentation,

CONTINUING EDUCATION determined with the method described by Walters (2004). The minimum sample size per group was determined to be 145, on the basis of power p < 0.05, and the minimum clinically significant mean difference between groups was set at 0.5 units (standard deviation ±1.0 unit) by using the periapical index (PAI) scale described by Orstavik, et al., (1996) (Figure 2). One hundred and twenty of 145 patients (79 women and 41 men), 18-60 years of age (mean = 45 years) with 150 eligible teeth consented to participate in the study. Fortytwo patients contributed more than one tooth. The study layout is shown in Figure 1. A medical history was obtained and a clinical examination performed. All teeth were asymptomatic with a diagnosis of pulp necrosis determined by hot and cold sensibility tests, and radiographically, all showed a small and irregular radiolucency at the apex. Periodontal probing revealed no increased probing depth around any of the teeth.

Clinical procedures All treatment sessions were approximately 45 minutes in length to allow for acceptable time for completion of treatment for one or two visits. After local anesthesia by 2% lidocaine with 1:100,000 epinephrine and rubber dam isolation, the tooth was disinfected with 5.25% NaOCl. All caries were removed and endodontic access cavities made with sterile high-speed carbide #331 (SS White) and Zekrya Endo burs (DentsplyMaillefer, Switzerland). Working length was established with the Root ZX® Electronic Apex Locator (J. Morita Manufacturing Corporation) and confirmed radiographically using the digital Schick system (Schick Technologies). The canals were negotiated and enlarged with hand instruments until reaching an ISO #20 at the working length. The coronal portions of the canals were flared with sizes 1-3 Gates Glidden burs (Dentsply-Maillefer, Switzerland). Canals were then irrigated with 2.0cc of 5.25% sodium hypochlorite. LightSpeed® LSX™ rotary instruments (SybronEndo) were used to complete the canal preparation to a size #80 for the anteriors and premolars and to a size #45-60 for molars followed by a final irrigation with 3ml liquid EDTA, which was used as a lubricant. After completion of canal instrumentation, all canals were irrigated with 2.5cc of 17% ethylenediaminetetracetic acid for 30 seconds. Chemomechanical procedures were completed by performing a final rinse 36 Endodontic practice

Assessed for eligibility (n=135)

Excluded (n=15)

Randomized (n=150)

Allocated to one-visit Regime (n=75 teeth)

Allocated to two-visit Regime (n=75 teeth)

Lost to follow-up: Failed to contact (n=3) Failed to attend (n=3)

Lost to follow-up: Failed to contact (n=4) Failed to attend (n= 4)

Analyzed (n=72) None excluded

Analyzed (n=71) None excluded

Figure 1: CONSORT flowchart for this study

Figure 2: The PAI was used to evaluate radiographic healing PAI score

Description of radiographic findings

Normal periapical structures

Small changes in bone structures (PAI ≤2)

Changes in bone structures (PAI ≥3)

Periodontitis with well-defined radiolucent area

Severe periodontitis

with 5ml of 2% aqueous chlorhexidine solution using the EndoVac® irrigation system (SybronEndo). The EndoVac system is able to apply the irrigant to working length and evacuate it using apical negative pressure. The negative pressure avoids forcing the irrigant beyond the apex into the periapical tissues (Nielsen, Baumgarnter, 2007). For the one-visit group, the canals were dried with sterile coarse paper points and obturated at the same appointment by using lateral condensation of gutta percha and Sealapex™ sealer (SybronEndo). Access cavities of anterior teeth were etched and restored with Fuji IX (GC Corporation). For posterior teeth, a buildup restoration was placed using the same etching technique and Fuji IX. For the two-visit group, the canals were dried, and calcium hydroxide paste was

spun into the canals with the aid of a lentulo spiral. Care was taken to fill the root canal with the calcium hydroxide paste without any radiographically visible air bubbles. The paste was condensed at the canal orifice level with the aid of a sterile cotton pellet. A sterile cotton pellet moistened in alcohol was used to clean the pulp chamber walls from calcium hydroxide residues. The access cavities (occlusal/palatal surface) were sealed with Cavit™ (3M™ ESPE™), and the quality of the calcium hydroxide powder filling was checked radiographically with posttreatment radiographs. Patients of the two-visit group were scheduled for a second appointment to complete root canal therapy at least 1 week after the initial appointment. At the second appointment, the patient was anesthetized, rubber dam was applied, the operative field Volume 8 Number 1

One-year follow-up The healing results were clinically and radiographically evaluated 1-year postoperatively. All radiographic films obtained preoperatively and at follow-up were coded blind and organized in random order. Two pre-calibrate endodontist examiners (author not included) independently evaluated all radiographs under moderate illumination at a light table using a 2X magnifying viewer equipped with a masking frame the same size as the dental film. Before evaluation of the study images, each examiner graded a series of 10 radiographic images not associated with the study sample and representing a wide range of periapical bone densities. To minimize a false-positive diagnosis, observers used a strict definition of periapical disease (Peters, Wesselink, 2002; Bystrรถm, Sundqvist, 1981). In case of disagreement, joint re-evaluation was performed until a consensus was reached on all images. The consensus score for each image was considered the true score and used for statistical analysis. Follow-up radiographs were made with the individual custom index and recorded exposure settings; all radiographs were obtained by using the same digital imaging system (Schick Technologies). The primary outcome measures were the presence of postoperative pain or abnormal

findings at 1 year (spontaneous pain, presence of sinus tract, swelling, mobility, periodontal probing depths greater than baseline measurements, or sensitivity to percussion or palpation) as shown in Table 2. Secondary outcome measure for this study was classified by using a modification of the Strindberg study (1956) used for radiographic healing assessment. Teeth with symptoms of persisting periapical inflammation were scored as not healed, as were the cases with periapical radiolucencies that remained unchanged or increased in size. Teeth with a reduced periapical rarefaction were judged as uncertain. Teeth with complete restitution of the periodontal contours were judged as healed. In teeth with more than one root, the least favorable outcome was recorded. The periapical index (PAI) was used as a scoring system to evaluate radiographic healing (Peters, Wesselink, 2002) as shown in Figure 2. Radiographic images were coded and stored and evaluated blindly and independently by two endodontists. Before evaluation of the study images, each examiner graded a series of 10 radiographic images not associated with the study sample and representing a wide range of periapical bone densities. The examiners then reviewed all scores to improve calibration and inter-rater agreement. Consensus was reached on images that were not formerly scored the same by all examiners. A chi-square test was used to test trends in contingency tables. Hypothesis tests were conducted at the 0.05 level of significance.

Results Randomization allocated 75 teeth to one-visit and 75 teeth to two-visit treatment. Seven teeth (three in the one-visit and four in the two-visit group) were lost to followup, leaving 143 teeth that were evaluated at the 1-year follow-up period (72 one-visit, 71 two-visit; Table 1). Seven cases (9.72%) experienced postoperative pain in the onevisit group, and two cases (2.81%) in the two-visit group (Figure 1 and Table 1). At the end of the study, 68 (94.4%) of the 75 teeth in the one-visit group and 69 (97.18%) of the 75 teeth in the two-visit group were classified as healed (Table 3). The number of cases classified as uncertain was lower (none) in the two-visit group as compared with one (1.38%) in the onevisit group. One patient (one-visit group) presented with persistent draining sinus tracts at 12 months (had sinus tract present at the initial treatment appointment), as seen in Table 4. The statistical analysis of the healing results did not show any significant difference between the groups (p=0.05).

Discussion Endodontic treatment consists of the complete shaping and cleaning of the main root canal followed by three-dimensional obturation usually with gutta percha. The best environment conducive to periradicular healing would be an absence of microorganisms, a condition similar to that found in vital cases that have a very high potential for success (Vieira, et al., 2012).

Table 3: Distribution of teeth according to outcome classification One-visit n=72(%)

Two-visit n=71%

Total

70 (97.22)

71 (100)

141 (91.33%)

Uncertain healing

1 (1.38)

(none)

1 (0.66)

Not healed

1 (1.38)

---------

1 (0.66)

143

Healed

Total

Table 4: Distribution of teeth by randomization factors (sinus tract) Tooth group

Maxillary n=150 (%)

Mandibular n=150 (%)

One-visit n=75 (%)

One-visit follow-up n=72 (%)

Two-visit n=75 (%)

Two-visit follow-up n=71 (%)

With sinus tract

27 (18.0)

11 (7.33)

23 (30.66)

3 (4.16)

15 (20.0)

2 (2.8)

Without sinus tract

61 (40.66)

51 (34.0)

52 (69.33)

2 (2.77)

60 (80.0)

1 (1.40)

Total

88 (58.66)

62 (41.33)

75 (100)

5 (100)

75 (100)

3 (100)

Volume 8 Number 1

Endodontic practice 37

CONTINUING EDUCATION

was disinfected as previously stated, and the calcium hydroxide was removed with hand instruments and copious irrigation with 2.5% sodium hypochlorite followed by 2.5cc of 17% ethylenediaminetetracetic acid and a final rinse of 5ml of 2% aqueous chlorhexidine solution using the EndoVac irrigation system. After complete removal of the calcium hydroxide, the canals were dried with sterile coarse paper points, and obturation was performed with the same protocol described for the one-visit group, and posttreatment radiographs taken. All teeth were restored with Fuji IX buildup. After completion of treatment, patients were instructed to return to their referring dentist for definitive restoration as soon as possible.

