Endodontic Practice US - May/June 2015 Issue - Vol8.3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews May/June 2015 – Vol 8 No 3

PROMOTING

EXCELLENCE

ENDODONTICS

The thick slice technique: a virtual periapical radiograph Dr. Richard S. Kahan

A case featuring Mani Silk Dr. Rich Mounce

A new paradigm in endodontics

An interview with Joseph Maggio, DDS

Optimal office design and planning with ASI Practice profile

Dr. Allen Ali Nasseh

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

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Volume 8 Number 3

he exciting phase of dentistry that enables patients to save their teeth that would otherwise be extracted is our specialty, endodontics. There can be nothing more satisfying than being able to save teeth critical to the health of our patients and having the privilege of that responsibility is something not to take lightly. Dentistry is a fabulous profession. In what other profession’s specialty can you go to work every day and help people, relieve pain, retain tooth function, and provide a pathway to a healthy digestive system? Isn’t that why we chose dentistry and specifically endodontics? To heal the inflicted? I chose to specialize in endodontics because I wanted the excitement of being able to diagnose the origin of a patient’s pain, to treatment plan appropriately, and to save teeth. Every day, every patient, every tooth, and every root canal anatomy is challengingly different. Dr. Herbert Schilder said that the best implant is the natural tooth, which is difficult to argue against. The rewards of saving teeth, even those treated heroically, outweigh the alternatives. The Schilders, Grossmans, Seltzers, Benders, Glicks, and Franks may be gone, but their legacies remain. They taught us the biologic systems and the basics of endodontics. Those do not change. The future of endodontics is bright for many reasons. Visibility has been improved with surgical glasses and the microscope. Radiology has traversed from the small wet film to digital radiology and the CBCT scans, providing a three-dimensional view of what we only previously had as two dimensions. The development of rotary instruments has enhanced cleaning and shaping of the root canal system. New sealing materials have been introduced, but the old standby of gutta percha using vertical condensation as an obturation technique is still my favorite, having long passed the test of time for success when following the basic Schildarian principles. Continued research and clinical studies as reported in journals and in conferences continue to teach us modifications of treatment and how to improve our techniques. We now embrace literature with evidenced-based dentistry. Our knowledge of pain control and the biologic system has also expanded. But the basics should never be vacated. The daily introduction of new and improved technology has to trigger passion and excitement in the conscientious practitioner. However, there is the gray area where the boundaries are being stretched in all phases of dentistry, which leads to the choice of extraction or retention. I’d prefer retention over extraction. However, there are those in our profession who subscribe to the opposite and push the envelope. It is our responsibility to teach our colleagues why we are so passionate about our specialty and just what we can do to retain teeth and provide the foundation for a healthy dentition. I’ve witnessed many changes and listened to my colleagues discuss and teach grafting, post and core buildups, and implantology. The discussion of root canal versus implants has been debated ad nauseam and is not up for debate in this editorial. Implants have also passed the test of time as an alternative to endodontic treatment, but only when root canal therapy on a tooth is strongly contraindicated. Unfortunately, there is an attitude by some dentists that even a good root canal is inferior to an implant. There is absolutely no truth in that type of thinking. Parenthetically, although there can be failures in endodontics, I have legally reviewed a number of cases of poor implant placement and failures and when viewing the original radiographs, root canal therapy would have been the better choice of treatment. The success rate in endodontics remains above the 95% range when done right. Remember the ethical basis for the standard of care? Beneficence! I don’t condone those who had a vision to expand endodontics into the areas of periodontics, prosthodontics and implantology, but neither do I subscribe to it. We all have to do what we have to do for the success of our practices. Dr. Michael Fallon’s doctrine of affability, availability, and ability summarizes success. The belief in my method of practice management is based on professionally communicating compassionately with my patients, discussing cases honestly with my referring colleagues, diagnosing and treating patients to the best of my ability. Staying within the basic boundaries of endodontics has fed my passion to remain in active practice. Disappointment is the loss of a tooth or teeth. Satisfaction is a successful root canal. Bruce Seidberg, DDS, MScD, JD is a Diplomate, American Board of Endodontics and American Board of Legal Medicine, Past President American College of Legal Medicine, Vice Chair NY State Board of Dentistry, Legal Consultant in Dentistry, and practices in Liverpool (Syracuse), New York can be reached at bseidberg@me.com

Endodontic practice 1

INTRODUCTION

May/June 2015 - Volume 8 Number 3

Extraction versus retention: stretching the boundaries

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TABLE OF CONTENTS

Clinical

Practice profile Allen Ali Nasseh, DDS, MMSc

Nonsurgical retreatment of a central incisor following dental trauma Dr. John Rhodes presents a nonsurgical retreatment of a central incisor that had previously suffered trauma..............................................16

Lights, camera, endo!

Case study

A case featuring Mani Silk Dr. Rich Mounce discusses a new anatomy-based, efficient, safe, and predictable system...........................22

Research

Frequency of location of a second mesiobuccal canal in maxillary first and second molars treated in a postgraduate endodontic program

Corporate insight A new paradigm in endodontics

Drs. Matthew Palazzolo, Kim Petkovich Vaglio, Stephen Clark, and Jennifer Osborne Rudy, MA, RDH ........................................................24

Sonendo速 and transformative product development: an interview with Joseph Maggio, DDS

ON THE COVER Background photo on cover courtesy of Dr. Richard Mounce. Article begins on page 22.

4 Endodontic practice

Volume 8 Number 3

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TABLE OF CONTENTS

Continuing education Use and abuse of antibiotics in endodontics Dr. Eoin Mullane examines the correct clinical use of antibacterial drugs in endodontics.....................................36

AAE preview......................40 Abstracts The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-todate with the most relevant research ....................................................... 46

Continuing education

The thick slice technique: a virtual periapical radiograph

Dr. Richard S. Kahan explores the benefits of using advanced CBCT techniques in radiographic comparison and illustrates its use in a clinical case

Endodontic insight Understanding what ROI is really about Dr. Brian Trava explains how ROI relates to CBCT technology..............48

Step-by-step Optimal office design and planning with ASI How to achieve a high-end look for the state-of-the-art endodontic treatment room.................................49

6 Endodontic practice

Step-by-step

Endospective

Anastomotic wound management The new Micro 1 x 2 tying forceps with thumb lock from Laschal................. 52

“Rich, I ain’t workin’ for free anymore.” Dr. Rich Mounce explores the good, the bad, and the ugly of being a key opinion leader...................................55

Product profile EndoUltra’s™ effective ultrasonic activation is a game changer .......................................................54

Materials & equipment .........................56

Volume 8 Number 3

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PRACTICE PROFILE

Allen Ali Nasseh, DDS, MMSc Lights, camera, endo!

What can you tell us about your background? I was born in Iran but left with my family after the 1979 revolution. We lived in Brussels, Belgium, for several years where I went to school before I moved to the United States at the age of 16. I finished high school in Los Angeles and majored in biochemistry in college. I then moved to Chicago in 1990 to attend dental school at Northwestern University Dental School. I moved to Boston in 1994 to complete my endodontic training at Harvard School of Dental Medicine in 1997. There I also received a Master in Medical Sciences in the area of bone biology following 3 years of research in an orthopedic laboratory at Boston Children’s Hospital. Immediately after graduation, I began teaching in Harvard’s Post-Doctoral Endodontic Program and began clinical practice as an endodontist in a large multi-specialty group practice. During early 2000, I built from scratch a solo endodontic practice called MicroSurgical Endodontics in downtown Boston. The practice quickly grew to four endodontists, and I continued to practice full time and teach part time. In 2008, I decided to go to film school for the next 4 years, to pursue another area I was passionate about. I also got married and had a son. In 2013, my program director at Harvard during my residency, Dr. Kenneth Koch, who had left Harvard in the 1990s to create a private endodontic education company called Real World Endo®, retired from his position as president and asked me to run the organization he had founded and developed with his business partner, Dr. Dennis Brave. I came on board as the Chief Executive Officer and President of Real World Endo in 2013 and began to apply my film and technology knowledge and mix it with my endodontic and pedagogical experience to develop Real World Endo’s next phase, when we 8 Endodontic practice

shared endodontic knowledge worldwide through the Internet.

When did you become a specialist and why? I was born into a dental family. My father is still a practicing oral surgeon! Growing up, I used to assist him with his surgeries and worked in his practice ever since I was a teenager. Therefore, I was destined for dentistry and specializing. In fact, I never considered anything else. Becoming a specialist was a natural progression of my dental education, and I’m very happy with how I managed to combine my two passions of dentistry and film.

Is your practice limited solely to endodontics, or do you practice other types of dentistry? My associates and I are all endodontists, and our practice, MicroSurgical Endodontics, is limited to surgical and nonsurgical root canal therapy.

Why did you decide to focus on endodontics? I chose endodontics because of its precision, delicacy, and the high level of dexterity required. I also found it an exercise in discipline and patience. Due to its emergency nature, it is a profession where immediate gratification may be gained by helping people in acute pain. I’m very happy I chose endodontics as a profession and find it fulfilling on many levels, the least of which is the flexibility it affords me to pursue my many other interests in life.

Do your patients come through referrals? Approximately 75% of our patients are referrals from colleagues; but we are particularly lucky to enjoy a high rate of referrals from our former patients and our reputation online. This is a testament to our “patient-based” philosophy of care at MSEndo that revolves around the idea of centering the care on each patient’s physical and emotional needs and focusing on patients’ complete satisfaction with our services as a measure of success Volume 8 Number 3

PRACTICE PROFILE versus the mere radiographic results we can achieve clinically. We don’t pat ourselves on the back based on our radiographic results but how our patients feel about the care we have rendered. All staff members, doctors, nurses, and front desk personnel in our office are rated anonymously by each patient at the end of a procedure based on his/her perception of the care and competence he/she experienced in our care. We constantly review these surveys and re-evaluate our own efforts in living up to our potential.

What training have you undertaken? I received an excellent endodontic education in the Harvard School of Dental Medicine’s PostDoctorate Endodontic Program where under the tutelage of Drs. Kenneth Koch and Robert White, I managed to get excellent clinical and academic training in the field. Although this program is a year longer than other programs, I found it a worthwhile investment for my particular interest in teaching and sharing what I know with others. I have stayed active at Harvard and have been on faculty in the post-doc endo program since graduation. I am also involved with the Alumni department, where I currently am the Editor of the Harvard Dental Bulletin.

Who has inspired you? I have been most inspired by my parents, whose complete dedication to their children set the bar very high in my personal life and my own relationship with my son. Today, I’m also inspired by my work and the great opportunity I have to work with a remarkable team of faculty endodontists at Real World Endo. Our faculty’s teamwork and dedication to teaching and sharing their knowledge is remarkable.

What is the most satisfying aspect of your practice? The most satisfying aspect of my practice is having implemented consistent systems in order to achieve that “wow” factor from our patients after experiencing our service. I promise a painfree root canal procedure to my patients, and since I taught anesthesia and head and neck anatomy at Harvard Dental School for many years, I sincerely believe that this is a predictably deliverable promise to all patients. I am most satisfied when my patients affirm my promise at the end of each procedure.

Professionally, what are you most proud of? I’m proud of my staff and having great relationships with my referring sources and our patients. I’m also proud of being able to consistently deliver the optimal results that are expected of us in challenging cases. 10 Endodontic practice

Volume 8 Number 3

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PRACTICE PROFILE What do you think is unique about your practice? We are a very small, boutique type of an endodontic practice and do not treat a large volume of patients on a daily basis. We work with a small group of highly reputable restorative dentists and provide them and our patients with the highest quality of service. Our office consists of only three staff members whom we value greatly, and they, in turn, make every effort to provide a warm, caring atmosphere. Therefore, although our procedures are very efficient, we take plenty of time to make sure patients are comfortable and at ease before, during, and after the procedure. We try to treat patients as guests in our house and not customers. We try to get to know them and are genuinely concerned about the interesting and highly diverse group of patients we have the privilege of treating.

What has been your biggest challenge? My biggest challenge has been to balance the inordinate amount of time that running a practice and an educational company consumes with the many other diverse interests I have both professionally and personally.

What would you have been if you had not become a dentist? Iâ&#x20AC;&#x2122;ve always been a fan of both science and arts. On the one hand, I may have become a biochemist and, on the other, a cinematographer or filmmaker. But I enjoy science the most and am constantly trying to combine such interests in the context of education.

What is the future of endodontics and dentistry? I think the foreseeable future of dentistry and endodontics is great. It is true that pressures from different directions may somewhat affect the amount and availability of endodontic cases in the future, but people still have the common sense to try to preserve their own dentition. And so long as we have people who want to save their teeth, we can provide them endodontic services to achieve their needs. At some point down the line, however, I hope that science will come through, and we are able to replace our missing or damaged teeth with their biological counterparts. I believe that the future will involve regenerative sciences for organ replacement, and missing teeth will likely be a prime candidate

for such procedures. This will be a great service for those in need.

What advice would you give to a budding endodontist? What are your top tips for maintaining a successful specialty practice? My advice to any young endodontist and the secret to my own practice success are to establish a patient-based endodontic practice. What I mean by that is that in dental school and even in the endo program, we only get trained in how to treat teeth. But itâ&#x20AC;&#x2122;s only when we learn how to treat people as a whole and not just their teeth that we fully reap the rewards of our potential as healthcare providers. Improving our Emotional Quotient (EQ) alongside our Intelligence Quotient (IQ) will go a long way to in making

View outside MicroSurgical Endodontics 12 Endodontic practice

Volume 8 Number 3

What are your hobbies, and what do you do in your spare time? My problem is that I have more hobbies and interests than spare time! Primarily, I love traveling and learning. I enjoy going somewhere new and discovering things I did not know. As a filmmaker, I enjoy creating travel videos and regularly help my filmmaker friends with their professional gigs such as commercials or short features. I’ve sold some of my own travel and documentary work to television and airlines. Obviously, I also make videos for our educational company Real World Endo. It’s now becoming a large

Volume 8 Number 3

library of educational videos at https://realworldendo.com/videos, and I intend to grow it over the next year. I also do quite a bit of photography, painting, and mixed media art in my spare time. On the athletic front, I play competitive squash year-round in the A ladder. I also swim and play tennis during the summer. I love listening to podcasts and music throughout the day. I consider teaching as a hobby. I’ve been teaching at the Harvard endo program since its inception 2 decades ago, which has greatly enriched

my life by trying to give back to my profession and share my experiences with my future colleagues. I have been consistently taking night classes at Harvard Extension School since 1996 on every conceivable scientific and non-scientific subject (from art history to astrophysics!). Now that I’m a father of a 6-year-old, however, many of my hobbies are taking a second seat to spending time with my son and developing him into a productive young man. I now hope to teach what I have learned to my son, Darian. EP

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Endodontic practice 13

PRACTICE PROFILE

us more successful. Treating patients rather than teeth and radiographs is not only the recipe for success, but also the recipe for obtaining happiness and fulfillment from our daily professional experience. Addressing patients’ concerns from their point of view, being sympathetic to their needs and demands, and providing an environment filled with sympathy, warmth, and respect are at the core of our mission statement and what we try to achieve as a team.

CORPORATE INSIGHT

A new paradigm in endodontics Sonendo® and transformative product development: an interview with Joseph Maggio, DDS Company mission and history Sonendo’s mission is to lead the transformation of endodontics through Sound Science®. At its core, Sound Science means that the company is committed to ensuring that its product development is based on sound scientific research and extensive proof source. Furthermore, Sonendo will continue to leverage its innovative approach to sound and its use in endodontics — as it works to bring this disruptive new technology to the endodontic community. Sonendo is a privately held company located in Laguna Hills, California, that currently employs more than 100 people. Sonendo was founded in 2006 by life science focused accelerator Fjord Ventures, LLC. President and CEO Bjarne Bergheim collaborates with a scientific advisory board that includes Scott Arne, DDS, FAGD; Gerald Glickman, DDS; Markus Haapasalo, DDS, PhD; Asgeir Sigurdsson, Cand. Odont., DDS, MS, Cert. Endo (UNC); and Ove Peters, DMD, MS, PhD. “Our goal is to transform endodontics by improving the clinical quality and business performance of practices performing root canal therapy,” said Bjarne Bergheim, President and Chief Executive Officer of Sonendo.

“Our goal is to transform endodontics by improving the clinical quality and business performance of practices performing root canal therapy.” — Bjarne Bergheim, President and CEO of Sonendo

14 Endodontic practice

Joseph Maggio, DDS

Q&A with Dr. Maggio With more than 40 years of experience in the industry, Dr. Joe Maggio has dedicated his professional career to the field of endodontics. During that time, he has been an advocate of breakthrough technology as a way to improve clinical outcomes. In the following Q&A, Dr. Maggio, a former President of the American Association of Endodontics (1988-89), shares his lessons learned with freelance writer and editor Len Hall.