CONTINUING EDUCATION In apical periodontitis of long-standing duration, bacteria can spread into ramifications, lateral canals, isthmuses, apical deltas, and dentinal tubules. Located in such areas, these microorganisms cannot be removed during the chemical-mechanical preparation. Some studies comparing the success rate of endodontic treatment of teeth with apical periodontitis performed in one or more visits revealed that two or more visits with calcium hydroxide as the intracanal medication offer a success rate that is 10%-20% higher than a one-visit treatment (Penesis, et al., 2008). The longer the intracanal medication remains inside the root canal system, it is able to act in sites not reached by the endodontic instruments or by the irrigating solution. Thus, it enhances the bacterial reduction as well as repair of the periapical tissues (Weiger, Rosendahl, Lost, 2000). However, in the last few years, great technological advances have made the operative stages simpler, allowing the endodontic treatment of teeth with periapical lesions to be performed in one session (Pocock, 1983). Variables that are not controlled (such as the patient’s immunological condition or the ability of the operator) exert some influence on the success of the endodontic treatment (Hülsmann, Rümmelin, Schäfer, 1997). In this study, such variables were kept under control. Treatment was performed by the same clinician and in the same individual, which meant teeth with similar periapical lesions were subject to the same immunological defense mechanisms. The maintenance of an aseptic protocol during endodontic treatment, the appropriate shaping of the canal root to allow its satisfactory irrigation with antiseptic solutions, is more important than performing treatments in one single visit or in multiple visits than concerns about periapical lesion repair (Hülsmann, Hahn, 2000). One argument in favor of treating infected root canals in one visit is that residual bacteria surviving treatment are entombed by obturation and die because their source of nutrients is denied (Sathorn, Parashos, Messer, 2005; Ricucci, et al., 2011; Peters, Wesselink, Moorer, 1995). This argument might be valid for bacteria remaining on untouched canal walls or within dentinal tubules (Peters, Wesselink, 2002). However, the simple fact that bacteria can be found in the main root canal of many cases with posttreatment disease (Siqueira, et al., 2002) indicates that entombment is not reliable. The aim of this study was to compare the incidence of postoperative pain in 38 Endodontic practice

This study gave evidence that a meticulously instrumented one-visit root canal treatment can be as successful as a two-visit treatment. oneversus two-visit root canal treatment of necrotic teeth with apical periodontitis after a 1-year healing period. Clinical outcome studies take a long time to monitor, demand substantial economic resources, and run the risk of losing patients at follow-ups. A determination of healed, not healed, or uncertain was made radiographically 1-year following treatment. Radiographic images of periapical bone lesions range from impossible or difficult to see to being easily seen. In this study, false-positives were minimized because periapical radiolucencies were recorded only when absolutely certain. No statistically significant difference in success rates (healed lesion) was observed between the one- and two-visit groups and corroborates the results of previous studies (Berger, 1991; Penesis, et al., 2008; Weiger, Rosendahl, Lost, 2000). Published studies including the present one have failed to show any statistically significant difference in the outcome between one- and two-visit root canal treatment (Hülsmann, Hahn, 2000; Sathorn, Parashos, Messer, 2005; Ricucci, et al., 2011). Other studies have compared the healing rate after one- and two-visit root canal therapy, although the criteria for endodontic success were often poorly defined and varied across the studies (Berger, 1991; Walton, Fouad, 1992; Peters, Wesselink, Moorer, 1995; Siqueira et al, 2002). Success and failure of endodontic treatment is determined by long-term results and not the presence or absence of shortterm postoperative pain. Our results agree with Mattscheck (2001), who found that root canal treatments with postoperative pain occurring shortly after treatment could result in long-term success, whereas treatment without such pain may result in failure. Glennon (2004) and Ng (2004) reported that discomfort was the most common short-term outcome of root canal treatment procedures. Patients with single-visit follow-up experienced postoperative pain less frequently (1.35%) than those with multiple-visit root canal treatment (2%). The adoption of clinical procedures in endodontic therapy depends not just on their effectiveness or biological

consequences but also on minimization of patients’ discomfort. Although successfully eliminating bacteria from the root canal system remains the most important therapeutic goal in endodontics, there is no consensus as to the most effective clinical approach. Our results agree with Sjogren (1990) and Doyle (2007), who found that the prognosis for complete healing of endodontically treated teeth with the pretreatment diagnosis of apical periodontitis is approximately 10%-15% lower than for teeth without apical periodontitis. Discomfort is the main short-term complication of root canal treatment. However, the measurement of discomfort is fraught with hazards and opportunities for errors. Therefore, it is necessary to rate the level of discomfort in categories arranged in advance and exactly described by authors. Some investigators, such as Yoldas, et al. (2004), have provided accurate criteria to categorize patient’s pain to accomplish this. Most studies on single-visit endodontics have focused on postoperative pain and flare-up (Siqueira, et al., 2002; Fava, 1991; Law, Messer, 2004), despite the fact that pain has been shown to have no effect on long-term healing success (Sathorn, Parashos, Messer, 2005; Yoldas, et al., 2004). It is known that uncontrolled variables, such as metabolic diseases and smoking, can affect success rates and result in poorer treatment outcomes (Vieyra, 2005). In our study, significantly less postoperative pain was observed in the singlevisit root canal treatment in anterior teeth. This is very close to the findings of Eleazer and Eleazer (1998), who reported fewer flare-ups for the single-visit group (3.0%) as compared to the multiple-visit group (8.0%). Historically, several treatments and inter-appointment dressings were used for infected teeth, but over the years, the number of sessions has been reduced (Fava, 1991). A two-visit model using an inter-appointment dressing with calcium hydroxide has been proposed as a standard (Law, Messer, 2004; Spangberg, 2001). The expectation that teeth treated in two visits with an interappointment dressing of calcium hydroxide Volume 8 Number 1

Conclusion Endodontic treatment tries to eradicate Volume 8 Number 1

microorganisms from the root canal system to promote periapical healing. This study gave evidence that a meticulously instrumented one-visit root canal treatment can be as successful as a two-visit treatment. Compelling evidence indicating a significantly different incidence of postoperative pain/flare-up of either single- or multiple-visit

root canal treatment is lacking. In conclusion, 12 months after initial non-surgical root canal therapy on necrotic teeth with apical periodontitis, there was no significant difference in radiographic evidence of periapical healing between one- and two-visit therapy with an interim calcium hydroxide/ chlorhexidine paste dressing. EP

REFERENCES

22. Peters LB, Wesselink PR. Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms. Int Endod J. 2002;35(8):660-667.

Abbott PV, Yu C. A clinical classification of the status of the pulp and the root canal system. Aust Dent J. 2007;52:(1 suppl):S17-S31.

Ashkenaz PJ. One-visit endodontics: a preliminary report. Dent Surv. 1979;55(1):62-67.

Berger CR. Endodontic Treatment in single or multiple sessions. RGO. 1991;39(2):93-97.

Byström A, Sundqvist G. Bacteriologic evaluation of the efficacy of mechanical root canal instrumentation in endodontic therapy. Scan J Dent Res. 1981;89(4):321-328.

Coutinho Filho T, Gurgel Filho ED, Diblasi F. Work philosophy in immediate fillings of teeth with necrosis and apical lesions. Rev Bras Odontol. 1997;54(5):281-284.

Doyle SL, Hodges JS, Pesun IJ, Baisden MK, Bowles WR. Factors affecting outcomes for single-tooth implants and endodontic restorations. J Endod. 2007;33:399-402.

23. Peters LB, Wesselink PR, Moorer WR. The fate and the role of bacteria left in root dentinal tubules. Int Endod J. 1995;28(2):95-99. 24. Pocock SJ. Clinical Trials. A Practical Approach. Chichester, UK: John Wiley & Sons; 1983. 25. Ricucci D1, Russo J, Rutberg M, Burleson JA, Spångberg LS. A prospective cohort study of endodontic treatments of 1,369 root canals: results after 5 years. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(6):825-842. 26. Roane JB, Dryden JA, Grimes EW. Incidence of postoperative pain after single- and multiple-visit endodontic procedures. Oral Surg Oral Med Oral Pathol. 1983;55(1):68-72., 27. Sathorn C, Parashos P, Messer HH. Effectiveness of singleversus multiple-visit endodontic treatment of teeth with apical periodontitis: a systematic review and meta-analysis. Int Endod J. 2005;38(6):347-355

Eleazer PD, Eleazer KR. Flare-up rate in pulpally necrotic molars in one-visit versus two-visit endodontic treatment. J Endod. 1998;24(9):614-616.

Estrela C, Sydney GB, Bammann LL, Felippe Júnior O. Mechanism of action of calcium and hydroxyl ions of calcium hydroxide on tissue and bacteria. Braz Dent J. 1995;6(2):85-90.

Fava LR. One-appointment root canal treatment: incidence of postoperative pain using a modified double- flared technique. Int Endod J. 1991;24(5):258-262.

29. Siqueira JF Jr, Rôças IN, Favieri A, Machado AG, Gahyva SM, Oliveira JC, Abad EC. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod. 2002;28(6):457-460.

10. Glennon JP, Ng YL, Setchell DJ, Gulabivala K. Prevalence of and factors affecting postpreparation pain in patients undergoing two-visit root canal treatment. Int Endod J. 2004;37(1):29-37.

30. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498-504.

28. Siqueira JF Jr, Araújo MC, Garcia PF, Fraga RC, Dantas CJ. Histological evaluation of the effectiveness of five instrumentation techniques for cleaning the apical third of root canals. J Endod. 1997;23(8):499-502.

11. Hülsmann M, Hahn W. Complications during root canal irrigation - literature review and case reports. Int Endod J. 2000;33(3):186-193.

31. Soares JA, César CAS. Clinic and radiographic evaluation of one-appointment root canal therapy in teeth with chronic periapical lesions. Pesqui Odontol Bras. 2001;15(2):138-144.