You’ve agreed to present SONENDO’s research at this year’s AAE meeting in Seattle. What inspired you to do so? I’m inspired by the out-of-the-box, exponential thinking by the Sonendo team in the development of its technology, particularly its approach to product development and product refinement. I’ve worked in endodontics for more than 40 years, and I’ve seen new technology develop in different stages. But over the years, Volume 8 Number 3

The GentleWave™ System Volume 8 Number 3

“Sonendo has brought exponential thinking to its product development, and the result is a new technology that is truly disruptive and a product that is truly transformative.” — Dr. Joe Maggio

With GentleWave’s Multisonic Ultracleaning™ technology, we can kill bacteria deep into the dental tubules and remove biofilm from root canal anastomes, and all of it needs to be cleaned and disinfected for proper healing to be achieved. Basically, all of the tissue from inside the entire root system is removed. In terms of exponential thinking, a great analogy is the famous Fosbury Flop high jump in track and field. American high jumper Dick Fosbury, for the first time challenged the conventional thinking — he wanted to jump over the bar backwards, head first rather than feet first. He was challenging the conventional thinking, but he had to wait until there was a new kind of padding in the highjump pit before he could move forward. In other words, you have to have an open mind to challenge conventional thinking and technology. That’s what Dick Fosbury did, and it’s exactly what Sonendo is doing with the GentleWave technology. What lessons have you learned over your career when it comes to evaluating technology? Again, over 40 years in endodontics, I have seen new products come and go, but what’s also new with the GentleWave System is the company’s approach to bringing it to market. The GentleWave System has been in development since 2006, and Sonendo has adopted a “perfect and launch” approach through Sound Science®. Typically, advances in dentistry have been made through what I call the “ship and test” method. You develop a new product and ship it to dentists who become the testers. But the problem was so many changes didn’t actually work in real practice. Once they were used on a real patient, they didn’t perform as they were designed. Sonendo has taken an entirely different approach. They have worked diligently on perfecting the product first, using well-known researchers and institutions of higher learning

to help them do the evaluating and testing, especially in terms of cleaning and disinfection, as well as, outcome. The GentleWave System is FDA cleared, and the testing has been done before the launch, which is the right way to bring a product to market. The exciting thing about the GentleWave System is that it’s an entirely new technology — using Multisonic Ultracleaning energy to clean a root canal system. There is a learning curve, although not a difficult one. You need a little more of a technical sense to understand what Sonendo has done and a little time to think about how to approach it, but if endodontists have an open mind, and clearly evaluate the technology, I think everyone will be excited to see it succeed. Ultimately, I believe the results will be much better for the patients we treat. Do you have any final thoughts? I’m very excited that I’ve been given the opportunity to present the results of the research on the GentleWave System at the annual meeting of the American Association of Endodontists (AAE), which this year will be held from May 6-9 at the Washington State Convention Center in Seattle. My corporate forum presentation, titled “A New Paradigm in Endodontic Therapy: GentleWave™, will be held at 10 a.m. Friday, May 8, in the Exhibit Hall. Visitors should also plan on visiting Sonendo Booth No. 133 at the meeting. Anyone visiting will be able to view the GentleWave System, understand and see the science behind it, and take part in demonstrations. I look forward to the meeting and the opportunity to talk about the exciting innovations going on at Sonendo. Sonendo has grown from a concept in 2006 to its selective commercial release today. The device is FDA cleared. For more information, visit www.sonendo.com or info@ sonendo.com. EP This information was provided by Sonendo®.

Endodontic practice 15

CORPORATE INSIGHT

while our tools have become progressively better, the conventional thinking in dental has been linear, and as a result, product development has remained mostly incremental. The changes in technology never went far enough to actually change our techniques. For instance, we have seen a steady advancement in files. First they were made out of carbon steel, then stainless steel, and then nickel titanium, which allowed us to use them in a rotary fashion, which gave us the ability to turn them 360 degrees. After rotary came reciprocation, which allowed us to turn the files clockwise as well as counterclockwise. That type of incremental development certainly improved the file itself, but we were still limited by our inability to remove tissue, bacteria, and to clean complex canal anatomies within the root canal system. The best we could do was to clean the main canals where the file and needle can reach, but we could not deliver adequate cleaning and disinfection elsewhere. Remember that a root canal is a system of complex anatomies. For the first time now, thanks to Sonendo and the GentleWave™ System, we are thinking outside of the box. Sonendo has brought exponential thinking to its product development, and the result is a new technology that is truly disruptive and a product that is truly transformative.

CLINICAL

Nonsurgical retreatment of a central incisor following dental trauma Dr. John Rhodes presents a nonsurgical retreatment of a central incisor that had previously suffered trauma

20-year-old woman was referred suffering from occasional, spontaneous toothache around the maxillary right central incisor (UR1). This radiated to an area underneath the nose and varied in intensity but could be sufficiently bad enough to disrupt normal activity, such as driving a car. She was unable to bite on the tooth without discomfort. When she was 9 years old, she had tripped and fallen onto a post, traumatizing the UR1 and causing an enamel-dentin fracture that did not expose the pulp. From the patient’s perspective, everything appeared to be fine until about 3 years after the accident when the UR1 started to become painful to bite on, and the gum was sore. The general dental practitioner root filled the tooth, and it settled down. More recently, this young lady had become very conscious of the tooth darkening and sought the opinion of a new dentist to see whether a veneer was feasible. When a periapical radiograph was exposed, it showed a poor root filling and large apical radiolucency, and at this point, the patient was referred to an endodontic specialist, in line with good practice (General Dental Council, 2013). Her medical history was uncomplicated, and apart from an allergy to penicillin, she was fit and well. This article describes the nonsurgical retreatment of a central incisor that had previously suffered trauma. The immature root was managed using a biological approach with micro-endodontic techniques.

Clinical examination Intraoral examination revealed that the UR1 was tender to palpation. It was not abnormally mobile nor was it ankylosed. The color was significantly darker than the

John Rhodes, BDS(Lond), FDS RCS(Ed), MSc, MFGDP(UK), MRD RCS(Ed), is a specialist in endodontics, author of textbooks and numerous papers, and owner of The Endodontic Practice in Poole and Dorchester, United Kingdom. He lectures and teaches on endodontics nationally.

16 Endodontic practice

Figure 1: Shows the maxillary anterior teeth. The UR1 is noticeably discolored

adjacent incisor teeth with a VITA equivalent shade of C3/C4 compared with healthy teeth at A2. Photographs were taken for patient records at this point. There was an incisal/ buccal composite restoration that was no longer a good color match and had visible margins. Soft tissue examination revealed no buccal swelling, but the mucosa was tender over the apex of UR1, and a sinus tract was present. Sensitivity testing with Hygenic® Endo-Ice® (Coltene) and electric pulp testing (SybronEndo Diagnostics Unit) revealed that the UR1 was the only non-vital incisor tooth. Paralleling periapical radiographs were exposed of the central incisor teeth using a Rinn Holder (Rinn, Dentsply), and all looked normal apart from the UR1. An attempt had been made to root fill the UR1, but the obturation material was significantly undercondensed in the apical third, and individual gutta-percha cones were visible. The dentist obviously had difficulty managing the large immature canal. They may also not have had confidence fitting the rubber dam on a 12-year-old, increasing the potential for bacterial contamination of the root canal. The coronal restoration provided an inadequate seal. The root length of UR1 was significantly shorter than the UL1, and a large radiolucent area was present at the apex. No evidence of replacement resorption, inflammatory resorption, or any root fractures could be detected.

Figure 2: A paralleling radiograph showing the root filling in UR1 and large periapical radiolucency

Diagnosis Although there was history of trauma, the most likely cause of current symptoms and clinical findings was periapical periodontitis. The root canal filling had most probably failed as a result of persistent bacterial infection in the root canal. The tooth had not undergone replacement or inflammatory resorption. Volume 8 Number 3

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CLINICAL Treatment options

Due to the history and chronicity of the infection, a two-visit strategy was adopted. This ensured adequate disinfection of the

root canal and the possibility to confirm healing of the sinus tract before obturation. Buccal infiltration of 4% articaine 1:100,000 adrenaline (Septodont) provided profound anesthesia, and the UR1 was isolated with latex rubber dam and a number one clamp. Using an operating microscope, the existing filling was removed with a longtapered diamond bur, and soft dentin (the result of microleakage) with a tunstgen carbide LN bur (Dentsply). This revealed a contaminated root canal containing poorly condensed gutta percha. The root filling was rapidly removed with Gates Glidden size 2 and Hedstroem file size 30 (Denstply). The loose gutta-percha points were washed out of the canal with sodium hypochlorite. The apical foramen of the canal was large (greater than a size 40 file) and could be visualized through the operating microscope. The coronal access was refined, and a working length estimation made with an apex locator (Endo Analyzer, Sybron) and size 40 FlexoFile® (Dentsply Maillefer). A steady zero reading was achieved, and this was confirmed by direct sight. Because the root had an immature morphology, there was no requirement for mechanical instrumentation. Instead, the canal was disinfected with a solution of heated 3% sodium hypochlorite (Teepol) irrigant, delivered using a safe-ended needle (Henry Schein®) bent short of the working length to prevent extrusion. Disinfection was carried out over approximately 40 minutes. The sodium hypochlorite was agitated with a size 20 IRRISAFE™ ultrasonic tip (Satelec) and an EndoActivator® (Dentsply) with a blue tip. The solution was replenished every 2 minutes. A final sequence with 40% citric

Figure 4: Endoperox, a carbamine peroxide material for internal bleaching

Figure 5: The completed restoration following bleaching

1. Root canal retreatment and restoration with composite 2. Extraction and replacement with a Maryland bridge or implantsupported crown The prognosis for root canal retreatment should be good, and the patient could expect the tooth to remain functional for many years. Replacement at an early age with an implant may provide a good cosmetic result initially, but over a lifetime, the result would be difficult to predict. Generally, well root-filled and restored teeth appear to function as well as single tooth implants and result in less costly repairs when things fail (Hannahan and Eleazer, 2008; Pennington, et al. (2009); Torebinejad, et al., 2007). The dark color of the tooth (and the main complaint of the patient) could be improved by: 1. Internal bleaching 2. Internal/external bleaching using trays 3. Placement of a veneer in composite or porcelain 4. Placement of a crown Bleaching techniques are low risk and non-invasive (Zimmerli, Jeger, and Lussi, 2010). Bleaching would, therefore, be the preferred means of improving tooth color. Matching the texture and color of adjacent teeth with a porcelain or composite veneer on a single tooth would be esthetically challenging and preparation of a crown unjustifiably destructive. After discussion with the patient, an internal-bleaching technique was the option of choice.

Treatment

18 Endodontic practice

acid (Cerkamed) and 3% sodium hypochlorite completed irrigation. The canal was dried with sterile paper points (Dentsply) and non-setting calcium hydroxide placed (Calasept®). The access was sealed with a cotton wool pellet at the level canal orifice, Cavit™ (3M ESPE) and Fuji IX (GC). One week later, the sinus had healed, the tooth was symptom free, the canal dry, odorfree, and the tooth ready for obturation. The apical portion of the canal was sealed with Biodentine® (Septodont), packed into place using a Machtou plugger with the microscope providing direct vision. On top of this, a layer of IRM® (Dentsply) was placed. Endoperox (Septodont) internal whitening agent was mixed and packed into the access cavity. This was then sealed with Fuji IX compomer.

Figure 3: A microsope view into the access cavity; IRM has been placed over the Biodentine to act as a barrier for placement of bleaching material

Volume 8 Number 3

CLINICAL

A week later, the tooth was reviewed. The tooth was symptom-free and the patient was happy with the color, so the access was permanently restored with Fuji IX, light-cured bulk fill composite SDR® (Smart Dentine Replacement, Dentsply) and Ceram-X™ Duo (Dentsply). The incisal tip was restored with Ceram-X duo. The tooth was reviewed at 3 months, when it was symptom and sign-free, and a paralleling radiograph showed good evidence of early bony healing at the apex. A further review will be carried out at 1 year, and subsequently, at 2 years and 4 years.

Discussion The International Association for Dental Traumatology (IADT) has produced guidelines for the management of traumatic injuries to teeth, available online as the Dental Trauma Guide (2010). The recommended treatment for an enamel-dentin fracture is as follows: 1. If a tooth fragment is available, it can be bonded to the tooth. Otherwise, perform a provisional treatment by covering the exposed dentin with glass-ionomer or a permanent restoration using a bonding agent and composite resin. 2. The definitive treatment for the fractured crown is restoration with accepted dental restorative materials. 3. Three angulations (periapical, occlusal, and eccentric exposures) should be used in the radiographic examination to rule out displacement or fracture of the root. 4. Radiograph of lip or cheek lacerations to search for tooth fragments or foreign material. 5. Follow-up — clinical and radiographic control at 6 to 8 weeks and 1 year. The importance of checking adjacent teeth cannot be over emphasized as it is not uncommon for collateral damage to have occurred as a result of trauma. Data from the dental trauma guide shows prognosis for an enamel-dentin fracture at 1 to 3 years to be very good, with the risk of pulp necrosis to be only extremely low. This suggests that the initial injury in this case may have been more severe. The root length of UR1 was shorter than UL1 and the root morphology immature, suggesting that root development had stalled shortly after injury. Ravn (1981) evaluated the prognosis for permanent incisors with enamel-dentin fracture only and those with enamel-dentin Volume 8 Number 3

Figure 6: A radiograph showing the completed nonsurgical retreatment. There is good homogeneity between the various layers of material

Figure 7: The review radiograph at 3 months shows evidence of a reduction in the size of the periapical radiolucency. This, combined with absence of clinical signs and symptoms, indicates good early signs of successful treatment

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Endodontic practice 19

CLINICAL fracture combined with other factors. Pulp death occurred in 3.2% of teeth with enameldentin fracture as the only damage. Enameldentin fracture and concussion resulted in pulpal necrosis in 5.8%, and cases involving both concussion and mobility showed pulpal necrosis in 30.1% of teeth. Teeth with combined intrusion injuries would have a much higher incidence of pulp necrosis (67.6% at 1 year and 70.9% at 3 years), inflammatory root resorption approximately 35% at 1 and 3 years, and ankylosis 8.8% at 1 year, and 12.1% at 3 years (Diangelis, et al., 2012). This confirms the requirement for meticulous examination of dental trauma cases and the potential risk of combined injuries. Compliance of the patient and parents to attend review is critical. Limited volume, high resolution cone beam tomography can be useful in the assessment of trauma cases and the detection of resorption defects in endodontics. Evidence-based guidelines for the clinical use of CBCT, known as the European Commission Radiation Protection guidelines (SEDENTEXCT 2012), and those from the American Association of Endodontists (2011) both recommend that the need for a CBCT scan should always be assessed after a risk versus benefit analysis before each exposure. In this case, the tooth had been traumatized 11 years earlier; it was not ankylosed and showed no sign of inflammatory resorption clinically or on radiograph. The risk of both following trauma is highest in the first 3 years (Diangelis, et al., 2012). It was therefore considered more likely that the tooth had become necrotic after injury, and the radiolucent area was the result of apical periodontitis; this was also confirmed by the presence of a sinus tract. The root canal was likely to be infected with bacteria so there was no indication to expose a CBCT scan at this stage. It is important in root canal retreatment to remove the failed root canal filling material as efficiently as possible to allow disinfection of the root canal (Van Nieuwenhuysen, Aouar, and D’Hoore, 1994). During retreatment, the existing material and any obstructions and missed canals should be prepared and disinfected at the first visit.

Two-visit approach Historically, it has been shown that mechanical preparation alone reduces the bacterial load in an infected root canal, according to Byström and Sundqvist, (1981), but sodium hypochlorite in a concentration of 20 Endodontic practice

at least 1% is required to kill any remaining bacteria (1983). Sodium hypochlorite also dissolves necrotic pulp tissue. The bacteria are present in planktonic form and as a biofilm. The bacteria in biofilms are surrounded by matrix and can be difficult to remove. The irrigant must therefore be agitated to break up these bacterial aggregations. Ultrasonic activation removes more debris form the root canal than syringe irrigation alone (Burleson, et al., 2007). A solution of 17% EDTA or citric acid as a final rinse (Byström and Sundqvist, 1985) is used to remove smear and has a positive benefit on outcome in retreatment cases (Ng, Mann and Gulabivala, 2011). In this case, the root canal had an immature morphology, and the terminal foramen was greater than a size 40 file. There was no requirement to carry out mechanical instrumentation as the canal was already sufficiently large to allow adequate irrigant interchange. Instead, the irrigant was activated with an ultrasonic tip, which was lightly brushed against the walls and oscillated passively in the lumen of the canal with the hope of inducing acoustic microstreaming (Ahmad, Pitt Ford, and Crum, 1987). The aim was to break up biofilm and remove contaminated surface layers of dentin. Dressing the canals (after preparation and disinfection) with calcium hydroxide for 7 days was shown to be effective at producing bacteria-free canals and so evolved the concept of a two-visit strategy using a chemomechanical approach (Byström, Claesson, and Sundqvist, 1985; Sjögren, et al., 1991). More recently, universal use of a twovisit approach has been questioned. Peters and colleagues (2002) concluded that a calcium hydroxide and sterile saline slurry limits but does not totally prevent regrowth of endodontic bacteria. Hargreaves in a systematic review of the literature reported that multiple visits with calcium hydroxide treatment did not improve upon clinical outcome, and there was a minimal level of evidence for considering one versus two appointments in nonsurgical endodontics (2006). Indeed, a single visit approach is used by many endodontists for many cases with no apparent repercussions for the patient nor reduced prognosis (Ng, Mann, and Gulabivala, 2011). However, not all cases are ideally suited to a single visit approach, and a two-visit strategy was adopted in this case to confirm resolution of the sinus tract before obturation and bleaching. The immature root canal morphology can be challenging to obturate. Lateral

condensation is difficult even with customized gutta-percha points, and excessive lateral pressure could potentially damage the thin root. Vertical compaction of gutta percha could result in extrusion of material unless a barrier or matrix is used at the terminal foramen. With the aid of an operating microscope, the terminus of the canal can often be visualized, and controlled placement of materials such as MTA (Dentsply) or Biodentine (Septodont) can be achieved. Bioceramics such as these have excellent sealing abilities and have many reported uses in endodontics, including management of open apices (Parirokh and Torabinejad, 2010). It was possible in this case to accurately place Biodentine without using a collagen matrix at the apex. Tooth discoloration occurs as a result of the formation of chemically stable chromogenic products; these are oxidized during bleaching. Most discolorations can be reliably bleached apart from those that result from metal ions (Plotino, et al., 2008). Tooth whitening following root canal treatment can be carried out using an internal bleaching technique (walking technique) with materials such as sodium perborate, or carbamine peroxide sealed in the access cavity (Zimmerli, Jeger, and Lussi, 2010), or via an internal/external approach with carbamine peroxide solutions (Poyser, Kelleher, and Briggs, 2004). According to Carraso and colleagues, carbamide peroxide has been shown to have the best penetration into dentin (2003) and the walking technique a better outcome than in-office bleaching (Dietschi, Rossier, and Krejci, 2006). The internal/external technique requires the fabrication of bleaching trays, and the access cavity can become contaminated with food particles and debris during use. Endodontic bleaching has been cited as a possible cause of external cervical resorption (Heithersay, 1999); however, the eiology of this condition is not entirely clear. Defects in the cementum layer could potentially allow hydrogen peroxide from the pulp chamber to reach the external root surface and induce an inflammatory response (Rotstein, Torek, and Misgav, 1991). Subsequent damage to the periodontium could therefore result in cervical resorption. Avoiding placement of internal bleaching agents below the cemento-enamel junction, checking for cervical lesions, and not using heat should prevent external cervical resorption (Patel, Kanagasinam, and Pitt Ford, 2009). After checking to make sure that there were no cervical defects, intermediate Volume 8 Number 3

11.