12. Hülsmann M, Rümmelin C, Schäfers F. Root canal cleanliness after preparation with different endodontic handpieces and hand instruments: a comparative SEM investigation. J Endod. 1997;23(5):301-306.

32. Spångberg L. Evidence-based endodontics: the one visit treatment idea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(6):617-618.

13. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol. 1965;20:340-349. 14. Kvist T, Molander A, Dahlén G, Reit C. 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.

33. Strindberg LZ. The dependence of the results of pulp therapy on certain factors. Acta Odontol Scand. 1956;14(suppl 21). 34. Trope M. Flare-up rate of single visit endodontics. Int Endod J. 1991;24(1):24-26. 35. Trope M, Delano EO, Örstavik D. Endodontic treatment of teeth with apical periodontitis: single vs. multivisit treatment. J Endod. 1999;25(5):345-350.

15. Law A, Messer H. An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments. J Endod. 2004;30(10):689-694.

36. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol. 1984;58(5): 589-599.

16. Mattscheck DJ, Law AS, Noblett WC. Retreatment versus initial root canal treatment: factors affecting posttreatment pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92(3):321-324

37. Vieira AR, Siqueira JF Jr, Ricucci D, Lopes WS. Dentinal tubule infection as the cause of recurrent disease and late endodontic treatment failure: a case report. J Endod. 2012;38(2):250-534.

17. Möller AJ, Fabricius L, Dahlén G, Ohman AE, Heyden G. Influence on periapical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scan J Dent Res. 1981;89(6):475-484.

38. Vieyra JP. Inzidenz und Ausmaβ postoperativer Schmerzen nach einzeitiger Behandlung nekrotischer Wurzelkänale mit Hand-oder rotirenden NiTi-Instrumenten. Endodontie. 2005;4:369-388.

18. Ng YL, Glennon JP, Setchell DJ, Gulabivala K. Prevalence of and factors affecting post-obturation pain in patients undergoing root canal treatment. Int Endod J. 2004;37(6):381-391.

39. Walters SJ. Sample size and power estimation for studies with health related quality of life outcomes: a comparison of four methods using the SF-36. Health Qual Life Outcomes. 2004;2:26.

19. Nielsen BA, Baumgartner CJ. Comparison of the EndoVac system to needle irrigation of root canals. J Endod. 2007;33(5):611-615.

40. Walton R, Fouad A. Endodontic interappointment flare-ups: a prospective study of incidence and related factors. J Endod. 1992;18(4):172-177.

20. Orstavik D. Time-course and risk analyses of the development and healing of chronic apical periodontitis in man. Int Endod J. 1996;29(3):150-155.

41. Weiger R, Rosendahl R, Löst C. Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions. Int Endod J. 2000;33(3):219-226.

21. Penesis VA, Fitzgerald PI, Fayad MI, Wenckus CS, BeGole EA, Johnson BR. Outcome of one-visit and twovisit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation. J Endod. 2008;34(3):251-257.

42. Yoldas O, Topuz A, Isçi AS, Oztunc H. Postoperative pain after endodontic retreatment: single versus two-visit treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;98:483-487.

Endodontic practice 39

CONTINUING EDUCATION

paste would result in improved healing when compared with one-visit root canal therapy was not supported by our results. Our results agree with Roane (1983) and Fava (1991), which included non-vital teeth with the presence or absence of symptoms. The quest for an effective, scientifically supported, onevisit procedure for non-vital teeth has been approached mainly by excluding an interappointment antibacterial canal dressing and including a short-time intra-appointment dressing instead. Studies by Trope (1999; 1991) and Weiger (2000) used the former approach or the one-visit treatment, and the meta-analysis could not show any statistically significant difference in the healing rate compared to the two-visit alternative. The probability that teeth treated in two visits with an inter-appointment dressing of calcium hydroxide would result in improved healing when compared with one-visit root canal therapy was not supported by our results. We also did not attempt to balance the number of multi-rooted teeth in each group, although multi-rooted teeth with apical periodontitis have a lower possibility of complete healing when compared with single-rooted teeth (Estrela et al, 1995). Our results reinforce the concept that, given a meticulously instrumented root canal, a one-visit antimicrobial treatment, including irrigant, disinfectant agents EDTA, and irrigation/aspiration, is as effective as a two-visit procedure using calcium hydroxide. Whether this ideal goal can be achieved or not with contemporary instruments and procedures, particularly in a one-visit treatment schedule, is an ongoing topic of debate. Further, the anatomical complexity of the apical third of the root canal system in posterior teeth is a factor that makes the task of total elimination of intracanal microbes difficult and allows for the presence of residual infection posttreatment (Vertucci, 1984). In this clinical stage, the use of an antibacterial interappointment agent is necessary to maximize bacterial reduction before filling. However, the occurrence of minor, transient pain is not likely to be a determining factor in treatment choices, and the frequency of flare-ups has been documented to be low with both types of treatment. Compelling evidence indicating a significantly different incidence of postoperative pain/flare-up of either single- or multiple-visit root canal treatment is lacking.

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 V8.1 VIEYRA

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Frequency of postoperative pain in oneversus two-visit endodontic treatment VIEYRA

1. When the pulp is vital, endodontic treatment ________________ is ideal if there is time for the accomplishment of the procedure. a. in a single session b. in two sessions c. over a period of time d. during the course of a year 2. ___________________ that teeth diagnosed with irreversible pulpitis should be treated in one session. a. Much controversy exists b. Little controversy exists c. Most endodontists disagree d. There is no evidence 3. ________ is (are) often indicators of an existing disease process associated with an offending tooth. a. Numbness b. Pain c. Swelling d. both b and c 4. Swelling is thought to be dependent on bacterial contamination of the periapical tissues caused by ____________ or host factors. a. instrumentation b. inadequate canal disinfection

40 Endodontic practice

c. bacterial recontamination of the root canal system because of unsatisfactory coronal seal d. all of the above 5. In apical periodontitis __________, bacteria can spread into ramifications, lateral canals, isthmuses, apical deltas, and dentinal tubules. a. of long-standing duration b. of short-term duration c. of vital teeth d. in people who drink alcohol 6. Some studies comparing the success rate of endodontic treatment of teeth with apical periodontitis performed in one or more visits revealed that two or more visits with calcium hydroxide as the intracanal medication offer a success rate that is ________ higher than a one-visit treatment. a. 10%-20% b. 25%-35% c. 40%-45% d. 50% 7.

Patients with single-visit follow-up experienced postoperative pain _____________ those with multiplevisit root canal treatment (2%). a. more frequently (2.67%) than b. less frequently (1.35%) than

c. at a rate equal to d. vastly different than (50%) 8. The adoption of clinical procedures in endodontic therapy depends not just on their _________ but also on minimization of patientsâ&#x20AC;&#x2122; discomfort. a. effectiveness b. biological consequences c. cost-effectiveness d. both a and b 9. Our results reinforce the concept that, given a meticulously instrumented root canal, a one-visit antimicrobial treatment, including irrigant, disinfectant agents EDTA, and irrigation/aspiration, is as effective as a two-visit procedure using __________. a. calcium hydroxide b. eugenol c. EDTA only d. liquid chlorhexidine 10. Endodontic treatment tries to __________ microorganisms from the root canal system to promote periapical healing. a. minimize b. eradicate c. encapsulate d. irradiate

Volume 8 Number 1

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LEGAL MATTERS

Risk management concepts for dentists*

†

Dr. Bruce H. Seidberg discusses three main factors that will reduce risk of legal issues

isk management involves the development of a plan to monitor areas of a dental practice, including, but not limited to, the doctor-patient relationship (DPR), informed consent, and documentation, otherwise referred to as a “triad of concerns” to avoid perceived or potential problems in the practice of dentistry.1,2 Understanding the issues, communicating appropriately when entering into a doctor-patient relationship, following the concepts of informed consent and documentation and then properly applying them are the ways to prevent dental malpractice litigation. Those three areas are more likely than not to be abused or neglected but are generally governed by the standard of care of the profession and can be the source of allegations. A combination of the economy and the conundrum of insurance has caused a type of stress on certain segments of the population that seek healthcare from doctors but have limited financial resources; some of these individuals might even believe there should be an entitlement plan. The dental profession is one of the healthcare professions where individuals with limited finances might feel there exists an entitlement program for treatment, and they are usually the ones who ultimately seek redress from a perceived mistreatment. It appears that some patients are more brazen with remarks and display attitudes to dentists that they would not make to their physicians. Real-life situations have created an environment where practitioners must practice intelligently, with integrity,3 and at the same time, defensively.4 It would be surreal to believe that anyone could predict

the type of patient who will file a malpractice lawsuit.3,5 Every patient is a potential plaintiff. Managing risk in dental offices offers a way to improve the profession, private practices, and protect dental licenses before, instead of after, attorneys and juries get involved and impose legal precedents — hence, the “triad of concerns” and a patient’s perceived ideas that misconduct occurred. Professional liability includes the risks of claims being brought against a practitioner. Malpractice embraces all liability-producing conduct arising from the providing of professional services6 and is a special kind of negligence arising out of the doctor-patient relationship. Negligence is an unreasonable act or omission by a dentist in which the treatment provided falls below the accepted standard of care and results in a perceived patient harm. The basic legal concepts that prevail for malpractice and negligence are that of duty, breach of duty, proximate cause, and damages. The basic concepts have to be proven in the case of a malpractice claim, but not that of negligence. The only proven issue in negligence is whether the dentist acted reasonably under the circumstances. A dentist might not be negligent if he/she exercises such reasonable care and ordinary skill even though he/she mistakes a diagnosis, makes an error in judgment, or fails to appreciate the seriousness of the patient’s problem.7 Legal allegations that dentists are at risk include, but are not limited to, crowns, bridges, and dentures done negligently or having an unsatisfactory result; failure to treat or improperly treat endodontic

Bruce H. Seidberg, DDS, MScD, JD, DABE, FCLM, FACD, FPFA, FAAHD, DABMM, is a Diplomate of the American Board of Endodontics, The American Board of Medical Malpractice, Fellow of the American College of Legal Medicine, American College of Dentists, American Association of Hospital Dentistry, and the Pierre Fauchard Academy. Dr. Seidberg has lectured at national and international meetings, and contributed articles to the dental and legal literature, including a chapter about dental legal issues in the 5th through 7th editions of Legal Medicine and a chapter in the 6th edition of Ingle’s Endodontics. He is a former Associate Professor of Endodontics at SUNY Buffalo School of Dentistry and Director of the Dental GPR at St. Joseph’s Hospital in Syracuse, New York. He has served two terms as a Director of the AAE and as President of the New York State Association of Endodontists and was Vice Chair of the ADA Council on Communications. He was awarded the President’s Award from the AAE in 2001, is a Past President of the American College of Legal Medicine, and the 2013 ACLM Gold Medalist for his contributions in law and dentistry. He is a Past President of the NYS Onondaga County and Cayuga County Dental Societies and NYSAE representative to the New York State Dental Association House of Delegates. He is currently Chairman of the American Board of Medical Malpractice, Secretary of the ACLM Foundation, Vice Chair of the NYS Board of Dentistry, Chief of Dentistry at Crouse Hospital in Syracuse, and a dental consultant for dental malpractice cases and risk management. Dr.Seidberg is in the private practice of Endodontics in Liverpool (Syracuse), New York.

42 Endodontic practice

Table 1: Additional Allegations Leading to Lawsuits Diagnosing nonexistent caries Failure to diagnose periodontal conditions Failure to diagnose endodontic pathology Implant failure Performing unnecessary dental procedures on healthy teeth Allowing unlicensed assistants to do dental procedures Unnecessary care provided by corporate dental clinics

pathology; failure to diagnose or treat periodontal disease; implant failure; problematic extractions or removal of the wrong tooth; paresthesia of tissues; Medicaid fraud; and performing unnecessary dental treatment procedures on healthy teeth (Table 1). Causes of Action claims that are usually covered by insurance are those of negligence, lack of informed consent, breach of contract, and wrongful death. Claims of deliberate, intentional harm or those arising from the negligence of a third party are usually not covered. Although the law does not obligate the dentist to maintain a malpractice insurance policy, it is recommended that an adequate amount should be maintained to protect one’s dental license, professional practice, and personal assets. The accepted definition of the standard of care is: that of reasonable care and diligence ordinarily exercised by similar members of the profession in similar cases in like conditions given due regard for the state of the art.8 National standards have replaced locality rules because of the ease of obtaining continuing education from local or national seminars or from the dental literature. The standards are usually set by the expert * †

Summarized from Dr. Seidberg’s Risk Management Lectures Disclaimer: The material presented in this seminar is for general information to be used as suggestions to reduce and manage various risks in the practice of dentistry and medicine, and not to be interpreted as legal advice. Readers should communicate with their personal attorney and malpractice carrier for actual legal advice pertaining to any legal dispute they may be involved in.

Volume 8 Number 1

Table 2: Consent for Local Anesthetic Injections Please circle the appropriate response where indicated. I, (print name) _________________________ hereby authorize Dr. ________________ to perform local anesthetic injections as necessary to perform the dental treatment I have been scheduled for. Very inflamed teeth may still have a sensation at the beginning of treatment due to the differences between the chemical makeup of the anesthetic agent and inflammation. If that occurs, additional anesthetic will be administered. There are some risks in the administration of local anesthetics. Most risks are related to the position of the nerves under the tissue at the site of the injection, which cannot be determined prior to the administration of the anesthetic agent. Although the risks seldom occur, they might include, but are not limited to, loss of, or disturbed sensation of the tongue and lip on the side of the injection. If this occurs it is often temporary, and the normal sensation usually returns in several days. However, in very rare cases, the loss of sensation may extend for a longer period and may become permanent. In addition, injecting a foreign substance into the body such as an anesthetic may result in an allergic reaction, which is very rare, but may take place. I further understand that individual reaction to treatment cannot be predicted, and that if I experience any unanticipated reactions following the injection(s), I agree to report them to the office as soon as possible. The success of my dental treatment depends upon my cooperation in keeping scheduled appointments, following home care instruction, including oral hygiene and dietary instructions, taking prescribed medication, and reporting to the office any change in my health status. I acknowledge that no guarantees or assurances have been given by anyone as to the results that may be obtained. I have had an opportunity to discuss all of the above with the doctor and have had all of my questions answered. I have (have not) had local anesthetic injections in the past. I do (do not) have a problem with local anesthetics with epinephrine (known as novocaine). _____________________________________ Patient’s Signature

___________________________________________ If a Minor, Signature of Parent or Legal Guardian

_____________________________________ Dental Assistant Signature

_____________________________ Dentist Signature

forefront by inadequate presentations to patients and poor documentation of findings and events. A patient who is properly informed is less likely to launch subsequent litigation over undisclosed risks that manifest. A health provider who has proper documentation memorializing the informed consent discussion and what was done is less likely to be involved in a lawsuit. Informed consent is a fundamental tenet of the U.S. healthcare system, rooted in the ethical principles of respect for the patient autonomy and enhanced patient well-being. It is the ongoing dialogue between the patient and dentist in which both parties exchange information, ask questions, and come to an agreement on the course of a specific treatment. An individual’s right to selfdetermination was expressed and preserved in the case of Schloendorff v. Society of NY Hospital when Justice Cardozo in 1914 stated that “every human being of adult years and sound mind has a right to determine what shall be done with his own body.”15 One

__________ Date

of the first cases to label the lack of informed consent as “professional negligence” instead of “battery” was the case of Nathanson v. Kline16 in which the fundamental distinction was made between assault and battery, which constituted an intentional act, whereas negligence or malpractice was an unintentional act. While the standard of care does not require a signed document for informed consent, any good lawyer will agree that an oral contract is only as good as the paper it is written on.17 Dentists are required by law to obtain consent from patients for any nonemergent treatment or diagnostic procedure, including consent for local anesthesia (Table 2). In an emergency situation, there may not be the opportunity to engage in a discussion, but action will be governed by what a reasonable person in similar circumstances would have consented to.18 It is the conversation a dentist has with a patient prior to treatment in which options and possible risks of the proposed treatment are explained and Endodontic practice 43

LEGAL MATTERS

witnesses who are the most convincing to the jury or judge and are convincing when citing a specialty organization’s guidelines as a basis for their evidence for the specific case for which they are testifying. The ethical concepts of the standard of care are beneficence: to recommend the best therapy while minimizing potential harm, to avoid placing a patient at an unreasonable risk of harm, and one that cannot be disputed in court by an opposing expert witness. Evidence provided may include elements of locality, availability of facilities, specialization or general practice, proximity of specialists, and special facilities as well as other relevant considerations. Generalists are usually held to the same standard of care as those of specialists when performing that particular phase of dentistry.9,10 When one holds himself/ herself out as a specialist as in the case of Simpson v. Davis or undertakes to perform procedures normally requiring the expertise of a specialist, he/she may be held to the professional standards of that specialty even though he/she may not have been certified in the specialty in question.11 The doctor–patient relationship (DPR) has been theorized to begin when the patient enters an office and completes the office documents requesting personal information, and they are reviewed by the dentist. The DPR actually begins when either the dentist gives dental advice with or without monetary consideration or enters the mouth to do an examination and offers advice.1,9 It is when the dentist agrees to provide a service or give an opinion on which the patient relies.12,13 The relationship is strengthened or weakened by the skills of communication. What is said and how it is said will set the stage for a patient’s opinions and acceptance. The DPR is adversely affected by perceptions of visual staff discontent and office ambiance. Practitioners must refrain from any and all sexual innuendos,14 which are another source of allegations. A patient cannot be terminated until commenced treatment has been completed. Once the relationship has started, it cannot end until both parties agree to end it, or if the dentist unilaterally decides to end it by following the appropriate methods of termination, or either party dies. The principles of documentation and informed consent are recognized worldwide. Very little has changed since the inception of the informed consent concept and current day practice, but documentation concepts have. The intensity and importance of each subject has recently been brought to the

LEGAL MATTERS discussed. It is a conversation that cannot be delegated to auxiliary staff or another non-treating dentist. Shelton clarified nondelegation by emphatically stating, “He who cuts (treats) must inform; he who prescribes must also inform.”19 It is the information for a procedure for which a reasonable person would expect to receive about impending treatment. Informed consent is imperative for invasive procedures and those with established foreseeable risks. The discussion must be in understandable terms; and reasons for the procedure, benefits of the procedure, alternatives and consequences of the alternatives, including no treatment at all and the risks associated with the procedure, are discussed20 (Table 3). The standard of disclosure of all material risks originated from the landmark decision of Canterbury v. Spence21 in which the doctrine of informed consent stated that a doctor has a duty to disclose all reasonable information about a proposed treatment to his/her patients, including the benefits, risks of doing it or not, and the alternatives. The concept of informed consent was refined and established as a new standard for information disclosure. Keep the discussion calm and relaxed, and give the patient time to ask questions and receive answers. Following the discussion, the dentist must determine whether or not the patient understood all of the information provided and then obtain a clear expression of the patient’s desire to proceed with the proposed treatment. Treatment performed in the absence of a valid consent may constitute battery16,22 and be actionable. Informed consent is the discussion and not the form (Table 4). The consent form should be designed for the specific procedure and individual treatment plan. It is the document that will provide evidence and memorialize that the informed consent discussion took place. It should be of a general description, rather than specific, to allow for interpretation. If uncertain how specific the form should be, use the legal phrase “the treatment will include, but not be limited to A, B, or C.” After concluding the necessary information for the patient to make an informed consent, patients are given the customized document to sign, acknowledging that the conversation with the dental provider regarding the risks and benefits of treatment or no treatment and the alternatives were discussed and agrees or refuses the recommended treatment. Document the informed consent in the progress notes, dating and initialing it.20 Only those 44 Endodontic practice

above the age of majority are allowed by law to give consent. The exception is if the minor is married or pregnant. A spouse cannot give consent for another spouse unless the spouse is mentally impaired. Only a parent or legal guardian can give consent for a minor: or in the case of a mentally impaired patient, the legally appointed guardian or court can give consent in the absence of a parent. An adolescent cannot give consent for an adult. The document becomes a permanent part of the patient’s chart. A patient can reject care or treatment deemed necessary and should then sign a substitute document of a “refusal

To avoid legal allegations and lawsuits, dentists must practice within the standard of care, communicate properly, inform patients, and legibly document everything.