European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J. 2006;39(12):921–930.

22.

Peters LB, van Winkelhoff AJ, Buijs JF, Wesselink PR. Effects of instrumentation, irrigation and dressing with calcium hydroxide on infection in pulpless teeth with periapical bone lesions. Int Endod J. 2002;35(1):13-21.

12.

General Dental Council (2013) Standards for the Dental Team. [Online]. Available at: <http://bit.ly/1avam3q> [Accessed: April, 2015].

23.

Plotino G, Buono g, Grande NM, Pameijer CH, Somma F. Nonvital tooth bleaching: a review of the literature and clinical procedures. J Endod. 2008;34(4): 394-407.

13.

Hannahan JP, Eleazer PD. Comparison of success of implants versus endodontically treated teeth. J Endod. 2008;34(11):1302–1305.

24.

Poyser NJ, Kelleher MG, Briggs PF. Managing discoloured non-vital teeth: the inside/outside bleaching technique. Dent Update. 2004;31(4):204-210, 213-214.

14.

Hargreaves KM. Single-visit more effective than multiplevisit root canal treatment? Evid Based Dent. 2006;7(1): 13–14.

25.

Ravn JJ. Follow-up study of permanent incisors with enamel-dentin fractures after acute trauma. Scand J Dent Res. 1981;89(5):355-365.

15.

Heithersay GS. Invasive cervical resorption: an analysis of potential predisposing factors. Quintessence Int. 1999;30(2):83-95.

26.

Rotstein I, Torek Y, Misgav R. Effect of cementum defects on radicular penetration of 30% H2O2 during intracoronal bleaching. J Endod. 1991;17(5):230-233.

16.

International Association of Dental Traumatology, Rigshospitalet Denmark (2010) The Dental Trauma Guide. [Online]. Available at: <http://www.dentaltraumaguide. org> [Accessed March, 2015]

27.

17.

Lim KC. Considerations in intracoronal bleaching. Aust Endod J. 2004;30(2):69-73.

SEDENTEXCT (2012) European Commission. Radiation Protection No 172: Cone beam CT for dental and maxillofacial radiology (Evidence based guidelines). [Online]. Available at: http://www.sedentexct.eu/files/radiation_ protection_172.pdf [Accessed April, 2015].

28.

18.

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.

Sjögren U, Figdor D, Spångberg L, Sundqvist G. The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. Int Endod J. 1991;24(3): 119–125.

29.

Torabinejad M, Anderson P, Bader J Brown LJ, Chen LH, Goodacre CJ, Kattadiyil MT, Kutsenko D, Lozada J, Patel R, Petersen F, Puterman I, White SN. Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures and extraction without replacement: a systematic review. J Prosthet Dent. 2007;98(4):285-311.

30.

Van Nieuwenhuysen JP, Aouar M, D’Hoore W. Retreatment or radiographic monitoring in endodontics. Int Endod J. 1994;27(2):75-81.

31.

Zimmerli B, Jeger F, Lussi A (2010) Bleaching of Non-vital teeth. A clinically relevant review. Schweiz Monatsschr Zahnmed. 2010;120(4):306-320.

19.

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

20.

Patel S, Kanagasingam S, Pitt Ford T. External cervical resorption: a review. J Endod. 2009;35(5):616-625.

21.

Pennington MW, Vernazza CR, Shackley P, Armstrong NT, Whitworth JM, Steele JG. Evaluation of the costeffectiveness of root canal treatment using conventional approaches versus replacement with an implant. Int Endod J. 2009;42(10) 874-883.

Conclusion This case highlights the management and diagnosis of periapical periodontitis in a tooth that suffered dental trauma 11 years previously. Nonsurgical micro-endodontic techniques were used to retreat the immature root morphology. No mechanical instrumentation was required, and the immature root was sealed with Biodentine. Internal bleaching as a non-invasive means of restoring natural color was demonstrated in this non-vital tooth. EP REFERENCES 1.

Ahmad M, Pitt Ford TJ, Crum LA (1987) Ultrasonic debridement of root canals: acoustic streaming and its possible role. J Endod. 1987;13(10):490-499.

American Association of Endodontists and American Academy of Oral and Maxillofacial Radiology. Use of cone-beam computed tomography in endodontics Joint Position Statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(2), 234-237.

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.

Byström A, Claesson R, Sundqvist G. The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment of infected root canals. Endod Dent Traumatol. 1985;1(5):170-175.

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

Byström A, Sundqvist G. Bacteriologic evaluation of the effect of 0.5 percent sodium hypochlorite in endodontic therapy. Oral Surg Oral Med Oral Pathol. 1983;55(3):307-312.

Byström A, Sundqvist G. The antibacterial action of sodium hypochlorite and EDTA in 60 cases of endodontic therapy. Int Endod J. 1985;18(1):35-40.

Carrasco LD, Froner IC, Corona SA, Pecora JD. Effect of internal bleaching agents on dentinal permeability of non-vital teeth: qualitative assessment. Dent Traumatol. 2003;19(2): 85-89.

Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, Andersson L, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Pohl Y, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012;28(1):2-12.

10.

Dietschi D, Rossier S, Krejci I. In vitro colorimetric evaluation of the efficacy of various bleaching methods and products. Quintessence Int. 2006;37(7): 515-526.

Volume 8 Number 3

Endodontic practice 21

CLINICAL

restorative material was placed over the gutta-percha root filling material and at the cervical level of the root canal. Sodium perborate mixed with water is considered safer than hydrogen peroxide as an intracoronal bleaching agent, and 35% carbamide peroxide (urea peroxide) combines the safety of sodium perborate together with the efficacy of 35% hydrogen peroxide (Lim, 2004). In this case, an internal bleaching technique was used with a commercially available material — Endoperox (Septodont), a carbamine peroxide material. The case was reviewed at 3 months and will continue to be reviewed at 1 year, 2 years, and 4 years posttreatment (European Society of Endodontology, 2006).

CASE STUDY

A case featuring Mani Silk Dr. Rich Mounce discusses a new anatomy-based, efficient, safe, and predictable system

his article was written to describe the clinical use of the new and novel Mani Silk (MS) nickel-titanium instrumentation system, now available in North America. MS is unique and a welcome addition to the endodontic marketplace. MS is: 1. Anatomy based. MS is packaged into Simple (relatively straight canals), Standard (moderate curvature, no calcification), and Complex pack configurations (moderate to severe curvature and/or calcification present) to treat the anatomy encountered. Clinically, the tooth is assessed, and the matching MS is chosen to address the given anatomy with a minimum number of files (three total). 2. Heat treated from the tip of the file through the first 10 mm of the cutting flutes — providing increased fracture resistance and flexibility where needed. 3. “Teardrop”-shaped in cross section. This design channels debris out of the canal efficiently and centers the file (maintaining the canal path) while minimizing transportation. In addition, the teardrop cross-section decreases the “screwing in” effect and simultaneously improves tactile sensation. 4. Easily integrated for use with the entire spectrum of Mani stainless hand files.

and .06/30 instruments. The Standard pack contains a .08/25, .06/20, and .06/25 instruments. The Complex pack contains the .08/25, .04/20, and .04/25 instruments. These three canal packs can shape virtually any canal. MS instruments are also available (3 files/pack) in the following individual sizes: .04/20, .04/25, .04/30, .04/35, .04/40, .06/20, .06/25, .06/30, .06/35, .06/40, and .08/25. All pack configurations and individual sizes are available in 21 and 25 mm. Orifice openers are also available in 18 mm lengths. MS is rotated at 500 rpm and 300 g-cm torque. Any torque-controlled endodontic motor can power MS. MS instruments have a constant taper (.08, .06, .04). The file is electropolished for increased fatigue fracture resistance.

Mani Silk clinical technique After straight-line access and removal of the cervical dental triangle with the MS orifice opener (.08/25), the canal is negotiated and the glide path created. After glide path preparation, MS is utilized as a two-file system (after the use of the orifice opener)

Figure 1A: The Mani Silk Simple pack configuration. The Simple pack includes (from left to right) a .08/25 orifice opener, .06/25, and .06/30 instruments.

Figure 1B: The Mani Silk Standard pack configuration. The Standard pack includes (from left to right) a .08/25, .06/20, and .06/25 instruments.

Figure 1C: The Mani Silk Complex pack configuration. The Complex pack includes (from left to right) the .08/25, .04/20, and .04/25 instruments.

Mani Silk system description MS packs have three files: The Simple pack configuration contains .08/25, .06/25,

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. He can be reached at RichardMounce@ MounceEndo.com, MounceEndo.com. Twitter: @MounceEndo. Disclosure: Dr. Mounce is a Mani dealer. He is a clinical consultant for Mani dental and receives an honorarium for this work.

22 Endodontic practice

Volume 8 Number 3

CASE STUDY

Figure 1D: The identification marks for Mani Silk

Figure 2: Case using Mani Silk

that can either be rotated or reciprocated (clockwise). When using the Simple pack, the .06/25 is followed by the .06/30. When using the Standard pack, the .06/20 is followed by the .06/25. When using the Complex pack, the .04/20 is followed by the .04/25. Specifically, for each of these sequences, the two files listed above are successively alternated until the desired taper is achieved to the true working length. If clinicians wish to prepare a larger apical diameter, they are able to do so using the individual sizes available for this purpose (.04/30, .04/35, .04/40, .06/30, .06/35, .06/40).

Case study

Figure 1E: The unique flute design of Mani Silk, .06/25 illustrated Volume 8 Number 3

In the case illustrated in Figure 2, straight-line access was prepared through the existing initial amalgam. The canals were negotiated with Mani K files (Nos. 6, 8, 10, 15, 20) and Mani Medium Files (Nos.12, 17). As an aside, where needed, Mani D Finders are an excellent option for negotiation of severely curved and calcified canals as Mani D Finders are much stiffer than standard K files. Both Mani K files and D Finders can be reciprocated by use a reciprocating handpiece like the ER-10 (NSK). Specifically, in the case illustrated, the Mani No. 6 K file was inserted to the apex first, followed by the Nos. 8, 10, 12, 15, 17, 20 Mani hand files and reciprocated with the ER-10 (NSK) to prepare the glide path.

After glide path preparation, an MS Standard Pack was used to shape this case. The .06/20 and .06/25 were alternated until the .06/25 reached the true working length. The master apical diameter was subsequently prepared with the .06/30. Insertion of MS is gentle, passive and to resistance, taking approximately 3 seconds and shaping approximately 4-6 mm of canal space per insertion. After every insertion of MS, the canal was recapitulated with a No. 6 Mani K file, irrigated copiously, and the flutes of the file wiped. The used MS files were discarded per the manufacturerâ&#x20AC;&#x2122;s instructions. Canals can be obturated with MS using any clinically acceptable method. In this case, the tooth was obturated with the vertical compaction of warm gutta percha delivered through an E&Q Master Obturation Unit (MetaBiomed). After obturation, the remaining amalgam and all caries were removed. The preparation was microetched (Danville Materials) and bonded with Rock Core (Danville Materials) dual-cure build core material. This case study has discussed the use of the new and novel Mani Silk nickel-titanium instrument system. Emphasis has been placed on hand file negotiation of canals using Mani K and Mani Medium K files, the importance of achieving and maintaining patency, and glide path preparation to utilize Mani Silk in simple, predictable, and safe endodontic canal shaping. EP Endodontic practice 23

RESEARCH

Frequency of location of a second mesiobuccal canal in maxillary first and second molars treated in a postgraduate endodontic program Drs. Matthew Palazzolo, Kimberly Petkovich Vaglio, Stephen Clark, and Jennifer Osborne Rudy, MA, RDH, University of Louisville School of Dentistry Abstract Background: The presence of a second canal in the mesiobuccal root (MB2) of maxillary molars is well documented in the literature. The purpose of this retrospective study was to assess the frequency of location of the MB2 canal in maxillary molars and variables affecting MB2 location by endodontic residents in a postgraduate endodontic program. Methods: Electronic records and digital radiographs of patients treated in the post-graduate endodontic clinic between July 1, 2006, and June 30, 2013, were reviewed by two calibrated observers. Data collected included treating resident code, 1st-year/2nd-year resident, tooth number, patient age and gender, presence of preoperative crown, pulp vitality status, MB2 canal located (yes/no), initial treatment, or retreatment. MB2 was considered present if location was confirmed in the patient record and treatment radiographs. Pearson chi-square and one-way ANOVA were used for statistical analysis. Results: 1,929 maxillary molars treated by 18 endodontic residents were reviewed. Frequency of locating the MB2 was 57.6% Matt Palazzolo, DDS, MSD, received his dental degree at the University of Michigan and his MSD in endodontics at the University of Louisville. He currently practices endodontics in Georgia. Kimberly Vaglio, DDS, received her dental degree at the University of Missouri-Kansas City and is a 2nd-year endodontic resident at the University of Louisville. She plans to practice endodontics in Los Angeles, California. Ms. Jennifer Osborne Rudy, MA, RDH, is an Assistant Professor of Dental Hygiene at the University of Louisville. She teaches Research Methods and Statistics and is currently pursuing a PhD in Applied Sociology. Stephen Clark, DMD, is Professor of Endodontics at the University of Louisville and serves as Director of the postdoctoral endodontic program.

24 Endodontic practice

and ranged from 29.2%-71.8% among residents. Frequency of location of the MB2 was significantly greater by 2nd-year residents, with MB2 location by 51.9% of 1st-year residents compared to 61.9% by 2nd-year residents (p < 0.0001). Frequency of MB2 location was significantly lower in teeth with preoperative crowns (50.6% crown compared to 58.6% no crown (p < 0.05), while MB2 canal location was significantly higher in male patients Figure 1: An example of a maxillary molar with the MB2 canal treated by (66.2%) than females (51.8%), endodontic resident (Treatment by Dr. Annie Jones) p < 0.0001. Conclusion: Resident clinical experience MB2 is high under ideal in vitro conditions was associated with frequency of location and use of a microscope. of the MB2 canal. Preoperative crowns Some studies have also evaluated were associated with increased difficulty frequency of location of the MB2 canal in locating the MB2 canal. The MB2 canal was maxillary molars during clinical treatment. A found significantly more often in males than clinical study conducted by Fogel, et al.,5 females. found the MB2 to be present in 71.2% of maxillary first molars. They attributed the higher number of clinically located MB2 Background The successful outcome of nonsurgical canals to magnification, use of headlamps, root canal therapy is highly dependent upon and modified access preparations. location, thorough debridement, irrigation, Stropko3 reported finding the MB2 canal and obturation of all canals and final restoin 93% of maxillary first molars and 60% of ration. Several studies have attempted to maxillary second molars after he became determine the presence of a second mesiomore experienced, used the dental operating buccal canal (MB2) in maxillary molars. microscope, allowed sufficient time for canal Historically, roots were sectioned with location, and used instruments adapted for micro-endodontics. magnification in order to determine the presence or absence of MB2. Using this methUsing strict defined criteria for location odology, Weine, et al.,1 found the MB2 canal of the MB2, Wolcott, et al.,6 found in a 5in 52% of maxillary molars. year clinical investigation that the MB2 was located by six endodontists in 66% of first Kulild and Peters2 used a standard molars during retreatment, and 58% during access and hand instruments to find the initial treatment and in 40% of retreatments MB2 canal in 54% of 32 maxillary molars, and 34% during initial treatment in second then used long-shank endodontic round burs in the â&#x20AC;&#x153;subpulpal grooveâ&#x20AC;? to locate the MB2 molars. The authors suggested that failure in an additional 31%, and finally used a dental to find and treat existing MB2 canals can operating microscope after crown removal to decrease the long-term prognosis. locate the MB2 in another 10% for a total of Studies have also been done on MB2 95% of their sample presenting with an MB2. location in postgraduate endodontic Their results indicated that the presence of programs. Hartwell, et al.,7 reported that, Volume 8 Number 3

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

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RESEARCH within a postgraduate endodontic program, the MB2 was found in approximately 70% of 121 maxillary first molars. Corcoran, et al.,8 reviewed MB2 location in clinical cases by three endodontic residents during their first 6 months of training and again during their last 6 months. The junior residents located the MB2 canal in 37% of 78 first molars and 46% of 37 second molars, while senior residents located the MB2 in 62% of 82 first molars and 63% of 40 second molars. The authors concluded that operator experience plays a significant role in the location and treatment of the MB2 canal. A review of the above literature indicates that location of the MB2 canal varies greatly among practicing endodontists

and endodontic residents. The purpose of this retrospective clinical study was to assess the frequency of location of the MB2 canal by endodontic

residents in maxillary molars and evaluate variables affecting location frequency in a post-graduate endodontic program over a 6-year period.