Table 3: Elements of Informed Consent 1. Date and time of the consent process 2. Diagnosis in layman’s language explaining the problem 3. Nature and purpose of proposed treatment in language understandable by the patient 4. Explanation of risks and consequences 5. Probability of success 6. Feasible alternative treatments 7. Expected prognosis if treatments are not accepted 8. Statement that patient was given the opportunity to ask questions or that the patient’s questions have been answered 9. Signature of patient or legal guardian and a witness 10. Signature of the health provider

Table 4: Important Distinction: Conversation vs. Form Informed consent is the conversation with the patient, not the signed form. The signed form is the evidence that memorializes the conversation.

Table 5: Informed Refusal for Consultation, X-Rays, Diagnosis, and/or Treatment Please Read and Sign I understand that the ___________________ (treatment) and/or other emergency care necessary and has been explained to me. _________ _________ _________ _________

I prefer not to proceed with the recommended treatment at this time. I understand that the prognosis, if treated, is either (circle one) favorable, guarded or unfavorable I wish to have a second opinion I want to think about the procedure and whether or not I will want to proceed; I will let your office know of my decision.

________________________________________________________________ Patient’s signature (If a Minor, Signature of Parent or Legal Guardian)

__________________ Date

___________________________ ___________________________ ___________________________ Relationship to the patient Witness Signature Doctor’s Signature Authorization must be signed by the patient, or by the nearest relative or guardian in case of a minor or when the patient is physically or mentally incompetent. Volume 8 Number 1

Volume 8 Number 1

“P” describes the plan for treatment recommendations. The worksheet becomes part of the complete record so all entries must accurately reflect why the patient is seeking treatment and what the findings are. A proper recordkeeping system insures that you always record the required

information consistently, using the same type of form for every patient for every visit. It infers a careful practitioner and enables one to follow the needs of a patient from visit to visit. Patient records are specifically used to record patient information that includes the evaluation, the treatment, and any patient

Table 6: Avoiding an Informed Consent Action Document the informed consent conversation (date and sign). Document the patient’s reactions and concerns. Document the patient’s agreement to the proposed treatment plan.

Table 7: S.O.A.P.: The Uniform Diagnostic Worksheet S = Subjective findings: referred to as the chief complaint of the patient O = Objective findings: what the practitioner finds during the physical and radiographic examination A = Assessment: what the diagnosis is compiled from looking and listening to the patient and testing and viewing diagnostic aids P = Plan: development of a treatment plan to address diagnostic findings

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Endodontic practice 45

LEGAL MATTERS

for treatment” form (Table 5). Informed consent allegations can be avoided (Table 6). If undisclosed risks materialize resulting in injury to the patient, and the patient can prove that he/she would not have consented to the treatment had the risk been disclosed, the chance for legal action increases.23 Dental records serve two major purposes.24,25,26 They are business records that tell a story about a patient’s dental health and treatment. They are also legal records, of which the accuracy would essentially be relied upon to help exonerate a practitioner from allegations of wrongdoing. Failing to maintain a written record that accurately reflects the evaluation and treatment of each patient can be construed as unprofessional conduct in many jurisdictions. Moreover, it reflects poorly on the practitioner and office when reviewed by either a patient, an investigator from the state licensing bureau, a plaintiff’s attorney, a judge, or a jury. Inaccurate or incomplete records could imply an uncaring and unprofessional provider, which becomes a foundation of suspect in cases of allegations. Thorough documentation is the best legal defense a dentist can have against malpractice litigation, even better than a good expert witness. Every member of the dental team is equally responsible for recording pertinent facts about a patient’s visit. Most jurors have never seen a dental chart but rely on the information within it, if they can read it. Juries usually believe what is charted and conversely wonder why something significant was not charted. It is generally believed what is not written has not been done. A good patient record must be accurate, complete, and authentic. Maintaining complete and accurate records (“charts”) is a sign of quality care and an integral part of our duty to record the care of the patients. We live in a litigious society, and all healthcare professionals face the very real risk of being the target of a malpractice claim. As such, our profession must implement procedures to minimize the risk of such actions. The universally accepted documentation format is that of S.O.A.P.24 (Table 7) and is outlined in a diagnostic worksheet format. “S” describes the subjective findings or the chief complaint the patient states as the reason for their concern. “O” describes the objective findings, or what is diagnosed using clinical testing combined with radiographic findings and any other aids used to make a definitive diagnosis. “A” describes assessment or the sum result of the diagnostic findings, and

LEGAL MATTERS reactions or concerns. They are not used for billing purposes; therefore, fee charges and payments are to be kept in a separate filing. Records are to be organized and legible to tell the patient’s story to the third party reviewing it. Illegible records can imply a careless practitioner and sloppiness; entries should be clear and unambiguous. Only the facts of what is seen and done should be recorded in ink and dated, and the person who makes the entries should initial it. There should be no erasures, white-outs, or blackouts. Corrective entries are made by placing one line through the error and inserting the

dated and initialed correction. All missed and cancelled appointments and failure to comply with instructions should be recorded, but derogatory comments and descriptive symbols that can be interpreted as derogatory should be left out. Referrals made and referrals refused or noncompliant patients must be recorded. The basic elements of a complete record must include, but are not limited to, those

items listed in Tables 8-11, such as demographics, medical and dental history, consent forms, progress notes, recommended guidelines, and other elements. Details for the contents of these charts can be found in the references cited.1,2,3,8,14,20,24 Going paperless using electronic records is allowable. However, the electronic system must have a “locking” system to prevent alteration within a reasonable period of time, and all details

Table 9: Content of Progress Notes Date and time of services rendered Amount and type of local anesthetic administered

Table 8: Demographics Patient’s name, address, and phone numbers Date of birth Occupation Dentist’s name and phone number Dental Specialist’s name and phone number Primary Physician’s name and phone number Medical Specialist’s name and phone number Emergency contact (relationship) and phone number

Use of nitrous oxide if applicable; who monitored patient Procedure(s) accomplished Material used (sedative, filling, and/or temporary material) Instructions to the patient Cancellations or missed appointments Referrals made and reports received Refusal for Treatment and/or Referrals (noncompliant patient) Patient comments or complaints

Telephone conversations with patient, physician, or another provider Initials of individual making the entry into the record

Table 10: Guidelines for Progress Notes

Table 11: Elements for Documentation

Progress notes are for services rendered and pertinent communications.

Patient demographics

Use a consistent style of entry for all patients.

Medical history

Record similar information in the same way for accuracy and completeness.

List all current medications and doses: prescribed and OTC and recreational

Use blue or black ink (red does not reproduce). Never alter a record. Never alter a record by using white-out, black-out, erasures. Any correction must be made with a single line through an erroneous entry. All corrections must be initialed and dated. Initial and date any additional after-the-fact entries. Write legibly so entries are clear and unambiguous. Express concern rather than negativity. Never write derogatory comments or acronyms that can be misinterpreted. Maintain a separate record for billing and fee information. Do not ignore patient complaints that have merit.

Dental history Signed informed consent forms S.O.A.P. details Progress Notes - record information immediately to avoid “memory distortion” - record positive and negative findings - use standard abbreviations - do not alter records - avoid subjectivity Lab and pharmaceutical prescriptions Referral prescriptions

Record and explain resolution of any complaint rather than make no entry.

Consultation reports, biopsy reports, referral reports

Date and initial every entry.

All written and email communications

Never part with the original record; only provide copies when requested.