Figures 2A-2B: A common finding in retreatment of the maxillary molar is a missed MB2 canal. A. Preoperative image. B. Postoperative image (Treatment by Dr. Joseph Platt)

Figures 3A-3C: Initially, the MB2 canal could not be located, but once the MB canal was enlarged, the tortuous MB2 canal could be found (Treatment by Dr. Brian Shaughnessy)

Figures 4A-4C: Angled radiographic images are often necessary to be able to visualize the MB and MB2 canals during and posttreatment (Treatment by Dr. Brian Shaughnessy) 26 Endodontic practice

Volume 8 Number 3

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• Better removal of debris • Square section • Smoother insertion of the instrument in the canal • Better resistance to distortion DENTSPLY MaiLLEfEr / T: 1-800-924-7393 / f: 1-800-924-7389 / MaiLLEfEr.DENTSPLY.coM • Consistent cutting sensation across the whole range of instruments • Square section • Increased safety *TO REDEEM YOUR FREE GOODS: Mail your invoice noting the promo code and free product(s) desired to: DENTSPLY Maillefer, 5100 East Skelly Drive, Suite 300, Tulsa OK, 74135 or (toll free) • Better resistance to distortion fax to 1-800-924-7389 or email to mailleferusa@dentsply.com. Offer is valid May 1, 2015 through June 30, 2015. Purchase must be made on ONE (1) invoice. Limit 5 redemptions of each offer per + • Range Doctor. Invoices beC received no later Julyrange 31, 2015 claim free goods. These offers may not be combined with any other DENTSPLY offers. All free goods fulfilled through DENTSPLY. • Consistent cuttingmust sensation across the than whole oftoinstruments Allow 4-6 weeks for delivery. Offer valid in the 50 United States only. Free goods must be of equal or lesser value than those purchased. • Increased safety • Two available lengths, 21mm and 25mm allow optimal efficiency in all clinical cases + • C Range ©2014 DENTSPLY International, Inc., DENTSPLY Maillefer. All rights reserved. For Dental Use Only Rx Only ADMAIC+ Rev. 0 07/14 REF A 012X REF A 012X 900 .c o m ly p ts n e • Two available lengths, 21mm and 25mm allowle optimal efficiency in all clinical cases fe r. d 006

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RESEARCH Materials and methods This study reviewed the electronic records and digital radiographs of patients treated by 18 endodontic residents who received nonsurgical root canal therapy in the graduate endodontic program at the University of Louisville from July 1, 2006, through June 30, 2013. Radiographs and records were reviewed collaboratively by two endodontic residents. Data collected included treating resident code, 1st- or 2nd-year treating resident, tooth number, patient age and gender, presence of preoperative crown, treated tooth pulp vitality status, MB2 located/not located, and initial treatment or retreatment. The location of the MB2 in the patient record was verified by both endodontic residents collecting data. MB2 was considered to be present if: 1. any portion of the MB2 could be visually observed in a postoperative or treatment radiograph with file or filling material present in the canal 2. documentation was present for location of the MB2 in the patient record All treating residents used a Global Operating Microscope (Global, St. Louis, Missouri) and were equipped with ultrasonics and various hand and rotary files. Chi-square analysis, odds ratio, and one-way ANOVA with Tukeyâ&#x20AC;&#x2122;s post hoc analysis were used for statistical analysis. Data was recorded in SPSS version 22.

Results The frequency of location of the MB2 canal in 1929 maxillary first and second molars was 57.6%. Among individual residents, the frequency of location by each resident varied widely from 29.2% to 71.8%. Frequency of MB2 location increased from 51.9% during the 1st year of residency, to 61.9% during the 2nd year (Table 1). The MB2 was found significantly more often in maxillary first molars at 64.2% (n = 904/1409) compared to maxillary second molars at 39.8% (n = 207/520) (Table 2). When comparing gender, the MB2 was found more often in males at 66.2% (n = 516/780) compared to females at 51.8% (n = 595/1149) (Table 3). The MB2 was found more frequently in younger patients. MB2 location ranged from a high of 70.1% in patients aged 21 and under to a low of 38.6% in patients aged 61 and older (Table 4). Significant differences were found between each age group with the exception of the comparison between age groups 41-60 and 60-plus (Table 5). 28 Endodontic practice

Table 1: The percentage of canals located increased between the 1st- and 2nd-years of residency from 51.9% the 1st year to 61.9% the 2nd year. This was found to be significant at the 95% confidence interval, with P < 0.0001

Table 2: The percentage of canals located in the maxillary first molar were significantly more than in the second molar at 64.2% and 39.8%, respectively. P < 0.0001

Table 3: The percentage of MB2 located differed significantly between female and male genders at 51.8% and 66.2%, respectively. P < 0.0001

Table 4: Frequency of canal location decreased as age range increased

Table 5: Comparison Among Age Groups (I) Age Range

(I) Age Range

Mean Difference (I-J)

Standard Error

Sig.

.10*

.027

.26*

95% Confidence Interval Lower Bound

Upper Bound

.001

.03

.17

.029

.000

.18

.33

.32*

.038

.000

.22

.41

-.10*

.027

.001

-.17

-.03

.16*

.030

.000

.08

.23

.22*

.039

.000

.12

.32

-.26*

.029

.000

-.33

-.18

-.16*

.030

.000

-.23

-.08

.06

.040

.461

-.04

.16

-.32*

.038

.000

-.41

-.22

-.22*

.039

.000

-.32

-.12

-.06*

.040

.461

-.16

.04

Dependent Variable: MBNumLocated Tukey HSD Based on observed means. The error term is Mean Square (Error) = .231 * The mean difference is significant at the .05 level.

Table 5: Comparison among age groups. Age range 1: 21 and under; 2: 21 to 40; 3: 41 to 60; 4: 60 and older. Note that when comparing group 3 to 4, there was no significance. Volume 8 Number 3

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RESEARCH

Table 6: Frequency of location of the MB2 canal varied depending on presence of a crown. (Crown Present 50.6%, No Crown 58.6%, p = 0.0217)

Presence of a preoperative crown affected the frequency of location of the MB2. In teeth with a preoperative crown, the MB2 was located in 50.6% (n = 119/235), and in teeth without a crown, location frequency was 58.6% (n = 992/1694) (Table 6).

Discussion The results of this retrospective study are similar to that of Corcoran, et al., in that greater resident experience was correlated with increased frequency of location of the MB2. While this study evaluated treatment on over 1,900 teeth, the study by Corcoran, et al., evaluated 100 teeth; however, the results were similar. In the 5-year clinical investigation by Wolcott, et al.,5 the frequency of location of MB2 was very similar to this study. They located the MB2 in 60% of maxillary first molars and 35% of second molars. This study reported 64.2% in first molars and 39.8% in second molars. However, Wolcott, et al., used a stricter definition of MB2 location. Their numbers may have been even higher with the definition used in this study. In this study, a significant difference was found in frequency of MB2 location between males (66.2%) and females (51.8%). These results agree with those of Fogel, et al.,3 and contrast with those of Neaverth, et al.,8 who found no difference by patient gender. Certainly, this is an interesting finding and should be pursued with further research on effects of patient gender and frequency of canal location. This study reported that the MB2 was located more often in younger age groups. That finding has been reported previously by Fogel, et al.,3 Neaverth, et al.,8 and Gilles and Reader.9 One can speculate that increased pulpal calcification due to aging or extensive restoration leads to increased difficulty in locating the MB2 canal during the endodontic treatment. 30 Endodontic practice

Figures 5A-5B: Severely curved buccal canals with treated MB2 canal (Treatment by Dr. Joseph Platt)

The successful outcome of nonsurgical root canal therapy is highly dependent upon location, thorough debridement, irrigation, and obturation of all canals and final restoration.

In this study, the MB2 was located less frequently in teeth with a preoperative crown. This finding could also be due to pulpal calcification and the loss of anatomic landmarks. The results of this study indicate that location and subsequent clinical treatment of the MB2 canal is affected by multiple variables. Future research should be directed toward techniques/strategies to mitigate the effect of these variables on location/treatment of the MB2 canal. The results of this study also indicate that in a teaching institution, endodontic faculty need to strive to make an additional effort to assist residents who are early in their training program in locating the MB2 canal during treatment of maxillary molars. Ideally, with faculty assistance, previous resident experience should not affect the frequency of MB2 canal location in a postgraduate endodontic program.

REFERENCES 1. Weine FS, Healey HJ, Gerstein H, Evanson L. Canal configuration in the mesiobuccal root of the maxillary first molar and its endodontic significance. Oral Surg Oral Med Oral Pathol. 1969;28(3):419-425. 2. Kulid JC, Peters DD. Incidence and configuration of canal systems in the mesiobuccal root of maxillary first and second molars. J Endod. 1990;16(7):311-317. 3. Fogel HM, Peikoff MD, Christie WH. Canal configuration in the mesiobuccal root of the maxillary first molar: a clinical study. J Endod. 1994;20(3):135-137. 4. Stropko JJ. Canal morphology of maxillary molars: clinical observations of canal configurations. J Endod. 1999;25(6):446-450. 5. Wolcott J, Ishley D, Kennedy W, Johnson S, Minnich S, Meyers J. A 5 yr clinical investigation of second mesiobuccal canals in endodontically treated and retreated maxillary molars. J Endod. 2005;31(4):262-264. 6. Hartwell G, Appelstein CM, Lyons WW, Guzek ME. The incidence of four canals in maxillary first molars: a clinical determination. J Am Dent Assoc. 2007;138(10):1344-1346. 7. Corcoran J, Apicella MJ, Mines P. The effect of operator experience in locating additional canals in maxillary molars. J Endod. 2007;33(1):15-17. 8. Neaverth EJ, Kotler LM, Kaltenbach RF. Clinical investigation (in vivo) of endodontically treated maxillary first molars. J Endod. 1987;13(10):506-512. 9. Gilles J, Reader A. An SEM investigation of the mesiolingual canal in human maxillary first and second molars. Oral Surg Oral Med Oral Pathol. 1990;70(5):638-643.

Conclusion In this study, the MB2 canal was located significantly more often in maxillary first molars, males, younger patients, and teeth without a crown. The MB2 canal was also located significantly more frequently by residents in their 2nd year of training. EP Volume 8 Number 3

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CONTINUING EDUCATION

The thick slice technique: a virtual periapical radiograph Dr. Richard S. Kahan explores the benefits of using advanced CBCT techniques in radiographic comparison and illustrates its use in a clinical case

ccuracy in endodontic diagnosis has always lacked total objectivity due to the limitations in both the sensitivity and specificity of our clinical and radiographic special tests (Mejàre, et al., 2015; 2012; Petersson, et al., 2012). The limitations of conventional two-dimensional radiography have been well documented, and the relatively recent introduction of limited volume cone beam computerized tomography (CBCT) in endodontics has significantly increased our ability to accurately visualize periradicular pathology through slices (Venskutonis, et al., 2014; Abella, et al., 2012), without the limitations imposed by surrounding hard tissues. Further clinical benefits include the ability of CBCT to accurately visualize the anatomical complexities of the root canal system (Zhang, et al., 2011), to appreciate the extent of resorptions (Kamburoglu, 2011), to observe the effects of vertical root fractures (Metska, et al., 2012), and to understand treatment failure through untreated anatomy. These factors significantly enhance diagnosis, treatment planning, and clinical activity. Using this enhanced knowledge in clinical endodontics can offer endodontists opportunities to provide patients with a greater degree of treatment predictability, and aids decision-making at the initial stages without the need for invasive procedures. Extending the use further can allow minimally invasive endodontics to treat challenging problems, such as I described in the article “Endodontics in 3D – a clinical series” (2014). This involves the continuous use of the scan during treatment utilizing head-up treatment displays.

Richard S. Kahan, BDS, MSc (Lond), LDS RCS (Eng), is a specialist endodontist working in Harley Street, London, and the former director of endodontic courses at UCL Eastman CPD. He has lectured widely on endodontics and technology, and set up the Academy of Advanced Endodontics to teach the fundamentals of endodontic treatment to GPs and master classes for specialists.

32 Endodontic practice

Educational aims and objectives

This clinical article aims to demonstrate an advanced CBCT technique in a clinical case using a time-shifted comparative virtual periapical radiograph created by a thick slice technique.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • See the use of virtual periapical radiographs from limited volume CBCT scans in successful endodontic diagnosis. • Realize the potential difficulty in endodontic diagnosis regarding the comparison of radiographic imaging over time. • Recognize the thick slice technique.

Advanced techniques in timeshifted endodontics Beyond these novel uses of the technology, further derivations can be made using advanced post-processing techniques, fully utilizing the increased information gathered through the scan, and further justifying the increased radiation. A particular area of difficulty in endodontic diagnosis is the comparison of radiographic imaging over time. The ability to determine whether radiolucency is increasing or decreasing in size is constantly in demand to determine the success or failure of endodontic treatment and the diagnosis of pain. This can translate further to diagnosis and treatment planning in the presence of an asymptomatic radiolucency associated with endodontically treated teeth. This common clinical conundrum can present itself on routine radiography, and the impulse to retreat should be tempered with an initial search for historical imaging of the area to try and determine whether the lesion has changed in size over time. The difficulties in achieving a precise comparison are well recognized, according to Wu, Shemesh, and Wesselink (2009). Beyond the subjectivity in determining the presence and size of a radiolucency with inter- and intra-observer variation, the

geometry of the image and the physical difficulty of lining up the X-ray over an extended time period is more than likely to produce inaccuracies. A radiolucency projected at different horizontal and vertical angulations will appear as different sizes. Bearing in mind all of these limitations in radiographic comparison, along with the inability to visualize up to 50% of periapical lesions using standard radiography (Venskutonis, et al., 2014), it is not surprising that our success-failure statistics are likely to be inaccurate. Those currently quoted will almost certainly be a victim of the data “garbage in, garbage out” principle (GIGO) (López, et al., 2014).

The thick slice technique A single limited volume CBCT scan can provide a baseline image that can be used both prospectively and retrospectively for comparison to a standard periapical radiograph taken at any horizontal and vertical projection achieved in the mouth. Increasing slice thickness The process involves the production of a virtual periapical radiograph from a limited volume CBCT scan by increasing the thickness of the coronal slice equal to, or larger than, the hard tissues imaged by a routine Volume 8 Number 3

Adjustments in the horizontal and vertical planes Adjustments need to be made to match the angulation of the central X-ray beam in both horizontal and vertical planes (Figures 3A-6B). This can be done through rotation in the axial and coronal planes and visual comparison with the true periapical radiograph. The correct angulations can be judged by the relative positions of two objects to

Figures 1A and 1B: 4 x 4 cm limited volume CBCT scan slices of an upper molar in the coronal and sagittal planes at 0.5 mm slice thickness

one another on the radiograph. Tooth and root morphology, restorations, and root filling materials can be effective markers. The resolution of the virtual periapical radiograph is inferior to standard radiography, and further post processing to increase the contrast (reducing the number of grayscales) is necessary.

Clinical case report A 41-year-old female patient who had fractured her jaw 10 years previously was referred by a specialist endodontist for a limited volume CBCT scan in order to help investigate and find the source of nonspecific

Figures 2A and 2B:The same molar scan at 30 mm slice thickness producing a virtual periapical radiograph

Figures 3A and 3B: Rotating the axial slice of the scan in a clockwise direction creates a distally -angled projection in the horizontal plane with the palatal root moving distally in the sagittal view

Limited volume CBCT scanning is a powerful diagnostic tool with particular benefit to endodontists.

Figures 4A and 4B: Rotating the axial slice of the scan in an counterclockwise direction creates a mesially angled projection in the horizontal plane with the palatal root moving mesially in the sagittal view

Figures 5A and 5B: Rotating the coronal slice of the scan in an counterclockwise direction creates the common effect seen when the X-ray plate is angled along the vault of the palate, creating an upward-angled projection, relatively elongating the palatal root Volume 8 Number 3

pain in her lower left quadrant. Both clinical and radiographic tests were inconclusive. The LL6 had been endodontically retreated 1 year previously. The tooth had been root treated 2 years previously by a general dental practitioner and had never felt right. The re-root filling appeared satisfactory, but the periapical review radiograph showed apical radiolucencies at both mesial and distal roots. Without a common alignment of the historical radiographs with the review radiographs, the possible healing signs observed could not provide the diagnostic confidence to rule out the LL6 as the source of the pain. The LL7 did not respond

Figures 6A and 6B: The opposite and clinically rarely seen effect of a downward-angled projection by clockwise rotation of the scan, relatively shortening the palatal root Endodontic practice 33

CONTINUING EDUCATION

periapical radiographic projection. This will produce a virtual periapical radiograph (Figures 1A-2B).