Keep billing and fee information separate

46 Endodontic practice

Volume 8 Number 1

REFERENCES 1. Seidberg BH. Chapter 14. In: American College of Legal Medicine. Legal Medicine; Legal Aspects of Dentistry. 5th ed. Chicago, IL: Harcourt Publishers; 2001. 2. Seidberg BH. Chapter 50. In: American College of Legal Medicine. Legal Medicine; Legal Aspects of Dentistry. 6th ed. Chicago, IL: Harcourt Publishers; 2004. 3. Seidberg BH. Ethics, morals and law in the professional office. Endodontic Practice US., 2014;7(2):57-59. 4. Stimson PG, George LA. How to practice defensive dentistry. J Gt Houst Dent Soc. 1990;61(8):11-13. 5. Toner JJ. Malpractice. What They Don’t Teach You in Dental School. Tulsa, OK: PennWell Books; 1996. 6. King JH. The Law of Medical Malpractice in a Nutshell; St. Paul, MN: West Publishing Co; 1986: 3. 7. King JH. The Law of Medical Malpractice in a Nutshell; St. Paul, MN: West Publishing Co; 1986: 71. 8. Seidberg BH. Chapter 3. In: Ingle JI, Bakland LK, Baumgartner JC, eds. Ingle’s Endodontics, Ethics, Morals and the Law in Endodontics.6th ed. 2008. 9. Graskemper JP. Professional Responsibility in Dentistry – a Practical Guide to Law and Ethics. Indianapolis, IN; WileyBlackwell: 2011. 10. Kimmel S. Standards of Care in Dentistry. Suwanee, GA; Harrison Company Publishers: 1999. 11. Simpson v Davis, 219 Kan. 584, 549 P.2d 950 (1976). 12. Seidberg BH. Chapter 50. In: American College of Legal Medicine. Legal Medicine; Legal Aspects of Dentistry. 7th ed. Chicago, IL: Harcourt Publishers; 2007. 13. Seidberg, B.H.: in Study Syllabus, American College of Legal Medicine; Dental Malpractice chapter, 2003

14. Seidberg BH. Harassment - Crossing the Professional Line; Endodontic Practice US. 2013;6(5):42-45. 15. Schloendorff v Society of NY Hosp, 211 NY 125, 129, 105 N.E. 92, 93 (1914). 16. Nathanson v Kline, 186 Kan 393, 350 P.2d 1093 (1960). 17. Eastern Dentists Insurance Co. Malpractice Insurance Company: The Value of Informed Consent – An EDIC Case Study, November 2014 18. Ibid: EDIC; 2014 19. Shelton, P. American Board of Legal Medicine, Annual Meeting. New Orleans, LA; February 2012. 20. Seidberg BH. Understanding the legal concept of informed consent; The Bulletin, New York State Fifth District Dental Society, v56#2, 2011 21. Canterbury v Spence, 464 F.2d 772, 783 (D.C.Cir. 1972), cert. Denied, 409 U.S. 1064 (1974). 22. Shuler v Garrett, 743 F.3d 170 (8th Cir. 2014). 23. Seidberg BH. American Board of Legal Medicine, Annual Meeting. New Orleans, LA; February 2012. 24. Seidberg BH. Record keeping in dentistry. Nevada Dental Journal. Winter 2010. 25. Oberbreckling, PJ. The components of quality dental records. Dent Econ. 1993;83(5):29-30, 32, 34. 26. Scott RW. Legal Aspects of Documenting Patient Care. Sudbury, M: Aspen Publishers, Inc; 1994. 27. Schilder H. Class notes. Boston, MA: Boston University School of Graduate Dentistry; 1966. 28. Fallon M. Personal communication. 2000. 29. Udey D. Within your control – ethics in dentistry. On the Cusp. 2014;18.

Table 12: How to Avoid Lawsuits Be professional and courteous. Communicate clearly and compassionately. Provide adequate information (informed consent). Keep accurate and complete records. Predict appropriate prognosis. Don’t be egotistical about diagnosis or second opinions. Don’t be greedy by overbilling.

Volume 8 Number 1

Endodontic practice 47

LEGAL MATTERS

that would appear in paper records must be included electronically. There will be a time in the near future when all records will be required to be electronic, rendering offices paperless. Front desk software will have to be able to convert to the world of electronics and be compatible with e-scribe and drug programs. Requests for records by third parties or by the patient must be responded to within a reasonable time period of no more than 10 days. All requests honored should be in writing. The last dated entry in the progress notes should state who and why the record was transferred to, and the authorization for the request must be kept in the record. Only copies of the record and/or radiographs should be given to the requestor, never the original. Each state determines the fixed rate that can be charged for the reproduction of records. In New York state, it is 75 cents plus a “reasonable” fee for duplicating radiographs and models. To further decrease risk, dentists must have the desire to obtain the knowledge and the skills to provide dental services27 and then follow the Fallon Three “A’s” Doctrine28 for success: Affability (be easy to speak to; approachable and gentle), Availability (be accessible to patients in need), and Ability (be able to think and accomplish the task and do it well), in that order. Ethics3 and risk management go hand in hand to render the best care possible to the patient. Ethics3,8 is the byproduct of providing safe and effective care29 while a solid risk management program protects the practitioner. To avoid legal allegations and lawsuits, dentists must practice within the standard of care, communicate properly, inform patients, and legibly document everything (Table 12). EP

TECHNOLOGY

Implementing the GentleWave™ System by Sonendo® Endodontists speak about the ins and outs of successful new tech integration

requent continuing education, remaining current on the scientific literature, and embracing new and clinically relevant technology are foundational pillars of professional growth. Knowing when to invest in the latest technology can be challenging. Price is certainly one consideration in technology integration, but not the primary or sole consideration. For many clinicians, of greater concern is the natural caution to ensure that new technology delivers both the intended benefit efficiently and, at the same time, in a cost-effective manner. The interviews that follow describe the introduction of the new and novel Sonendo® device into the endodontic specialty practices of Dr. Thomas Jovicich (TJ) of Encino, California; Dr. Randy Garland (RG) of Encinitas, California; and Dr. Khang Le (KL) of Santa Ana, California. These doctors share what a transformative difference the GentleWave™ system is making in their daily practice.

After making the decision to purchase but prior to installation, what were your ROI expectations around those important investments?

TJ — Being an early adopter definitely poses some challenges. I believe having your entire team on board in the process mitigates the hurdles. In my experience, the Jovicich technology and what it brings to my practice supersede any hiccups. While ROI is important, I’m focused on how this technology will make me a better clinician. Doing anything with the focus on ROI interferes with using that technology as a part of my armamentarium. Excellence in care and service will always meet or exceed my expectations as it relates to my ROI on new technology in our practice. RG — My expectation with the GentleWave system is that my practice will grow significantly as more and more general dentists are educated on the significant Garland improvement that this system provides in endodontic therapy. 48 Endodontic practice

The GentleWave™ System by Sonendo®

KL — I did not expect to have any positive ROI right after the purchase because it would take both time and effort to first do the marketing and then see the Le numbers that would indicate any improvement in cost savings. But my rationale for purchasing or leasing the device is to achieve the best clinical outcome and treatment comfort for my patients. Once this is accomplished, then everything else will take care of itself in a positive way. In regards to ROI, I hope to use less endodontic rotary files and time to complete a root canal treatment procedure and still have good or even better results than as if I didn’t have the device. I will have the peace of mind that the procedure was done to the best level without compromising anything.

Once the technology was fully in place, did it meet those initial expectations?

RG — In only a couple of months with the GentleWave system, I’ve already added two new referring offices. These are doctors that have been referring to a competitor for

years. Its potential to improve success rates and decrease the incidence of root fractures are pretty easy selling points.

Getting your staff fully trained and comfortable with the use of new technology can be a significant undertaking for the practice overall. What did you do to ensure that this learning curve was as short as possible, and how did it go?

TJ — I make sure my staff is fully on board from day one. In order for anything to work in my practice, it first and foremost must be a team effort. I can have the greatest ideas, but successful implementation is totally dependent on working as a team. RG — It’s very important to engage the staff in a new technology in a positive way. By educating them thoroughly in the advantages of having this in our office and encouraging them to take pride in the fact that they work in a cutting-edge practice, they get excited about learning how to use it. The more they know about how it works, what it does, and the benefits it provides to a patient, the more invested they become in the process. Volume 8 Number 1

TECHNOLOGY

GentleWaveTM case pre-op CBCTs. Note the accessory canal near the apex connecting the main mesial canals and the large isthmus filled between the two distal canals

KL — I did not do much to shorten the learning curve. Sonendo did an outstanding job by having its support personnel present in the office for the first few weeks, ready to train and/or troubleshoot any problems that arose from using the device.

Integrating new technology can present some challenges in even the most modern and progressive endodontic practice. What has your experience been overall in that area?

KL — Technology is wonderful and essential in helping or enhancing the ability of the practitioner to achieve his or her goal. I totally embrace any new technology introduced to dentistry. However, the challenges are keeping up with the constantly changing technology introduced or updated by research and development, learning new skills to utilize it, and having the budget for the purchase. If there is enough sound research from reputable institutions proving the efficacy of the device, the credibility of that technology will be heightened, and it will take time. A good experience with the new technology in our practice is always a result of good training and support from the company that sells it. My experience with the GentleWave system from Sonendo has been outstanding because they have provided us with “white glove” service and support. Above all, they conducted excellent research projects to back the efficacy of their product and to introduce the endodontic community to something that is promising and a push to achieve better successful outcome.

Aside from providing a higher standard of patient care by utilizing the latest technology, what tools did you use to educate the patient on your investments?

TJ — That’s a great question. We host a

Volume 8 Number 1

GentleWaveTM case post-op CBCTs Images courtesy of Randy Garland, DDS, Encinitas, California

study club for our referring dentists, so that is one avenue we pursue to educate the dentist. Our practice relations coordinator will reach out to our referring offices as well

to educate the office staff about our technology. I will personally reach out to my referrals to discuss with them in person any new technology we incorporate. Often, we follow Endodontic practice 49

TECHNOLOGY that up with a mass mailing to announce technologies that keep up in the forefront of our specialty. For our patients, we work to keep our website current on a daily basis. We use social media to present technology that we are excited about as well as asking our patients who have experienced it to use social media to share their good experiences with their network of friends and family. RG — I explain when we are just about to use the GentleWave™, that this is a “special system that I will be using that uses multiple sound waves and irrigation fluids to clean out and disinfect their roots far better than the old way of doing root canals.” I keep it simple and offer to answer any questions they may have. Some patients show a lot of interest and ask detailed questions. I am also currently trying a public awareness campaign by placing an educational ad in a couple of local newspapers introducing this new technology and seeing if patients either call us or start asking their general dentists about it. KL — Brochures lay out on the table in the reception area. They were also given to referring dentists so that they would learn about our new technology and, in turn, educate their patients.