CONTINUING EDUCATION

Figure 7: Preoperative periapical radiograph

Figure 8: Postoperative periapical radiograph following endodontic retreatment of the LL6

Figures 9A and 9B: One-year postoperative LL6 review radiographs taken at different angles showing periapical radiolucencies

Figure 10: 4 x 4 cm limited volume CBCT sagittal slice of the lower left quadrant at 1 mm slice thickness showing widening of the PDL spaces below the mesial root of the LL7

Figure 11: 4 x 4 cm limited volume CBCT sagittal slice of the lower left quadrant at 25 mm slice thickness with mesial angulation in the horizontal plane

Figure 12: 4 x 4 cm limited volume CBCT sagittal slice of the lower left quadrant at 25 mm slice thickness with upward angulation in the vertical plane

to vitality testing but had only a shallow restoration. The question was whether the LL6 should be retreated once again, other teeth investigated, or a referral made for atypical facial pain. Four periapical radiographs were provided, one preoperative (Figure 7), one postoperative (Figure 8), and two review radiographs at different angles (Figures 9A and 9B). A 4 x 4 cm limited volume CBCT scan of the lower left posterior quadrant was taken using a Morita Veraviewepocs 3D,

imaging the LL5 to the LL7. A metal plate was screwed into the buccal cortical plate below the LL6 and LL7. The LL6 had been root treated with all three canals filled to the radiographic apex. A small radiolucency was associated with the mesial root apex together with widening of the periodontal ligament (PDL) space around the distal root apex. The LL7 had a small occlusal restoration with minimal depth. The pulp chamber and the coronal third of the root canals showed significant sclerosis, and there was very definitive widening of the PDL space

around the mesial root apex (Figure 10, arrowed). The LL5 showed no signs of any periradicular pathology. A virtual periapical was produced using the thick slice technique within the One Volume Viewer imaging software and then compared to the postoperative view taken 1 year previously. Horizontal angulation was judged through the relative positions of the mesiobuccal and mesiolingual root fillings (Figure 11). The vertical angulation was judged using the distance of the distal root apex of the LL7 to the metal plate (Figure 12).

34 Endodontic practice

Volume 8 Number 3

Conclusion Limited volume CBCT scanning is a powerful diagnostic tool with particular benefit to endodontists. The increased radiation dose needs to be well justified, and it is up to the clinician to use all of the high-quality data captured for the benefit of the patient. Through careful and thoughtful processing, a single CBCT scan can be used together with standard radiography, not only for direct reporting at one instance in time, but also retrospectively as demonstrated in this article, and prospectively, for reviewing treatment carried out following a scan.

Volume 8 Number 3

Figure 13: A correctly lined up comparison between the postoperative radiograph following endodontic retreatment of the LL6 and a virtual periapical created from the CBCT scan 1 year later, showing a reduction in lesion size at the mesial and distal roots of the LL6 and some increased widening of the PDL space around the mesial root of the LL7

Acknowledgment The author would like to thank Dr. Bina Patel for providing the patient radiographs. EP REFERENCES 1. Abella F, Patel S, Duran-Sindreu F, Mercadé M, Bueno R, Roig M. Evaluating the periapical status of teeth with irreversible pulpitis by using cone-beam computed tomography scanning and periapical radiographs. J Endod. 2012;38(12):1588-1591. 2. Kahan RS. Endodontics in 3D – a clinical series. Dentistry. 2014;May:68-70. Accessed online. http://endodontics. co.uk/wp-content/uploads/2014/12/VertfractMay14.pdf.

of the dental pulp: a systematic review. Int Endod J. 2012;45(7):597-613. 6. Mejàre IA, Bergenholtz G, Petersson K, Tranæus S. Estimates of sensitivity and specificity of electric pulp testing depend on pulp disease spectrum: a modelling study. Int Endod J. 2015;48(1):74-78. 7. Metska ME, Aartman IH, Wesselink PR, Özok AR. Detection of vertical root fractures in vivo in endodontically treated teeth by cone-beam computed tomography scans. J Endod. 2012;38(10):1344-1347. 8. Petersson A, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, Norlund A, Mejàre I, Portenier I, Sandberg H, Tranaeus S, Bergenholtz G. Radiological diagnosis of periapical bone tissue lesions in endodontics: a systematic review. Int Endod J. 2012;45(9):783-801.

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

9. Venskutonis T, Daugela P, Strazdas M, Juodzbalys G. Accuracy of digital radiography and cone beam computed tomography on periapical radiolucency detection in endodontically treated teeth. J Oral Maxillofac Res. 2014;5(2):e1.

4. López FU, Kopper PM, Cucco C, Della Bona A, de Figueiredo JA, Vier-Pelisser FV. Accuracy of cone-beam computed tomography and periapical radiography in apical periodontitis diagnosis. J Endod. 2014;40(12):2057-2060.

10. Wu MK, Shemesh H, Wesselink PR. Limitations of previously published systematic reviews evaluating the outcome of endodontic treatment. Int Endod J. 2009;42(8):656-666.

5. Mejàre IA, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, Norlund A, Petersson A, Portenier I, Sandberg H, Tranaeus S, Bergenholtz G. Diagnosis of the condition

11. Zhang R, Wang H, Tian YY, Yu X, Hu T, Dummer PM. Use of cone-beam computed tomography to evaluate root and canal morphology of mandibular molars in Chinese individuals. Int Endod J. 2011;44(11):990-999.

Endodontic practice 35

CONTINUING EDUCATION

A diagnostically acceptable comparative virtual periapical radiograph was created (Figure 13). The radiolucencies at both mesial and distal roots certainly appeared to be smaller. Furthermore, the widening seen at the apex of the LL7 appeared more pronounced in the virtual periapical than the radiograph taken a year earlier. The analysis was able to confirm healing at the LL6 and suggested a deteriorating pulpal issue at the LL7 with severe sclerosis and PDL widening. Without further clinical evidence and testing, this would not be a definitive diagnosis, but it was able to increase diagnostic confidence.

CONTINUING EDUCATION

Use and abuse of antibiotics in endodontics Dr. Eoin Mullane examines the correct clinical use of antibacterial drugs in endodontics

he discovery of safe, systemic antibiotics has been a major factor in the control of infectious diseases. As such, antibiotics have increased the life expectancy and quality of life for millions of people (AAE ENDODONTICS: Colleagues for Excellence, 2012). But this life-altering benefit comes at a price — drug-resistant bacteria. The problem is not with the antibiotics themselves, but with how they are being used and, to a larger extent, prescribed (AAE ENDODONTICS: Colleagues for Excellence, 2012). A recent study, highlighted by the Irish media at the beginning of this year, found a 44-fold increase in the prevalence of MRSA strains and a sixfold increase in the number of strains resistant to multiple antibiotics (Kinnevey, et al., 2014). These bacterial strains were mostly associated with skin and soft tissue infections, and were found in patients with serious lifethreatening illnesses. The dental profession also plays a part in the selection of drug-resistant bacterial strains, through inappropriate drug prescribing (Sweeney, et al., 2004). There is ever-increasing evidence from current endodontic literature of antibiotic resistance in endodontic infections (Jungermann, et al., 2011; Montagner, et al., 2014) — but there is a glimmer of hope. By examining the following five myths, we can strive to achieve correct clinical use of antibacterial drugs and assist with clinical decisions regarding antibiotic therapy (AAE ENDODONTICS: Colleagues for Excellence, 2012).

The five myths 1. Antibiotics cure patients Antibiotics do not cure patients. Once a proper balance is re-established between the host defense (immune system and Eoin Mullane, BDS, MS Cert Endo (Michigan, United States), graduated from the University of Manchester in 1999, going on to practice general dentistry for 6 years. He received his masters in endodontics at the University of Michigan. He currently runs a practice limited to endodontics in Limerick and Dublin, Ireland.

36 Endodontic practice

Educational aims and objectives

This clinical article aims to explore both the benefits and risks of antibiotic therapy in endodontic treatment.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize some statistics regarding the prevalence of antibiotic use in endodontics. • Identify specific conditions which necessitate the use of antibiotics. • Identify specific conditions for which antibiotics should be avoided. • Realize some antibiotics’ spectrum of activity.

Figures 1A and 1B: One-year recall following root canal treatment

There is ever-increasing evidence from current endodontic literature of antibiotic resistance in endodontic infections — but there is a glimmer of hope. inflammatory system) and the bacterial agents, patients cure themselves (Figures 1A and 1B). 2. Antibiotics are a substitute for clinical intervention It’s simple: Antibiotics are not a substitute for surgical intervention. Endodontics removes the source of infection; patients then heal themselves (Figures 2A and 2B).

3. The most important decision is which antibiotic to use The most important decision is not which antibiotic to use, but whether or not we need to prescribe one at all. Most endodontic infections resolve once the source of the infection has been removed (AAE ENDODONTICS: Colleagues for Excellence, 2012). Volume 8 Number 3

Never prescribe antibiotics for an irreversible pulpitis. Patients may request that you prescribe. Explain your rationale and advise analgesics only (e.g., ibuprofen), as the pulp is inflamed and not infected. In most cases, the inflammatory process eliminates bacteria that emerge from the apical foramen, and the immune system also stops bacteria spreading into the periapical tissues. Asymptomatic apical periodontitis does not require antibiotic therapy, and endodontic treatment alone is sufficient (AAE ENDODONTICS: Colleagues for Excellence, 2012).

Conditions requiring antibiotic therapy • • • • • • • •

An acute apical abscess can cause a localized fluctuant intraoral swelling with associated pain. Treatment involves endodontic therapy, and there is no need to prescribe antibiotics, but the patient should be advised to take non-steroidal anti-inflammatory drug (NSAID) analgesics such as ibuprofen. If the intraradicular infection overwhelms the immune system, bacteria will gain access to the periapical tissues. This can result in an acute abscess with a concurrent facial swelling. Endodontic treatment with incision and drainage and antibiotics are indicated in Figure 4. In order to prescribe an antibiotic, practitioners need to be aware of their spectrum of activity, so that the antibiotic can target the bacteria, which are responsible

CLINDAMYCIN 300MG

666mg x two stat

300mg x two stat

666mg 4 times daliy

300mg 4 times daily

4-5 days

Penicillin V

For allergy to Penicillin V

Figure 3: Examples of recommended antibiotics. Notice loading dose

for causing endodontic infections. Bacteria that are commonly found in infected root canals are mixed gram positive and gram negative, facultative anaerobes, and strict anaerobes (e.g., Fusobacteria, Prevotella, and Porphyromonas) (Baumgartner, et al., 2008). Penicillin V is the antibiotic of choice, as its spectrum of activity is ideally suited to the bacteria that are found in infected root canals (Baumgartner, Xia, 2003). Antibiotics should be prescribed at a high dose over a short period of time. This reduces the chance of selecting drugresistant bacteria and lowers the risk to the patient with respect to toxicity and allergy (Pallasch, 1994). The initial dose of the antibiotic should always be higher than the maintenance dose.

Fever greater than 37.8ºC Malaise Lymphadenopathy Trismus Cellulitis Persistent infection Increased swelling Osteomyelitis

Conditions not requiring antibiotic therapy • Pain with no signs and symptoms of infection – Symptomatic irreversible pulpitis – Symptomatic apical periodontitis • Necrotic pulps and radiolucency • Teeth with an associated sinus tract • Localized fluctuant swellings Figure 4: Gutta-percha point, tracing a sinus tract, originating from an apical lesion of endodontic origin Volume 8 Number 3

Endodontic practice 37

CONTINUING EDUCATION

Figures 2A and 2B: GP-tracing sinus tract. Two-year recall orthograde root canal treatment and apicectomy

CALVEPEN 666MG

CONTINUING EDUCATION A loading dose should always be employed, and it should be twice the maintenance dose (AAE ENDODONTICS: Colleagues for Excellence, 2012). This guarantees rapid and high blood levels of the antibiotic. Traditionally, metronidazole was prescribed for endodontic infections, but its spectrum of activity is limited to anaerobes. Metronidazole should therefore not be prescribed on its own, as it is not effective against facultative anaerobes (Baumgartner, 2003). Erythromycin was also traditionally prescribed for patients who are allergic to penicillin; however, it should never be prescribed, as it is not effective against anaerobic bacteria (Baumgartner, 2006). 4. Multiple antibiotics are superior to a single antibiotic Multiple antibiotics will guarantee a greater antibiotic spectrum, but this will result in the selection of drug-resistant bacteria (AAE ENDODONTICS: Colleagues for Excellence, 2012). The only indication for combined antibiotics is a severe infection.

5. Bacterial infections need a “complete course” of antibiotic therapy There is no such thing as a “complete course of antibiotics” (Pallasch, 1994). The only guide is improvement in the patient’s symptoms, and this is based on the effectiveness and duration of antibiotic therapy (Hessen, Kaye, 1989). Orofacial infections do not rebound, as long as the source of infection has been removed. Endodontic treatment will remove the source of infection. Therefore, once the patient’s swelling has subsided, the course of antibiotics should be stopped.

Alter existing prescribing regime In summary, we have discussed and dispelled five myths relating to antibiotic therapy. Antibiotic resistance is an everincreasing issue, and it can only be combated by effective prescribing with reduced abuse of antibiotics. By analyzing these myths, practitioners can alter their prescribing regime. This alteration, most importantly, can be implemented the next time you think about prescribing an antibiotic for your patients. EP

REFERENCES 1. American Association of Endodontists. Use and abuse of antibiotics. Endodontics: Colleagues for Excellence newsletter. Winter 2012. 2. Baumgartner JC. Antibiotics and the treatment of endodontic infections. American Association of Endodontics Colleagues for Excellence newsletter. Summer 2006. 3. Baumgartner JC, Siqueira JF, Sedgley CM, Kishen A. Microbiology of endodontic disease. In: Ingle, JI, Bakland LK, Baumgartner JC, eds. Ingle’s Endodontics 6. People’s Medical Publishing House-USA. 2008:221-308. 4. Baumgartner JC, Xia T. Antibiotic susceptibility of bacteria associated with endodontic abscesses. J Endod. 2003;29(1): 44-47. 5. Hessen MT, Kaye D. Principles of selection and use of antibacterial agents. Infect Dis Clin North Am. 1989;3(3): 479-489. 6. Jungermann GB, Burns K, Nandakumar R, Tolba M, Venezia RA, Fouad AF. Antibiotic resistance in primary and persistent endodontic infections. J Endod. 2011;37(10):1337-1344. 7. Kinnevey PM, Shore AC, Brennan GI, Sullivan DJ, Ehricht R, Monecke S, Coleman DC. Extensive genetic diversity identified among sporadic methicillin-resistant Staphylococcus aureus isolates recovered in Irish hospitals between 2000 and 2012. Antimicrob Agents Chemother. 2014;58(4):1907-1917. 8. Montagner F, Jacinto RC, Correa Signoretti FG, Scheffer de Mattos V, Grecca FS, Gomes BP. Beta-lactamic resistance profiles in Porphyromonas, Prevotella, and Parvimonas species isolated from acute endodontic infections. J Endod. 2014; 40(3): 339-344. 9. Pallasch TJ. Pharmacology of Anxiety, Pain and Infection. In: Ingle JI, Bakland LK, eds. Endodontics. 4th ed. Williams and Wilkins: Malvern, PA, 1994. 10. Sweeney LC, Dave J, Chambers PA, Heritage J. Antibiotic resistance in general dental practice — a cause for concern? J Antimicrob Chemother. 2004;53(4): 567-576.

Disclaimer: The information in this article is designed to aid dentists. Practitioners must use their best professional judgment, taking into account the needs of each individual patient when making diagnoses/treatment plans.

38 Endodontic practice

Volume 8 Number 3

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 V8.3 KAHAN REF: EP V8.3 MULLANE

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Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Endodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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The thick slice technique: a virtual periapical radiograph

Use and abuse of antibiotics in endodontics

KAHAN

MULLANE

Accuracy in endodontic diagnosis has always lacked total objectivity due to the limitations in the ______ of our clinical and radiographic special tests. a. sensitivity b. specificity c. factuality d. both a and b The limitations of conventional two-dimensional radiography have been well documented, and the relatively recent introduction of limited volume cone beam computerized tomography (CBCT) in endodontics has significantly increased our ability to accurately visualize periradicular pathology through slices, without the limitations imposed by ___________. a. the technician b. the sensor c. surrounding hard tissues d. the traditional film Further clinical benefits include the ability of CBCT to accurately visualize the anatomical complexities of the root canal system __________. a. to appreciate the extent of resorptions b. to observe the effects of vertical root fractures c. to understand treatment failure through untreated anatomy d. all of the above Beyond these novel uses of the technology, further derivations can be made using _____ and further justifying the increased radiation. a. advanced post-processing techniques b. fully utilizing the increased information gathered through the scan c. the garbage in, garbage out principle d. both a and b A particular area of difficulty in endodontic diagnosis is the _____ of radiographic imaging over time. a. choice b. comparison

Volume 8 Number 3

c. quality d. pixel size 6.

Bearing in mind all of these limitation in radiographic comparison, along with the inability to visualize up to ____ of periapical lesions using standard radiography, it is not surprising that our success-failure statistics are likely to be inaccurate. a. 15% b. 30% c. 43% d. 50%

Adjustments need to be made to match the ________ of the central X-ray beam in both horizontal and vertical planes. a. angulation b. radiation emission c. fan shape d. cone shape The resolution of the virtual periapical radiograph is inferior to standard radiography, and further post processing to _______ the contrast (reducing the number of grayscales) is necessary. a. increase b. decrease c. eliminate d. scatter

______ is a powerful diagnostic tool with particular benefit to endodontists. a. Traditional 2D film imaging b. Transillumination c. Limited volume CBCT scanning d. Digital 2D radiography

10.

The _______ needs to be well justified, and it is up to the clinician to use all of the high-quality data captured for the benefit of the patient. a. discomfort b. amount of digital photography c. increased radiation dose d. scatter

A recent study, highlighted by the Irish media at the beginning of this year, found a 44-fold increase in the prevalence of MRSA strains and a _______ increase in the number of strains resistant to multiple antibiotics. a. negligible b. threefold c. fourfold d. sixfold

c. Penicillin V d. Metronidazole 6.