How do they respond to that education?

TJ — Today’s patients crave information. They want to be involved as partners in their dental care and welfare. We want them to be an integral part of this journey. To date, we have had nothing but positive responses and feelings of surprise at how advanced our practice is. It has been my firm belief over my 29 years in practice that treating my patients as equals and speaking to them in plain English has reaped great dividends. RG — I’ve found that most patients appreciate new technology more when they know more about it and tend to share that with their referring dentist. They also don’t seem to fuss about the price of treatment when they understand the value of what they are getting. KL — So far, so good! One patient mentioned the GentleWave system and was excited to have the procedure. This patient did come from the GP referral.

Many successful endodontic practices have robust communication strategies designed to build and maintain a steady stream of referrals. What did you do that was effective to leverage this new 50 Endodontic practice

These endodontists practice with confidence that the canal is being truly cleaned to a degree never before possible....

technology for the purpose of stimulating better business for your practice?

TJ — There is no one thing that is the “magic bullet” here. We try to get the word out over a multitude of fronts from educational videos to word-of-mouth from patient to patient. RG — I did an educational seminar and sent brochures and patient education materials to my referring offices, as well as many that I am not currently working with. Dentists all seem to be interested in this new technology, even if they aren’t using it themselves. KL— An invitation to a presentation (i.e., lecture and hands-on) about the new technology at my practice appeared to capture their interests.

How active was the manufacturer in helping you with this effort, and what tools did the company provide?

TJ — Manufacturer support, especially in nascent technology, is tantamount to success. Having great support staff is essential to getting things off the ground. Let’s not kid ourselves; technical snafus happen all of the time. What makes it bearable is being able to reach out to the manufacturer for a quick answer or go on a website to find the answer. It’s readily apparent when you don’t have good support; then the technology hinders my practice, and my willingness to use it decreases. RG — Sonendo was instrumental in helping me with my presentation to educate my referring doctors. They have also provided me with brochures and other educational materials for patients. Sonendo suggested doing a patient awareness campaign and assisted me in designing and implementing the ad that I am currently using. They are working on video material that I can use on my website to educate both patients and referring doctors.

KL — The design of patient brochures and the template of the PowerPoint GP referral presentation were very helpful.

Overall, what have been your primary motivational factors when considering and/or purchasing new technologies? Is it more about keeping up with the trends in order to be competitive, or being a leader ahead of it?

TJ — Being a leader in my field has been my motivation since day one. Any patient going to a specialist should be given platinum treatment. That entails offering the best possible patient experience from the moment the patients walk in the door to the moment they leave our practice. Offering our patients the latest and greatest technology is included in that experience. Treating the patient as an extension of our referring doctors’ practice has given me a very satisfying professional career. RG — I have always chosen to try the latest technology so that I can provide the best treatment available for my patients. I do a lot of research on each one and select what will work best in my practice. The fact that this also seems to give me a competitive edge is a nice perk. Keeping up with the latest innovations also makes my work more enjoyable on a daily basis. Rather than getting bored with what I’m doing, I get excited about being involved with things that are improving my profession. KL — Everything. From being the leader ahead of trends, keeping updated with modern technology, possible savings (time and money) in using the device, but above all, it works as proven by credible research. These interviews have described the adoption of the GentleWave™ system by Sonendo®. Each, in his own way, powerfully describes the confidence and benefits gained from using the GentleWave™ in daily practice. These endodontists practice with confidence that the canal is being truly cleaned to a degree never before possible, while simultaneously providing the benefits of reducing treatment complexity, file costs, iatrogenic events, and patient and doctor stress — all the while gaining the real potential to improve treatment outcomes and the quality of their patients’ lives. Sonendo has grown from a concept in 2006 to its limited commercial release today. The device is FDA cleared. Located in Laguna Hills, California. For more information, contact Sonendo at info@Sonendo.com. EP This information was provided by Sonendo®.

Volume 8 Number 1

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PRODUCT SPOTLIGHT

Your loved one needs a root canal … Which result would you want them to have? Conservation matters For strength and restoration life Conservation is the preservation of structurally sound tooth. The more dentin you save, the longer the tooth will last. Dentin is not replaceable. Once lost either by decay or by removal due to dental procedure, the tooth becomes significantly weaker as we cannot currently replace its flexibility, strength, and crack-resistant qualities. Dentin in the cervical third of the tooth, the peri-cervical dentin, is especially vital to the longevity of the final restoration. SS White worked with a team of leading GPs and Endodontists to design and develop the first Minimally Invasive Endodontic Root Canal Treatment System. We have designed both conservation and efficiency into three procedural steps:

Step 1: Access Piranha® Diamonds Piranha® Single-Patient-Use Diamond can reduce heat and postoperative sensitivity while making crown preparations predictable and efficient. Over 1 year, they can also save 52% in rotary instrument material and aseptic control costs and $4,200 in chair time. Great White Z Diamonds Reducing endodontic access for crowns that contain a zirconia coping from 10-15 minutes to 1-3 minutes, Great White® Z Diamonds can save an estimated 45 hours of chair time on over 300 crowns. ®

Great White® Carbides Ideal for plunge cut-like access, doctors who previously used two or three carbides to remove crowns reported using one Great White® to remove two-to-three crowns. EndoGuide® Burs By replacing Gates Glidden Burs and Ultrasonic tips, clinicians have stated they conserve 40%-70% more peri-cervical 52 Endodontic practice

SS White worked with a team of leading GPs and Endodontists to design and develop the first Minimally Invasive Endodontic Root Canal Treatment System.

dentin, key to strength and fracture resistance in endodontically treated teeth, while gaining visibility and safety. 85% of general dentists surveyed stated they would refer future root canal cases to endodontists who used EndoGuide® Burs to create more conservative access.

Step 2: Debridement and shaping V-Taper™2H Files Differentiating V-Taper™2H instruments is the patented variable descending taper, increased flexibility and strength in the file, and a shape that respects the natural anatomy of the root canal system with a deep apical shape for proper disinfection, as well as a conservative coronal shape. This allows for fewer instruments per case (Molar/PreMolar = 2-3. Anterior = 1-2). V-Clean™ Agitator Used to remove the smear layer within the root canal, dislodge and remove debris, and provide an agitating action with disinfecting or irrigating solutions, V-Clean™ Agitator can reduce bacterial contamination by 90.2% compared to use of irrigation alone.

Step 3: Obturation V-Taper™2 Custom Gutta-Percha Cones Size-matched to the V-Taper™2H file system, the custom-fit cone system provides a reliable obturation protocol. V-Fill™ Obturators An efficient alternative to cones, a clinician who fills six-to-eight root canals per day can save 20-27 hours of chair time using V-Fill™ Obturators over conventional filling techniques and materials. Buy 400 SS White Burs, and get an SS White CORE Endo All-Inclusive Kit for Free! EP

This information was provided by SS White®. Volume 8 Number 1

Minimally Invasive by Design. Practice Growth by Accident. Minimally Invasive

• Access

Along with increased visibility the Endoguide™ Bur’s conical shaped tip acts as a self-centering guide for canal location, eliminating “runoff” associated with round burs that can lead to gouging and unnecessary loss of peri-cervical dentin.

• Debridement & Shaping The unique V-Taper2H file design safely produces the deep apical shape necessary for proper disinfection while conserving maximum amounts of mid and coronal root dentin.

Practice Growth

“All dentin is not created equally, EndoGuide® Burs and V-Taper™2H Files foster conservation at the heart of the tooth, peri-cervical dentin. The preservation of healthy dentin leads to longer lasting restorations.” – Dr. Eric Herbranson, Endodontist

•

85% - The actual percentage of GPs who prefer the MI Endo restoration to the straight line preparation.*

•

We can help communicate this to your doctor.

Unique File Performance • Flexibility & Strength The proprietary manufacturing process and design of its core has created a file with remarkable flexibility and strength backed by university studies, and a shape that respects the natural anatomy of the tooth. • Effectiveness The unique design allows for a reduction in the number of files needed, with 1-2 for Anteriors and 2-3 for Molar/Pre-Molars possible.

Call to Order Your Access & Shaping Kit Or for an in-office demo. 295

800-535-2877 Ref Code: EP-JANFEB-15

simply better endodontics

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1145 Towbin Avenue Lakewood, New Jersey 08701

Visit us on the web at www.sswhitedental.com

©2015 SS White Burs, Inc. All Right Reserved. SS White® andV-Taper2H® are a registered trademarks of SS White Burs, Inc. * Data on file. †SS White’s 100% guarantee is on all of our products. If you are not completely satisfied with your purchase, we will issue a full refund of the purchase price.

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Septodont introduces BioRoot™ RCS BioRoot™, the only bioactive and biocompatible root canal sealer, is a breakthrough in the latest generation of mineral-based root canal filling materials for permanent canal obturation. Based on the Active Biosilicate Technology and designed for general dentists and endodontic specialists, BioRoot incorporates an easy-to-use cold obturation technique that ensures a long-lasting, leak-free seal. A high pH (>11) helps stop bacterial growth and alleviates any risk of intracanal re-infection. BioRoot is biocompatible and resin-free, meaning it will not have any impact on human cells in case of over obturation. The product is easy to hand-mix and place, giving practitioners greater efficiency. BioRoot is also competitively priced compared to the market leaders and contains 35 applications per kit. Advantages over existing resin and eugenol-based RCS are: 1. Resin-free — made from highly pure calcium silicate and monomer free, which ensures zero shrinkage and equals zero sensitivity for the patient. 2. Hydrophilic — works with moisture in the root and continues the sealing process in the presence of moisture. This is an issue with resin-based RCS, which leave voids in the root for bacteria to re-enter the canal causing sensitivity and failures. 3. Antibacterial — due to its high pH, BioRoot stops bacterial growth, has less risk of intracanal re-infection, and has no effect on human cells in cases of over obturation. 4. Strong seal — void-free, tight interface with outstanding adhesion to dentin, and gutta-percha points. As the next generation in RCS, BioRoot is bioactive and biocompatible for greater patient outcomes and priced competitively for cost savings for the practitioner. BioRoot RCS comes in a box with one 15g bottle and 35 0.20mL pipettes. The product is scheduled to launch at the Chicago Dental Society (CDS) Midwinter Meeting on February 25th, 2015. Ask your Septodont representative for further details.

Vista Dental’s new cordless ultrasonic activator, EndoUltra™, significantly improves debridement Science has shown that irrigants are more effective when they are electro-mechanically activated. Acoustic streaming and cavitation of endodontic solutions have been shown to significantly enhance cleansing of difficult anatomy. Studies have shown that low-frequency (sonic) oscillation (160-190Hz) was not sufficient in creating acoustic streaming or cavitation within the canal space. EndoUltra™ is the only cordless, compact, battery-operated piezo ultrasonic (40kHz) activation device. Only EndoUltra™ is capable of producing acoustic streaming and cavitation in small canal spaces, resulting in significantly improved debridement, disruption of biofilm, improved penetration of irrigants into dentinal tubules, and the removal of vapor lock. EndoUltra™ features unique 15/02 Activator Tips, which resonate along the entire length of the tip and do not engage tooth structure. Activator tips feature depth markers at 18 mm, 19 mm, and 20 mm. The EndoUltra™ ultrasonic activator is another example of product innovation and Vista’s dedication to endodontics. For information, visit vista-dental.com or call 877-418-4782.

CS 8100 3D with EndoHD mode The CS 8100 3D system, with the smallest footprint on the market, is the perfect imaging machine for endodontic practices. Featuring an EndoHD mode (5 cm x 5 cm) for high-resolution scans with 75 µm precision, the CS 8100 3D captures images that show even the smallest details of root and canal morphology for confident diagnosis and treatment planning. For even more control, the system features four selectable fields of view, so endodontists can further customize image size, resolution, and the dose for each individual examination. For more information, visit http://carestreamdental.com.

54 Endodontic practice

Volume 8 Number 1

TeamSmile®, a unique national dental outreach program, gains continued support from DEXIS™, a brand of the Kavo Kerr Group, for the 7th consecutive year. Since the inception of the TeamSmile program in 2007, DEXIS has been a proud supporter through its donation and maintenance of its digital imaging systems, DEXIS™ Platinum sensors, CariVu™ caries detection, and DEXcam™ intraoral cameras, as well as financial contributions. TeamSmile partners with dental professionals and athletic organizations to bring together athletic role models and underserved children in communities across the country at events held throughout the year. These events allow the children to obtain free screening and treatment and also learn about the importance of their overall health. DEXIS has rededicated efforts to assist TeamSmile with company volunteers, on-site systems, and funding. By partnering with professional sports organizations, TeamSmile creates an experience that develops bonds between children’s organizations, oral health professionals, surrounding communities, and the athletes that solidify the message that oral healthcare is vitally important to long-term health. Understanding that these patients deserve the very best, volunteer dentists, dental assistants, dental hygienists, and educators provide the highest level of care and use industry-leading materials and equipment. Through this experience, children are taught that the mouth and body are linked for overall health, and they receive free oral health education, screening, and treatment. For more information about DEXIS, visit www.dexis.com.

LED Medical Diagnostics officially opens new Atlanta training facility and support center LED Medical Diagnostics Inc. is officially announcing the opening of its new training and support facility in Atlanta, Georgia, which has been in use since October 15, 2014. LED Dental Inc. a wholly owned Canadian operating subsidiary of LED Medical, has completed a 20-person training room, which is equipped with Wi-Fi and wireless high-resolution displays for customers, installers, and employees. The training facility includes a leadlined laboratory for X-ray emission from intraoral and extraoral units and a fully functional RAYSCAN Alpha – Expert dental imaging system, with 3D cone beam computed tomography (CBCT) as well as panoramic and cephalometric capabilities. A dedicated LAN for testing within various types of dental clinic networks, including commonly used operating systems and practice management software, is also available. On-site technical support staff members manage a 12-hour, 5-day-a-week call center. In addition, the training facility includes conference and board rooms for meetings with current and potential customers. For more information, visit www.leddental.com.

Volume 8 Number 1

Planmeca rolls out cloud service product at Greater New York Dental Meeting Dental equipment manufacturer Planmeca Oy developed Planmeca Romexis® software as an open-architecture platform, making it compatible with most software operating systems and dental equipment. Now, Planmeca has taken this technology to a new level with Planmeca Romexis Cloud service, which works with Planmeca Romexis software so dentists can access and share diagnostic images from any imaging unit. This information is then accessible on most digital platforms, including mobile, Mac, and Windows-based operating systems, and can be stored for up to 14 days. Planmeca Romexis Cloud service lets dental professionals communicate with colleagues and transfer images and key case information securely, quickly, and seamlessly. This brings new possibilities to the dental practice, such as providing access to specialists from remote general practitioners, giving rural dentists the same referral base as any dentist in a large metropolitan area. The Planmeca Romexis Cloud service also includes these features: • All treatment plan elements are automatically added, including annotations and measurements. • Virtual patient cases include 2D X-ray images and photos, CBCT volumes and 3D photos • Images and reports are easily shared with patients. With a North American office located in Roselle, Illinois, and international headquarters in Helsinki, Finland, Planmeca is well established in high-tech dental markets and currently serves 120 countries worldwide. Planmeca’s dental product line includes: • 2D and 3D dental X-ray equipment • Open-architecture dental imaging software • Dental care units and equipment • Dental cabinetry and furniture For more information, visit http://www.planmecausa.com.

Share your good (endodontic) news! Submit your press release for consideration to managing editor Mali Schantz-Feld via email at Mali@medmarkaz.com.

Endodontic practice 55

INDUSTRY NEWS

DEXIS™ and TeamSmile® demonstrate teamwork in bringing dental care to underserved children

ENDOSPECTIVE

Seven clinical practice truths Dr. Rich Mounce offers some advice on the pursuit of endodontic happiness

fter 23 years as an endodontist in private practice, seven foundational clinical practice truths have manifested themselves to me. These are shared in no particular order of importance with the goal of stimulating readers to assess if any of these might have tangible value in their practices. 1. Endodontics is humbling to the true student intent on mastery. Mistakes are the best teacher. Accessing the wrong tooth for example is a significant mistake, but if it leads to marking every tooth slated for treatment with a grease pencil (once the problem tooth is identified), it will never happen again. Forgive yourself, learn, and move on with confidence. 2. Staff are our greatest strength and our biggest weakness. Praise when they perform well, and go the extra mile. Despite all manner of trying, I have yet to change an underperforming employee into a dependable and competent one. Employees who are not performing satisfactorily should be set free to pursue their dreams somewhere they can be happy and personally effective. If it’s not working, let them go early. If it’s working, move heaven and earth to make your office the greatest place in the world to work. 3. Endodontists in your same city, rarely, if ever, want to be friends or will be complimentary of you, especially if you are competing for the same referrals. Don’t expect respect from your fellow endodontists. Sad, but true. Brush it off. People criticize because they feel threatened. If you are being “slagged off” by

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 is a clinical consultant for Sonendo. He has not been paid to make the comments included in this article about Sonendo. He can be reached at RichardMounce@MounceEndo.com, MounceEndo.com. Twitter: @MounceEndo

56 Endodontic practice

Tell patients where appropriate, “It’s OK to be afraid; I understand,” and “You are safe here.”

your local competitors, it means you are doing something right. 4. Tell patients where appropriate, “It’s OK to be afraid; I understand,” and “You are safe here,” and then make them comfortable with whatever means necessary. Profoundly numb means profoundly numb, make them so. People can’t judge your technical skill, but they know if you care and if they were pain-free during the procedure. It is the greatest single marketing tool available to us. 5. We live in an emotional space not occupied by our general dental colleagues. Tough patients are the reason the general dentist referred the patient in the first place! As such, don’t take it personally. By whatever means necessary, such negativity cannot be internalized. Taking care of oneself physically, emotionally, spiritually, and in our relationships cannot be overstated in value. It’s no good to be the highest producer in your city or state and be miserable. 6. The dental industry is not made up of our friends. Beware the young perky sales representative with the “buy 10 get 2 free” offers of the latest and greatest. The markup on dental equipment and supplies is often 50%-100%. Bargain hard for your supplies and equipment. Never take the first offer made by a

company on anything. They can almost always do better, until they can’t. The sales representatives have to make their quotas or they get fired. The higher the price you pay, the closer to their goals they become. Only one party wins in that transaction. Strange advice from a man who owns an endodontic supply company, but true. Savvy clinicians are consistently asking us for quotes. I appreciate that both as a clinician and owner of MounceEndo.com. 7. Don’t be afraid to “go big” on new and innovative technology. For example, Sonendo® is virtually certain to forever change the endodontic landscape with regard to “ultracleaning” canals, simplifying technique, reducing iatrogenic events, and ultimately improving the quality of patients’ lives by retaining teeth that otherwise might be subject to “cold steel and sunshine” and ultimately implants. The pendulum is likely to swing back to natural tooth retention. If I were an oral surgeon or periodontist, I would be concerned. But Sonendo will come with a cost, a learning curve, and require a bold step for the early adopters. Putting one’s head in the sand and waiting will carry a heavy cost for the doubters. I welcome your feedback. EP Volume 8 Number 1

Thinking ahead. Focused on life.

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