Antibiotics should be prescribed at a ________. a. low dose over a short period of time b. high dose over a short period of time c. low dose over a long period of time d. single dose administered by injection

7. (In the case of irreversible pulpitis) Explain your rationale and advise ______, as the pulp is inflamed and not infected. a. analgesics only (e.g., ibuprofen) b. penicillin c. clindamycin d. Calvepen

The initial dose of the antibiotic should always be _______ than the maintenance dose. a. higher b. lower c. the same d. a different type

If the intraradicular infection overwhelms the immune system, bacteria will gain access to the periapical tissues. This can result in a(n) _______. a. acute abscess b. concurrent facial swelling c. respiratory infection d. both a and b

Traditionally, _____ was prescribed for endodontic infections, but its spectrum of activity is limited to anaerobes. a. penicillin b. metronidazole c. Keflex d. Calvepen

Erythromycin was also traditionally prescribed for patients _______; however, it should never be prescribed, as it is not effective against anaerobic bacteria. a. who are allergic to ibuprofen b. who request it c. who are allergic to penicillin d. who have heart conditions

10.

Multiple antibiotics will guarantee a greater antibiotic spectrum, but this will result in _______. a. stomach problems b. liver problems c. kidney problems d. the selection of drug-resistant bacteria

Bacteria that are commonly found in infected root canals are ________. a. mixed gram positive and gram negative b. facultative anaerobes c. strict anaerobes (e.g., Fusobacteria, Prevotella, and Porphyromonas) d. all of the above

_______ is the antibiotic of choice, as its spectrum of activity is ideally suited to the bacteria that are found in infected root canals. a. Erythromycin b. Clindamycin

Endodontic practice 39

CE CREDITS

ENDODONTIC PRACTICE CE

AAE

AAE PREVIEW

Rethinking the cabinet-based operatory How to reduce costs while improving efficiency

ndodontists looking to increase revenue and productivity should consider the following five goals when designing their treatment room: 1. Have a flexible operatory space that can be easily reconfigured as needed

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or upgraded with new technology as it becomes available. 2. Invest in technology versus nonproductive and expensive cabinetry costs. 3. Enhance the patient experience and perception through a technology interface, without the clutter of wires and cables. 4. Improve efficiency and treatment time without compromising quality. 5. Facilitate ergonomic positioning and methodology for both the endodontist and the assistant. Come see how ASI can help you avoid unnecessary costs and streamline your operatory designs.

Announcing … ASI has partnered with Dental Fix Rx™ for a nationwide service option to assist you with installations, upgrades, preventative maintenance, and on-site support.

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Brasseler USA XP-3D Finisher™

BC RRM-Fast Set Putty™

Brasseler’s XP-3D Finisher is being introduced at this year’s AAE in Seattle. The revolutionary file allows for the three-dimensional cleaning of even the most complex root canal systems. This unique parallel (zero taper) instrument features MaxWire™ NiTi technology, which provides for unparalleled flexibility, safety, and debridement. The minimally invasive file is straight at room temperature and expands its working circumference (up to 100x) once introduced into the root canal system (body temp). This gentle expansion allows the XP-3D Finisher to clean where no previous file has been able to clean before, all while respecting the original morphology of the canal.

Tired of hassling with conventional manual mix root repair and “dentin replacement” materials? Premixed with superior handling and healing properties, EndoSequence® BC RRM-Fast Set Putty™ is ideal for all your root repair needs. BC RRM-Fast Set Putty™ contains the same characteristic as our triedand-true BC RRM Paste ™ and BC RRM Putty™ but with a new fast-set chemistry and improved Sanidose™ syringe delivery. Visit the booth, or call your Brasseler rep today to demo this remarkable product.

BC Sealer™ and BC Points™ for Warm Vertical Obturation BC Sealer’s unprecedented growth and acceptance among specialists has been slowed only by a common misunderstanding of the properties of this novel pre-mixed bioceramic. Research now confirms that BC Sealer™ performs best when used with BC Points™ (bioceramiccoated and impregnated points), and with the launch of the new “150 Series™” you can now utilize BC Sealer with a warm vertical condensation technique at 150ºC. Visit the booth, or call your Brasseler rep today to demo this remarkable product.

Visit Brasseler at Booth No. 311, and test-drive our latest innovations! 40 Endodontic practice

Volume 8 Number 3

Carestream Dental’s RVG 6200 sensor with CS Adapt

he RVG 6200 sensor with CS Adapt is Carestream Dental’s newest digital intraoral imaging solution. The RVG 6200 continues the legacy of durable digital intraoral sensors, while the CS Adapt module adapts the sensor to the needs of the practitioner, not the other way around. The RVG 6200 offers an efficient, three-step acquisition process: position, expose, and view. Practitioners simply position the sensor in a patient’s mouth, capture the image, and the image appears within seconds, further streamlining workflow. The sensor offers a broad exposure range and provides extreme flexibility for image capture over a wide range of exposure. Both accommodating and versatile, the RVG 6200 sensor does not require timeconsuming fine-tuning of exposure

to produce a clinically useful image. However, if needed, a convenient dose indicator identifies potential over- or underexposures, so the users can adjust the settings as necessary while refining their expertise. The new CS Adapt module further enhances the user experience. Forty filters stored in 10 filter families, with DEJ, endo, perio, and restorative pre-sets, are available to optimize images. These filters allow practitioners to select the image contrast according to their diagnostic

needs and visual preference for faster, more accurate diagnoses. For example, filters options can replicate the preferred look of traditional film or help reduce artifacts around radiopaque materials. Additionally, the system’s easy-to-use custom filters enable clinicians to customize the appearance of images even further by modifying brightness and contrast in order to better suit clinical needs or monitor performance. Once users determine the perfect look and feel, they can then indicate up to four of their favorite filter options, making them accessible with one click. The RVG 6200 with CS Adapt is available with three optional warranties, including an all-new lifetime warranty. Learn more about the RVG 6200 sensor with CS Adapt in Booth No. 911 at the American Association of Endodontists (AAE) Annual Session in Seattle, Washington.

Visit Carestream at Booth No. 911

Part of saving more teeth is saving more tooth

ndodontists like you are already polymicrobial biofilms in mesial roots of lower molars, leaving significantly working to save teeth in ways only a specialist can, with new less bacteria when compared to and advanced technologies that conventional ISO rotary file systems.2 continually improve the standard TRUShape 3D Conforming Files look and feel different than convenof care. Just as our understanding of the true complexity of the tional files because they are. Their unique shape and motion provide canal anatomy has grown, so has the sophisticated armamentarium superior overall shaping over convenavailable for achieving predictable tional ISO rotary files — even as they clinical outcomes. remove less dentin. TRUShape® 3D Conforming The file’s unique S-shape creates an innovative envelope of motion within the TRUShape is designed for use by Files are the next evolution in canal that conforms to unconstrained spaces while respecting constrained spaces. endodontic specialists, and training cleaning and shaping the complex is required prior to utilizing them in canal anatomy. They allow you to preserve files,1 while contacting up to 75% of canal a clinical setting. Discover the TRUShape more dentinal structure while removing pulp walls. They also let you create a predictdifference, and receive your free CE training and debris along the entire root canal. And at TulsaDentalSpecialties.com. able shape in the important apical region, they provide several advantages to cleaning producing up to 32% less apical transporta1. Peters OA, Arias A, Paque F. Three dimensional analysis a root canal system compared to convention than conventional ISO prepared canals.1 of the root canal geometry of oval canals after preparation with a novel rotary instrument. Submitted for publication. tional instrumentation techniques with ISO The key to the TRUShape difference lies 2. Pileggi R, Bruder G, Wallet SM, Sorenson H, Walker C, in the file’s unique S-shape design, allowing rotary files. Neiva KG. Quantitative analysis of a polymicrobial biofilm removal following instrumentation with a new file system. When it comes to superior overall it to conform to areas of the canal larger Submitted for publication. than the nominal file size. In addition to shaping, the TRUShape name says it all. TRUShape 3D Conforming Files remove up conforming to the canal, this design creates Visit DENTSPLY Tulsa at Booth No. 401 to 36% less dentin than conventional ISO an envelope of motion that better disrupts

Volume 8 Number 3

Endodontic practice 41

AAE PREVIEW

PREVIEW

AAE PREVIEW

Global Surgical™ Corporation

AAE

The leader in dental microscopes is excited to announce the unveiling of the new A-Series™ microscope

lobal’s latest technological advancement sets the standard in dental microscopy and will debut in Seattle, Washington at the AAE Annual Meeting. Designed by dentists for dentists, the new A-Series™ Microscope features the intuitive AXIS™ Control System. Offering a greater range of motion from a single point of reference, the A-Series is easier to maneuver than any other brand. Features include the brightest LED light source available and a new Multi-Focal Lens. The MFL provides an enhanced range of fine focus adjustment. Once gross focus is achieved, the fine focus can be adjusted up to 150 mm without moving the microscope head. There is no need to adjust the binoculars or move the scope, keeping you “in the zone” while maintaining a healthy ergonomic position.

At Global Surgical, we are committed to providing the best microscope experience in the dental market. Our products are used in universities and learning facilities worldwide, and we pride ourselves in offering knowledgeable customer service and prompt technical support.

With headquarters in St. Louis, Missouri, Global’s products are the only microscopes manufactured in the USA. Discover the advantages of our dental microscopes by contacting your local representative or calling 1-800-767-8726 today.

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J. Morita USA FREE portable charger and “don’t miss” speaker events

ttention dentists — get a FREE portable charger with trial of the NEW Root ZX® II OTR Low Speed Handpiece Module!* OTR offers a safer way to clean and enlarge canals with a unique 90° auto torque release and file advancement feature, while displaying precise and accurate measurements. OTR reduces file fatigue, as well as the possibility of file breakage. Morita will also be hosting the following speaker events at the AAE 2015, including a corporate workshop focused on use of the Root ZX II OTR Module.

To-the-point lectures (Rear of exhibit floor) Safe and Efficient Root Canal Instrumentation – With More Predictability Speaker: Yoshitsugu Terauchi, DDS, PhD 2:30 p.m.-3:30 p.m. Thursday, May 7 42 Endodontic practice

Morita CBCT Update and Applications in Your Daily Practice Speaker: Samuel Kratchman, DMD 11:30 a.m.-12:30 p.m. Friday, May 8

www.morita.com/usa * Dentists ONLY. While supplies last, May 6-9, 2015. No purchase necessary. Gifts may be subject to reporting requirements for the Physician Payments Sunshine Act.

Visit J. Morita at Booth No. 901 Volume 8 Number 3

Mani launches Mani Silk

ani of Japan is proud to announce the global launch of their new and novel rotary nickel-titanium file system, “Mani Silk” at the AAE in Seattle, May 6-9, 2015. Mani Silk features an innovative breakthrough in heat treatment technology. The files are heat treated from the tip through the first 10 mm of the cutting flutes, providing flexibility where it is needed most. In addition, the file has a teardrop cross section, which channels debris coronally, reduces the “screwing in” effect, and improves tactile control, hence the name Mani Silk. Extensively researched and clinically tested, easy to integrate into clinical practice,

Mani Silk is anatomy based. Simple packs (.08/25, .06/25, and .06/30) are configured for “simple canals” (little or no curvature or calcification). Standard packs (.08/25, .06/20, and .06/25) are configured for “standard canals” (moderate curvature and calcification). Complex packs (.08/25, .04/20, and .04/25) are configured for “complex canals” (severe curvature and calcification). After using the orifice opener (.08/25) and creating the glide path, Mani Silk files

are alternated from the smaller tip-sized instrument to the larger until the final shape is prepared. For example, when using the Simple pack, the .06/25 is followed by the .06/30. When using the Standard pack, the .06/20 is followed by the .06/25. When using the Complex pack, the .04/20 is followed by the .04/25. Larger apical diameters can be prepared using Mani Silk .04/30, .04/35, .04/40, .06/30, .06/35, and .06/40 instruments if desired. You are encouraged to visit the Mani booth at the AAE to learn more about Mani Silk and see the impressive range of Mani products, including burs, stainless hand files, nickel-titanium hand files and the Mani GPR (Gutta Percha Remover) instruments, among many other fine Mani endodontic products. Visit Mani at Booth No. 1015

NOMAD Pro 2™ With everything at your fingertips, why should your X-ray be any different?

he NOMAD Pro 2 is a handheld, portable X-ray system changing the way dental offices take intraoral X-rays. Its lightweight, 5.5-pound body and extended battery life make it a great choice for all types of dental offices. The NOMAD Pro 2 allows the operator to stay with the patient while taking X-rays, which makes it perfect for endodontists. Never again pause a procedure to leave the room and take an X-ray — endodontists can now safely take X-rays chairside. By removing the hassle of leaving the room each time, procedures can go smoother and faster than ever before. Plus, the NOMAD Pro 2 is so versatile; it can cover any other imaging needs in the office. Experience all the freedom a handheld unit can bring.

Best workflow design • Because the NOMAD Pro 2 does not need walls, pass-throughs, cabinets or other space obstacles, Volume 8 Number 3

you can create a more open space environment that is comfortable and efficient. No more designing your operatory around your X-ray.

Flexibility — let NOMAD Pro 2 go with you • The NOMAD can be shared across multiple rooms, giving your staff the ability and the flexibility to take X-rays in any operatory. • Just one NOMAD handheld unit can easily serve two to three operatories, eliminating the need for multiple X-ray units. • The NOMAD is ideal for treating a variety of patients including children, geriatrics or special needs.

Did you know that the Gendex GXS700™ sensors and the NOMAD Pro 2 work GREAT together? New! Shorter positioning bars for

GXS-700 sensors — these positioning bars facilitate the use of the GXS-700 sensors with the NOMAD Pro 2. Use the shorter bars with GXS-700 rings and sensor holders. The shorter bars are 2.16 inches shorter than standard aiming bars and are available in universal, bitewing, and endodontic versions. Dental professionals worldwide are discovering that the NOMAD Pro 2 gets their diagnosing done faster. That means they can spend their time where it matters most — with the patient.

Visit NOMAD at Booth No. 728

Endodontic practice 43

AAE PREVIEW

PREVIEW

AAE PREVIEW

AAE

Introducing the new, cutting-edge ONE ENDO™ File Designed from tip to handle Obtura Spartan® Endodontics has expanded its endodontic product line with the addition of the new, cutting-edge ONE ENDO™ File, which offers the best all-around performance of any similarly sized file.* Decades of research and thousands of tests have culminated in the patented ONE ENDO File, a flexible rotary nickel-titanium file designed from tip to handle by Dr. John T. McSpadden, DDS.

Self-Piloting Cut Flip Tip The ONE ENDO File’s Self-Piloting Cut Flip Tip effectively forms dentinal chips while an opposing curved area smoothly pilots the tip into the canal. This design allows clinicians to navigate challenging canals without screwing in or pushing debris in advance of the cutting tip or through the apical foramen. The result is a flexible tip that manages torsion, quickly pulls

away debris, and nearly eliminates the tendency to bind in the canal.

Two unequal tapers side-by-side Two unequal tapers, side-by-side, wrap from the tip of the file to the base, affording greater cutting efficiency, superior debris removal, reduced torque loading, and improved flexibility. This feature, combined with the Self-Piloting Cut Flip Tip, helps to greatly reduce the risk of instrument fracture. “The clinician’s number-one concern while using a rotary file is unexpectedly breaking the instrument inside the root canal,” said McSpadden, who authored the book, Mastering Endodontic Instrumentation. “The ONE ENDO File is specifically designed to maximize efficiency and minimize stress. The ONE ENDO File consistently delivers

superior efficacy and efficiency, test after test — and we performed over 2,000 tests. The ONE ENDO File is vastly different from files currently available on the market.”

Progressive heat treatment Larger ONE ENDO Files have been heattreated, giving the thicker files greater flexibility to work in complex canal anatomy and navigate curvatures like smaller files, thus helping reduce the number of instruments required to perform root canal procedures. For special introductory pricing and demonstrations, visit the Obtura Spartan Endodontics Booth No. 717 during the AAE Annual Session from May 6-9. * Internal data on file. Express opinion of NanoEndo based on testing data.

Visit Obtura Spartan at Booth No. 717

Introducing BioRoot™ RCS from Septodont

ew BioRoot™ RCS (root canal sealer) is the only bioactive and biocompatible root canal sealer on the market today. It is a breakthrough in the mineral-based root canal filling materials for permanent canal obturation. Based on the Active Biosilicate Technology™ (of Biodentine™), it is designed for general dentists and endo specialists. BioRoot RCS incorporates an

44 Endodontic practice

easy-to-use cold obturation technique that ensures a long-lasting, leak-free seal and releases calcium hydroxide for a high pH = 12. The alkalinity of BioRoot RCS promotes antimicrobial effects in the root and lateral canals. BioRoot RCS is resin-free, alleviating concerns on the reported histological data, which finds resin-based materials may not be biocompatible with apical tissue. BioRoot RCS is easy to mix into a creamy, easy-toapply consistency for use in predictable techniques that clinicians are familiar with. In addition, when faced with a difficult to dry canal, BioRoot RCS will set even in the presence of residual moisture, due to its hydrophilicity. It easily adheres to both root dentin and gutta percha. BioRoot RCS gives an excellent, strong seal and has superior microleakage resistance. Through its dentin mineralization, it forms hydroxyapatite and crystalizes inside

dentin tubules to create a three-dimensional seal. In addition, post-op sensitivity is eliminated due to its biocompatibility. BioRoot RCS has a highly stable setting reaction and is non-staining and color stable to maintain the esthetics of the root dentin. Easy followup evaluations are made possible with a high radiopacity (5mm Al) for clear images. Used in combination with gutta-percha points, BioRoot RCS can easily be removed for retreatment. BioRoot RCS gives practitioners the ability to mix the product to their preferred viscosity, enabling their handling preferences. Available in a kit of 35 applications, BioRoot RCS from Septodont is available from your authorized dental dealer. For more information, please visit www.septodontusa. com, or call 1-800-872-8305.

Visit Septodont at Booth No. 713 Volume 8 Number 3

AAE PREVIEW

PREVIEW Sirona’s comprehensive 3D imaging

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

ORTHOPHOS® XG 3D — a hybrid approach ORTHOPHOS® XG 3D combines the advantages of 2D and 3D into one comprehensive unit. With an extensive selection of panoramic and cephalometric programs to choose from, the right 2D diagnostic images are now augmented with the ability to capture 3D X-ray.

Precise endodontic treatment The 3D X-ray images generated by the ORTHOPHOS XG 3D are a precise

culmination of 200 images captured during one revolution. Endodontists will enjoy the ability to instantly view the digital images required for endodontic procedures, combined with the crisp, well-defined 3D volumetric images for revealing canal shapes and anatomies, as well as precise measurements for canal depths, widths, and apicoectomy procedures. CBCT scans of patients with a large number of metal restorations require a higher dynamic range of the dose/image quality ratio. For such cases, Sirona has developed the Endo HD mode. During the Endo HD cycle, 500 images are taken. The additional 300 images (compared to Standard mode) allow ORTHOPHOS XG 3D to construct an image that is lower in noise and higher in contrast, which allows for a faster and more reliable diagnosis of

the imaged volume. To sum it all up — Sirona means solutions for dental practices. It is all part of Sirona’s goal of constantly striving to provide doctors with the ultimate in dental products, services, and solutions. For more information on Sirona and 3D Imaging, please visit www.sirona3D.com, or call 800-659-5977. Visit Sirona Dental at Booth No. 301

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ABSTRACTS

The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research 5-year results comparing mineral trioxide aggregate and adhesive resin composite for root-end sealing in apical surgery Von Arx T, H채nni S, Jensen SS. Journal of Endodontics (2014) 40(8):1077-81 Abstract Aim: Recent meta-analyses of the outcome of apical surgery using modern techniques, including microsurgical principles and high-power magnification, have yielded higher rates of healing. However, the information is mainly based on 1- to 2-year follow-up data. The present prospective study was designed to re-examine a large sample of teeth treated with apical surgery after 5 years. Methodology: Patients were recalled 5 years after apical surgery, and treated teeth were classified as healed or not healed based on clinical and radiographic examination. (The latter was performed independently by three observers.) Two different methods of root-end preparation and filling (primary study parameters) were to be compared (mineral trioxide aggregate [MTA] versus adhesive resin composite [COMP]) without randomization. Results: A total of 271 patients and teeth from a 1-year follow-up sample of 339 could be re-examined after 5 years (dropout rate = 20.1%). The overall rate of healed cases was 84.5% with a significant difference (P = .0003) when comparing MTA (92.5%) and COMP (76.6%). The evaluation of secondary study parameters yielded no significant difference for healing outcome when comparing subcategories (i.e., sex, age, type of tooth treated, post/screw, type of surgery). Conclusion: The results from this prospective non-randomized clinical study with a 5-year follow-up of 271 teeth indicate that MTA exhibited a higher healing rate than Kishor Gulabivala, BDS ,MSc, FDSRCS, PhD, FHEA, is professor and chairman of endodontology, and head of the department of restorative dentistry at Eastman Dental Institute, University College London. He is also training program director for endodontics in London.

46 Endodontic practice

COMP in the longitudinal prognosis of rootend sealing.

The effect of photodynamic therapy in root canal disinfection: a systematic review Chrepa V, Kotsakis GA, Pagonis TC, Hargreaves KM. Journal of Endodontics (2014) 40(7):891-8 Abstract Aim: Effective root canal disinfection is a fundamental component of successful root canal treatment. Photodynamic therapy (PDT) has been proposed as a new adjunctive method for additional disinfection of the root canal system with the possibility of improved treatment outcomes. The aim of this systematic review was to investigate the effect of PDT on bacterial load reduction during root canal disinfection. Methodology: Two reviewers independently conducted a comprehensive literature search using a combination of medical subject heading terms and keywords to identify studies relevant to the population intervention control outcome question. The selection of articles for inclusion was performed in two phases, based on predetermined eligibility criteria according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inter-reviewer agreement for each phase was recorded. The effect of PDT on bacterial load reduction during root canal disinfection was evaluated as the primary outcome variable during data extraction. Results: The literature search provided 57 titles and abstracts. Three articles met the inclusion criteria and were selected for this systematic review. The reasons for study exclusion in each phase were recorded. Because of the heterogeneity in clinical indications and PDT protocols among the included studies, a meta-analysis could not be performed. All included studies showed a positive effect of PDT in the reduction of microbial load in root canal treatment ranging from 91.3%-100%. Conclusion: Limited clinical information is currently available on the use of PDT

in root canal disinfection. If supported by future clinical research, PDT may have efficacy for additional root canal disinfection, especially in the presence of multi-drugresistant bacteria.

Periapical status of non-rootfilled teeth with resin composite, amalgam, or full crown restorations: a cross-sectional study of a Swedish adult population Dawson V, Petersson K, Wolf E, Akerman S. Journal of Endodontics (2014) 40(9):1303-8 Abstract Aim: Experimental studies show that dental pulp cells respond unfavorably to contact with resin composite restorative material. Hypothetically, in a random population, the frequency of apical periodontitis should be higher for teeth restored with resin composite than with amalgam. Therefore, the aim was to compare the periapical status of non-root-filled teeth restored with resin composite, amalgam, or laboratoryfabricated crowns in an adult Swedish population. Methodology: The subjects comprised 440 individuals from a randomly selected sample of 1,000 adult residents of a Swedish county. The type, material, and quality of the restorations were recorded for all non-rootfilled teeth by clinical examination and intraoral clinical photographs. Periapical status was evaluated on panoramic radiographs. The association between periapical status and type, material, and quality of the restorations was analyzed using the chi-square test and logistic regression analysis. Results: There was no significant difference in the frequency of apical periodontitis (AP) between teeth restored with resin composite or amalgam (1.3% and 1.1%, respectively). The frequency of AP for teeth restored with laboratory-fabricated crowns was significantly higher (6.3%). Regression analysis showed no association between AP and resin composite restorations but a significant association with laboratory-fabricated crowns. Volume 8 Number 3

The critical time lapse between various restoration placements and subsequent endodontic intervention Kwang S, Aminoshariae A, Harding J, Montagnese TA, Mickel A. Journal of Endodontics (2014) 40(12):1922-6 Abstract Aim: The purpose of this study was two-fold: first, to investigate the critical time lapse of endodontic intervention subsequent to various restorations and tooth surfaces, and second, to assess and compare the risk factors associated with the restorations, tooth surfaces, and endodontic treatment. Methodology: A comprehensive computerized analysis of all dental school patients at the Case Western Reserve University School of Dental Medicine who received restorations from 2008-2013 was obtained. Inclusion and exclusion criteria were applied. The sample size was limited to teeth with endodontic treatment completed by the endodontic postgraduate dental clinic. Data collected included restoration type, restored tooth surfaces, tooth type, and the dates of restoration and subsequent endodontic treatment. A two-sample paired t-test (95% confidence interval, P < .05) and pair-wise comparison with Bonferroni corrections were implemented. Results: The mean time between restoration placement and resultant endodontic intervention was 270 days, with a mean difference of 247-294 days (P <.0001). Further analysis revealed composite resin was 1.91 times more likely than amalgam and 5.69 times more likely than crowns to cause endodontic intervention. Teeth with two or more restorative surfaces required endodontic intervention (P < .001). Conclusion: Of the patients who required endodontic treatment after restoration placement, the critical time lapse was 9 months. Composite restorations and teeth with two or more restorative surfaces were significantly associated with endodontic treatment. From the results of the current study, we recommended that all dental practitioners should Volume 8 Number 3

Effective root canal disinfection is a fundamental component of successful root canal treatment. Photodynamic therapy (PDT) has been proposed as a new adjunctive method for additional disinfection of the root canal system with the possibility of improved treatment outcomes. perform a thorough endodontic evaluation and diagnosis before, during, and after all restorative procedures.

Histological evaluation to study the effects of dental amalgam and composite restoration on human dental pulp: an in vivo study Chandwani ND, Pawar MG, Tupkari JV, Yuwanati M. Medical Principles & Practice (2014) 23(1):40-4 Abstract Aim: To study and compare the effects of dental amalgam and composite restorations on human dental pulp. Methodology: One hundred sound premolars scheduled for orthodontic extraction were divided equally into two groups: group A, teeth restored with silver amalgam, and group B, teeth restored with composite resin. Each group was equally subdivided into two subgroups (extracted after 24 hours [A-1 and B-1] or 7 days [A-2 and B-2]), and the histological changes in the pulp related to the two different materials at the two different intervals were studied. Results: It was found that after 24 hours, the inflammatory response of the pulp in teeth restored with amalgam and composite was similar (p = 1.00). However, after 7 days, the severity of the inflammatory response of

the pulp in teeth restored with amalgam was less compared to that in teeth restored with composite (p = 0.045). Conclusion: This study confirmed that amalgam continues to be the mechanically as well as biologically more competent restorative material. Composite could be a promising restorative material to satisfy esthetic needs for a considerable period of time. However, its biological acceptance is still in doubt.

Treatment outcome of the teeth with cemental tears Lin HJ, Chang MC, Chang SH, Wu CT, Tsai YL, Huang CC, Chang SF, Cheng YW, Chan CP, Jeng JH. Journal of Endodontics (2014) 40(9):1315-20 Abstract Aim: A cemental tear is a special type of surface root fracture noted in combination with periodontal and/or periapical bony destruction. It was hypothesized that clinical characteristics and treatment techniques may affect the prognosis of teeth with cemental tears. Methodology: Treatment outcome for the teeth with a cemental tear was assessed in a multicenter cemental tear study project. Of the 71 teeth with cemental tears, 38 teeth (53.5%) were extracted. The remaining 33 teeth (46.5%) were examined for a treatment outcome of healed, questionable, or failed. Results: Outcome assessment found that 51.5% (17/33), 42.4% (14/33), and 6.1% (2/33) of teeth were classified as healed, questionable, and failed, respectively. Additive bivariate analysis indicated a significant difference between treatment outcome and the length (P = .01) and apicocoronal location (P = .02) of the separated root fragments. Logistic regression analysis found that treatment technique and apicocoronal location of cemental tears may affect the treatment outcome. The percentage of healed cemental tear cases located in the apical, middle, and cervical third of roots was 11.1%, 66.7%, and 60.0%, respectively. By surgical management, 57.7% of cemental tears were healed, whereas only 28.6% cases were healed after nonsurgical treatment. Conclusions: Most teeth with cemental tears can be retained to function by nonsurgical and surgical periodontal and endodontic treatment. Clinical diagnosis and treatment of cemental tears should also consider the apicocoronal location and the type of treatment technique to improve outcomes. EP Endodontic practice 47

ABSTRACTS

Conclusion: The results indicate that the risk of damage to the pulp-dentin complex from exposure to resin composite material and dentin bonding agents shown in experimental studies is not reflected in the clinical setting. However, in the study sample, AP was diagnosed in a significantly higher proportion of teeth restored with laboratoryfabricated crowns.

ENDODONTIC INSIGHT

Understanding what ROI is really about Dr. Brian Trava explains how ROI relates to CBCT technology

he acronym ROI is frequently used when discussing cone beam technology, but depending on your orientation, it may have two different meanings. The diagnostician will tell you that ROI would be defined as “Region of Interest.” The businessman will tell you it means “Return on Investment.” With CBCT technology, you really are investing in the capability to see detail. But if you don’t understand the details of your purchase, you may come up short in your investment and, most importantly, in your diagnosing. Many practitioners do very little research before making their imaging purchase, which leads to very little understanding both before and after the purchase. Having an underutilized CBCT taking up space is like an exercise bike at home with clothes hanging on it. In the decision-making process, price should be at the bottom of the list. Multimodality and software capability should be at the top of your list. With the diversity of financing, Section 179 of the tax code, and added value to office resale, the long-term numbers are insignificant. If the machine you choose is limiting or not upgradable, it may be no different than an old dental chair that costs money to dispose of. Evaluate your current practice needs, and make your decision on your future needs. Here is a really good tip before purchasing a CBCT machine for your practice: artifacts influence clinical diagnosis and treatment. Detail gives higher patient acceptance and increased accuracy. When studying a Region of Interest (ROI), how does the software handle metal artifacts to provide detail and not distort it? You know, those nasty high-density objects such as amalgam fillings, PFM crowns, posts, and implants with high-attenuation coefficients that create all the streaks, starbursts, and dark shadows corrupting the imaging detail are unavoidable when most of your scans will be on patients with a wide range of dental work. Diagnosing is about detail; you are purchasing detail, and you expect detail to be delivered. Can your machine manage this without any compromise of detail? Brian Trava, DMD, is an endodontist in New Jersey. You can learn more about his practice at http://njrootcanal.com/. Disclosure: Dr. Trava is a paid lecturer for Planmeca.

48 Endodontic practice

Figure 2: Raw volume, no artifact removal Figure 1: Small volume with streaks

Uses for the ProMax 3Ds new imaging mode for endodontics • Determining root curvature • Diagnosis of periapical pathosis • Diagnosis of trauma • Determining exact location of root apex in presurgical planning • Obtaining true anatomical measurements

So, when studying the ROI of any dental imaging purchase, how are artifacts handled within the field of view (FOV), and how is that related to detail? A CBCT machine can run an algorithm artifact removal program to reduce the streaks, but the actual metal object that is causing those streaks must be within the FOV for the artifact removal algorithm to work. Above, the image shows a small volume 5 X 5 FOV, an artifact removal was run, but streaks and interference are present — why? The artifact removal algorithm program has no effect on any metal objects that are outside the FOV volume, and your Region of Interest (ROI) can be detail compromised (Figure 1). So, if you are looking for a fracture in a tooth in a small volume size, you need to consider what high-density objects are in the contralateral and surrounding teeth. When considering and researching CBCT machines, our office made the decision on the Planmeca ProMax® 3D for many reasons. With regard to FOV and artifact removal, the software platform is the most versatile. You have the option of a small FOV to a larger field of view of 8 X 8 if needed to capture within and process out high-density metal artifacts

Figure 3: Artifact removal program

pending their proximity to your ROI. Next, the ProMax 3D gave us the option to have a raw volume with no artifact removal, or to run a scaled integrated amount of artifact removal depending on the quantity of high-density artifacts that may interfere with the ROI. These programs may be non-forgiving because they cannot distinguish between important and not important in the ROI. Endodontics is about detail. We did not want a CBCT machine that locked us into a standard artifact removal program that we had no control over. In Figure 2, there is no artifact removal program with an obvious fracture. In Figure 3, an artifact removal program was run showing a dilution of detail with regard to the fracture. In many patient cases, we need that edge, and prefer not to run any artifact removal. As our practice grew, a second CBCT was needed. More companies and machines had entered the marketplace. When doing the research, versatility again was an important factor. It was decided to add a second Planmeca ProMax 3D. Endodontics is about detail. CBCT is really about detail, diagnosing and treatment planning. Educate yourself before your purchase, recognize your needs in the future, become a better diagnostician, and your Return on Investment (ROI) will always be long-term. EP Volume 8 Number 3

STEP-BY-STEP

Optimal office design and planning with ASI How to achieve a high-end look for the state-of-the-art endodontic treatment room

Designing your treatment room Modern endodontists who are looking to increase revenue though optimized patient referrals should consider the following five goals when designing their treatment room: • Invest in technology versus nonproductive office build-out costs. In today’s competitive environment, it is vital that endodontists invest proportionally more of their office development costs into revenue- or referral-generating technology that will distinguish the treatment room from that of traditional dental office designs. • Enhance the patient experience and perception through the technological interface used during procedures and by removing unsightly clutter of cabling, wires, and extra foot controls. • Improve treatment efficiency to minimize unnecessary motions in order to perform treatment in the least amount of time necessary, allowing more procedures to be performed in one day without compromising quality. • Facilitate ergonomic positioning and methodology for both the endodontist and the assistant. A more comfortable practice method is critical for extended treatments and improves the mental focus of the team. • Have a flexible operatory space that can be easily reconfigured as needed or upgraded with new technology as it becomes available.

Implementation steps to achieving your office design goals Once you have determined your goals, achieving a distinctive operatory that is optimized for endodontic treatment can be accomplished in three easy steps. Volume 8 Number 3

Step 1: Consider alternatives to cabinets Create an operatory design that will be flexible enough to grow with you to help you to achieve your ultimate financial goals. A system that allows modular integration can save significantly on office build-out costs by eliminating traditional expensive wooden dental cabinets. The considerable amount saved by potentially not buying cabinets can go a long way toward the technology purchases you do want to prioritize. ASI provides integrated delivery systems designed for the endodontic specialist and assistants’ carts that work in conjunction with digital radiography, microscopes, and computerized inputs. Endodontic practice 49

STEP-BY-STEP Step 2: Design your system for the way you practice ASI’s exclusive instrument panel design allows integration of your preferred instruments in the order you choose. Each modular panel accommodates a wide range of electronic instrumentation, including electric motors, rotary motors, ultrasonics, apex locators, and obturation devices. Select from various brands while choosing the placement of each instrument and control them all with a single foot pedal. Add an assistant’s cart for a customizable and ergonomic delivery system that complements your own. The modular design allows for easy upgradability of your instruments or incorporation of new technology as it develops.

3’ TOE-BOX (Floor Opt.)

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ASI provides integrated delivery systems designed for the endodontic specialist and assistants’ carts that work in conjunction with digital radiography, microscopes, and computerized inputs. Step 3: Integrate the best technology Consider designing your system to integrate computer monitors, USB connection ports, CPUs, and any additional required cabling neatly within the system yet with convenient access. This makes the entire system your communication control hub from treatment instruments to diagnostic devices. In addition, keep wiring and utilities safely and attractively hidden from view. ASI’s unique Junction Box allows computer connections such as video, USB, network, and other IT connections throughout the treatment room to be easily organized along with standard utilities. A final touch is to consider running the foot control under the floor. The foot control tubing of an ASI system can be run underneath the floor through a conduit from the junction box to the patient dental chair. This enables easy access to the foot control without tubing running across the floor.

You can convey the ultimate perception to your patients that the treatment they are receiving is a highly specialized procedure from someone with true expertise. Consider the value and confidence the patient will perceive while in your fully integrated, seamless treatment room rather than looking at scattered instrument control boxes, multiple foot pedals, and various cords draped across expensive, space-eating storage cabinets and countertops. Whether remodeling an existing treatment room or starting from scratch, ASI brings 20 years of experience to your operatory design and planning process. We’ve coupled a service-minded customer sales and support team with a seasoned team of production experts to create the best possible solutions for your practice. Visit asimedical.net, or contact the customer sales team at 800-5669953 for more information. EP This information was provided by ASI.

ASI J-BOX

50 Endodontic practice

Volume 8 Number 3

STEP-BY-STEP

Anastomotic wound management The new Micro 1 x 2 tying forceps with thumb lock from Laschal

nastomotic wound management in the oral cavity has always presented unique ergonomic challenges. Delicate mucogingival closures in tight, confined surgical sites, demanding two sets of hands holding assorted retractors, suction apparatus, forceps, and needle holders, often lead to frustration at the end of a perfectly performed procedure. Add to that mix, a fresh suture with its full 18" length, and we have an additional challenge. Do we transfer the needle to the fingers of our non-dominant hand for convenience, or do we follow standard surgical protocol and transfer the needle to a forceps? • While transferring the needle to a forceps limits control over the needle, which may slip or spring out of the prongs, and requires continuous finger pressure to maintain its grasp, it remains the recommended method. • While convenient, transferring the needle to our fingers may result in the puncture of gloves or skin. It also puts the needle and fingers at least 16" away from the tail end of the suture, making an instrument tie a bit more difficult. Also, any small needle presents its own difficulties. The challenge, therefore, is to create an instrument and method of use that will safely and securely hold any size suture while at the same time facilitating and making the anastomosis more ergonomic. The new micro 1 x 2 tying forceps with thumb lock from Laschal, coupled with a slight change in standard procedure, solves both issues. 1. Grasp the forceps in the nondominant hand so that the thumb is positioned on the riveted portion of the thumb lock, and the middle finger is positioned above the hole that will receive it. 2. Use the tips of the forceps to firmly and gently grasp the tissue and the needle holder to complete the passage of the needle through both sides of the anastomotic site. 3. Transfer the needle to the forceps by grasping the suture just distal to 52 Endodontic practice

the needle. The forceps are so well engineered that it will ﬁrmly hold a 12-0 suture. By doing so, the needle is not ﬁrmly affixed to the forceps and will dangle. This is advantageous because any contact [of

the needle] with drapes, gloves, or skin will not cause any puncture or destabilization. 4. Squeeze the forceps tightly so that the thumb lock is engaged, and draw the suture to its most maximal Volume 8 Number 3

STEP-BY-STEP

and comfortable length to facilitate anastomosis. 5. Rotate the forceps in your hand so that the back end of the spring is positioned close to and points to the anastomotic site. This improves ergonomics by greatly reducing the length of the suture in preparation for the first instrument tie. 6. Complete the knots, using the freed-up thumb and index finger for

manipulation, and trim the suture in preparation for the next instrument tie. 7. Rotate the forceps back to its original position, transfer the needle back to the needle holder, and repeat the process for all additional instrument ties. Come see Laschal Surgical, Inc. at AAE booth No. 206. EP This information was provided by Laschal Surgical, Inc.

ANASTOMOTIC WOUND MANAGEMENT

The new Micro 1 x 2 Tying Forceps with Thumb Lock from Laschal

Our challenge is to create an instrument and method of use that will safely and securely hold any size suture while at the same time facilitating, and making the anastomosis more ergonomic.

NEW! Model PLAF/R/1X2/L

• Micro 1x2 teeth gently and securely manipulates mucogingival tissue • Perfectly engineered platforms securely grasp any size microsuture • Simpliﬁed technique enhances ergonomics Come see us at AAE booth number 206 Laschal Surgical, Inc., 4 Baltusrol Drive, Purchase, NY 10577 | Phone: 914-949-8577 | Fax: 914-683-3938 | Web: www.laschaldental.com

Volume 8 Number 3

Endodontic practice 53

PRODUCT PROFILE

EndoUltra’s™ effective ultrasonic activation is a game changer

mproving outcomes is a primary goal of endodontic treatment. Clinical studies have proved that ultrasonically created acoustic streaming and cavitation when combined with effective irrigating solutions produce cleaner canal anatomy. As the leader in Endodontic Irrigation, Vista Dental™ continually focuses on improving the effectiveness of endodontic irrigating solutions and the means to more safely and reliably deliver those solutions in complex canal anatomy. In 2014, Vista Dental launched the EndoUltra™ — the world’s only ultrasonic activator that operates with tip frequencies of 40,000Hz. Research shows that competitive sonic activation devices, which operate at 160Hz, are simply not effective in creating acoustic streaming and cannot produce cavitation. Research also proves that irrigants are more effective when they are electromechanically activated. Ultrasonic energy not only disrupts biofilm while improving penetration of irrigants and removal of dentinal debris, but also greatly reduces bacteria levels and improves root sealing. Numerous clinical studies support passive ultrasonic irrigation (PUI) over passive or sonic irrigation techniques. 54 Endodontic practice

Clinical studies have proved that ultrasonically created acoustic streaming and cavitation when combined with effective irrigating solutions produce cleaner canal anatomy.

EndoUltra™ is the only activation device 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™ is engineered and designed to deliver optimal clinical outcomes. The momentum for this pioneered and innovative technology is increasing rapidly. EndoUltra™ is cordless, compact, and easy to use, which features unique 15/02 Activator Tips, that resonate along the entire length of the tip and do not engage

tooth structure. Activator tips feature depth markers at 18, 19, and 20 mm. The EndoUltra™ also contains a LED light for improved visualization. For more than 20 years, Vista Dental Products has developed solutions and delivery systems that are designed to help clinicians improve endodontic outcomes. The EndoUltra™ ultrasonic activator is another example of product innovation and Vista’s dedication to the industry. To find out more information, visit www.vistadental.com, www.endoultra.com, or call 877-418-4782. EP This information was provided by Vista Dental™.

Volume 8 Number 3

ENDOSPECTIVE

“Rich, I ain’t workin’ for free anymore.” Dr. Rich Mounce explores the good, the bad, and the ugly of being a key opinion leader

eople have, at times, referred to me as a key opinion leader (KOL), but I don’t think of myself as one. If anything, I passionately enjoy teaching and learning about the business side of endodontics and dentistry in general. Over the years, I have met many KOLs of various disciplines (in addition to endodontics) and listened to their stories. Few if any of these KOLs started out with the intent to get their pictures and articles in magazines. For most, one small lecture or piece of writing became the proverbial match on gasoline. This Endospective column was written to relate my “The Good, the Bad, and the Ugly” experiences of having a public profile outside the office and to challenge readers to see if teaching outside the office holds any appeal for them. On the “good” side of the ledger, I’ve lectured in dozens of countries and made friends all over the world. It’s been the equivalent of a second endodontic residency, preparing lectures and learning through meeting other clinicians. I have also learned a lot about both how dentistry is practiced globally and the dental industry (outside of clinical practice). On this latter point, there is a portion of the dental world unseen by clinicians who focus solely on clinical practice. Dental product conception, design, testing, marketing, and distribution is fascinating (at least to me) and entirely unrelated to what happens in an operatory — with the sole caveat that the final product must be clinically effective to survive in the marketplace. My global exposure to the dental industry has been the inspiration of my endodontic supply company, MounceEndo.com. I could not have started this company without my industry experience.

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

Volume 8 Number 3

Iowa AGD MasterTrack class in Des Moines, Iowa, in September 2014. Course instructors : Dr. Richard Mounce, background, and Dr. David McCarty, foreground

On the “bad” side of the ledger, there are the days spent away from home and family, cancelled flights, jet lag, bad airport food, hecklers, among many such annoyances. One additional challenge is that if you speak for company X but use a competing product by a rival company Y, company X is not going to tolerate you advocating products in direct competition. The KOL is often married to one company. This phenomenon is a challenge with hotel courses, as some of these courses can become little more than infomercials designed to sell the latest and greatest widget with you as the widget salesman. The winner in the equation ultimately ends up being the sponsoring company. Not much has been “ugly” about my teaching experience, but if there is one thing to put a finger on, it’s the company that wants KOLs to work for little or no honorarium on the vague promise that something big is in the future. Expensive dinners, fancy hotels, Lincoln Town Cars, the ego stroke are all nice, but in lieu of an honorarium that makes being out of the office financially feasible, it’s a poor use of a clinician’s time, unless you just really

love to teach. More than one KOL has told me, “Rich, I ain’t workin’ for free anymore.” Amen. My suggestion to anyone who wants to be a KOL is, first and foremost, to figure out why you want to do it. While there are many positive motivations (teaching, learning, travel, professional exchange), for embarking on a KOL track, if it’s for the money, forget it. For the vast majority of KOLs, being a clinician is far more remunerative than speaking and running study clubs, except at the very highest level. Bear in mind, “A List” KOLs have certainly spent a lot of time working their way up from being a C List to B List KOL, etc., and when viewed in that light, the big daily honorarium earned now evens out with the many free gigs done earlier in their career. Would I do it again? Yes. Would I recommend it to others? Maybe. If you are truly passionate about teaching, able to roll with the punches, and like to travel, then absolutely yes. If not, better to stay home and focus on your family and office. They will endure long after the glow of being on a magazine cover has faded. I welcome your feedback. EP Endodontic practice 55

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Carestream Dental releases Logicon Caries Detector 5.1 Carestream Dental’s latest release of Logicon Caries Detector 5.1 further automates the detection process and produces improved displays of caries sites, making exams and diagnoses even more efficient than in the past. Logicon 5.1, the only commercially available FDA-approved computer-aided radiographic caries diagnosis software, is a unique and clinically proven tool that helps practitioners detect and treat interproximal caries at an early stage, enabling minimally invasive treatments. Studies show that Logicon more than doubles dentists’ capability to find early caries in the dentin over traditional visual diagnostic methods.* Logicon is clinically proven to help dentists quickly find up to 20% more interproximal caries on permanent teeth.** The technology is exclusive to Carestream Dental RVG sensors. With Doctor’s Diagnosis, clinicians can manually examine multiple potential carious sites/surfaces on a single radiographic image. Another new feature, PreScan, scans a radiographic image and applies a detection algorithm on all eligible interproximal surfaces to generate a view of potential caries, helping users verify manual findings by focusing on surfaces that need further investigation. For more information, call 800-944-6365, or visit www. carestreamdental.com. *Tracy KD, Dykstra BA, Gakenheimer DC, Scheetz JP, Lacina S, Scarfe WC, Farman AG. Utility and effectiveness of computer-aided diagnosis of dental caries. Gen Dent. 2011;59(2):136-144. **Gakenheimer DC. The efficacy of a computerized caries detector in intraoral digital radiography. J Am Dent. 2002;133(7):883-890.

Vista Dental™ introduces new products Vista Dental™ Products introduces Brite-N-Lite™, a powerful oral illumination device that offers direct illumination of the working area during any surgical procedure. This clip-on LED device is autoclavable and easy to use with virtually any aspirator. The cool white LED light optimizes visibility within the oral cavity. Brite-NLite™ features a long-lasting, rechargeable battery for hours of procedural use. Free with every Brite-N-Lite™ comes one free surgical aspirator of your choice. Also, Vista Dental offers a new patent-pending EDTA-based formula SmearOFF™, which effectively removes the smear layer and kills bacteria in one easy step. Vista’s SmearOFF™ formula is enhanced with chlorhexidine, which removes the smear layer and kills 99.9%* of bacteria. Compared to other 2-in-1 mixes, SmearOFF™ provides better calcium suspension.** This enhances its ability to open dentinal tubules and penetrate lateral canals for improved disinfection of instrumented canal systems. The company also has recently expanded its line of toothwhitening products, which includes Fluorescent™ EXpress White, an in-office whitening system, and Fluorescent™ for doctorsupervised take-home whitening. Fluorescent™ EXpress White is packaged as an easy-to-use (no mixing required), complete single procedure kit that contains everything needed for immediate whitening. A powerful non-light-activated in-office whitening system containing a 35% hydrogen peroxide gel, Fluorescent™ EXpress White works fast to whiten patients’ teeth in just one office visit. For take-home whitening, the original Fluorescent™ comes in convenient syringes that are easy for the patient to continue to apply at home. Fluorescent™ is a clear viscous gel and offered in either 16% or 22% carbamide peroxide formulas. The higher percentage formula provides the same outstanding results while increasing patient comfort through a shorter user-wear time. Fluorescent™ also contains fluoride, which helps lower sensitivity, and is packaged in either convenient Doctor or Refill kits in 16% and 22% formulas. To learn more, visit www.vista-dental.com or call 877-418-4782. * Independently confirmed by Nelson Labs; Time Kill Study protocol #STP0158.2

SIDEXIS 4: for clinicians and their patients Intuitive software and new features, such as patient timeline and lightbox for gathering and displaying images, sets a new standard in clinical diagnosis and patient care. Private practitioners Neal Patel, DDS, of Powell, Ohio, and Tarun Agarwal, DDS, of Raleigh, North Carolina, recently discussed how this innovative software with a sleek modern look has improved their ability to diagnose and treatment plan and effectively communicate their findings to patients, who are then more likely to accept recommended treatment. Dr. Agarwal said, “SIDEXIS 4 takes ease of use to another level. What was previously hidden in the menu bar is now clearly visible in workflow icons arranged to match typical clinical procedures. Our team was using it literally 30 minutes after we installed it.” Dr. Patel considered the software integration to be seamless and the workflow streamlined, offering the ability to move quickly from the mode of diagnosing an image and transition to patient education, treatment planning, and ultimately, case acceptance. For more information, visit www.Sirona3D.com.

56 Endodontic practice

** According to internal laboratory data when compared to other 2-in-1 solutions and used according to manufacturer’s instructions

ASI’s Ergo iTech™ delivery system integrates auxiliary technology ASI’s newest Advanced Endodontic delivery system — the Ergo iTech™ — integrates, houses, and hides auxiliary equipment, streamlining the use, look, and feel of the operatory. A door-mounted shelf can house a miniature computer CPU, and the network cable runs hidden alongside the umbilical to connect to the server. Dual USB connections link devices such as digital sensors. Extra storage space hides tabletop instruments such as obturation devices and charging stations. An articulating monitor mount can attach an LCD screen to the cart, which can make explaining treatment plans easier with clear digital imaging. The patient’s experience is enhanced by creating a well-designed, fully integrated setting for a one-on-one consultation. Visit ASI’s website at www.asimedical.net, or call 303-7663646 for more information.

Volume 8 Number 3

ProMax 3Ds OWN THE FUTURE™

PRACTICE PLANMECA

REVEAL THE FINEST ANATOMICAL DETAIL The ProMax 3Ds is a versatile and dynamic 2D/3D imaging system that brings new possibilities for diagnostics, treatment planning, and patient counseling. With a new imaging mode for endodontics featuring a 75µm voxel size, it is ideal for diagnostics requiring the finest anatomical details: • Determining root curvature • Diagnosis of periapical pathosis • Diagnosis of trauma: root fractures, luxation, displacement of teeth, and alveolar fractures • Determining exact location of root apex in presurgical planning to mitigate endodontic treatment complications • Obtaining true anatomical measurements

ENDO

Endodontic imaging mode is optional on all ProMax® 3D Models

See Planmeca at the American Association of Endodontics Dental Meeting

Booth #937 for a free in-office consultation, please call 1-855-245-2908 or visit us on the web at www.planmecausa.com

LET’S REDEFINE IMAGING

WE’RE ON A MISSION TO REDEFINE IMAGING. If you haven’t looked at Carestream Dental imaging systems lately, it’s time. Because our new innovations make it easier than ever to improve diagnoses, streamline workflow – and save valuable time.

MISSION ACCOMPLISHED. For details on special financing and limited-time values, call 800.944.6365 or visit www.carestreamdental.com/MISSION.

NEW CS 8100 3D CBCT • Compact, lightweight design fits virtually any practice. • Four selectable fields of view cover daily diagnostics. • Precise, high-resolution 3D scans (75 µm) facilitate more-accurate diagnoses.

NEW RVG 6200 SENSOR • Endo, perio and dentin-enamel filters for more-accurate diagnoses. • Always-active sensor provides a simplified workflow: Position. Expose. View. • Provides high-resolution, film-quality digital images.