Endodontic Practice US - July/August 2015 Issue - Vol8.4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews July/August 2015 – Vol 8 No 4

PROMOTING

EXCELLENCE

ENDODONTICS

Using a bioceramic sealer in conjunction with vertical condensation Drs. Allen Ali Nasseh and Dennis Brave

Nonsurgical retreatment and perforation repair in a maxillary first molar Corporate profile

Dr. John Rhodes

Mani, Inc.

Practice profile Dr. Reid V. Pullen

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Relationship between clinical and histopathologic findings of 40 periapical lesions Drs. Francisco Javier Jiménez Enriquez, Jorge Paredes Vieyra, and Fabian Ocampo Acosta

Is Your Practice State of the Art?

Surface of a root canal cleaned with conventional endodontic instruments (8000x magnification)

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ASSOCIATE EDITORS Julian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICD Richard Mounce DDS Clifford J Ruddle DDS John West DDS, MSD

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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com GENERAL MANAGER | Adrienne Good Email: agood@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118

ndodontics has traditionally focused on the prevention and/ or treatment of apical periodontitis. Practically, this means the prevention or removal of microbes from the root canal using various instruments and techniques. After the microbial control phase, the resultant low microbial environment has been maintained with a dense root filling comprising a maximal (usually gutta-percha) core material and thin sealer layer. Traditional sealers need to be thin because they shrink upon setting and are susceptible to wash out when in contact with tissue fluids. The root filling is then protected by a critically important well-sealing coronal restoration. The implication has been that everything Dr. Martin Trope should be done to remove microbes and seal the canal even at the expense of sound tooth structure. Recently, the availability (and competition) from dental implants has shifted the focus on the survivability of natural teeth after different procedures, including root canal treatment. The minimally invasive restorative revolution has been transferred to root canal treatment with some claiming that sound tooth structure is equally or even more important than controlling the microbes in the root canal. The question has remained as to how to adequately root fill these canals that have not been overly shaped (and weakened) to allow a plugger to reach the apical third. The new class of bioceramic sealers allows just that. They do not shrink on setting and are resistant to wash out when in contact with tissue fluids. With this sealer, the previous necessity of maximal core material and a thin layer of sealer no longer holds true. Thus now the sealer does the work in resisting microbial leakage, and the role of the gutta-percha point is to create hydraulic pressure to force the sealer into the irregularities of the canal. Ongoing research suggests that the use of the bioceramic coated and impregnated cones enhance the bond strength and seal of canals obturated with bioceramic sealer. Thus it is not imperative to heat the gutta percha or to use multiple points. It is important to note that bioceramic bonded obturation is now possible with both warm and cold obturation techniques. I feel strongly that if these new cleaning and filling technologies are correctly used, we can fulfill both needs in endodontics — a healthy periradicular periodontium through adequate microbial control and a superior seal of the space created while maintaining enough tooth structure to maximize the survivability of the tooth long-term.

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Michelle Manning Email: michelle@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

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Volume 8 Number 4

Martin Trope, BDS, DMD, is a Diplomate of the American Board of Endodontics. He has served as Chair of Endodontology, Temple University, Philadelphia, and Chair of Endodontics, University of North Carolina, Chapel Hill. He served as Editorin-Chief of the journals Dental Traumatology and Endodontic Topics. He is presently in private endodontic practice in Philadelphia and is a Clinical Professor at University of Pennsylvania. He also serves as Clinical Director at Brasseler, USA®.

Endodontic practice 1

INTRODUCTION

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July/August 2015 - Volume 8 Number 4

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TABLE OF CONTENTS

Endo essentials Measuring success Dr. Roger Levin explains how to audit your management systems.............. 14

Practice profile Reid V. Pullen, DDS

His badge of honor: to protect and serve endodontic patients

Technology Using a bioceramic sealer in conjunction with vertical condensation Drs. Allen Ali Nasseh and Dennis Brave discuss a new low melting point gutta percha....................................16

Ni-Ti goes Gold 10 clinical distinctions Dr. John West specifically evaluates the new ProTaper Gold®: a 1-year clinical performance retrospective ........................................................21

Endodontic insight The Glide Path — laying the groundwork for proper endodontic instrumentation Dr. Barry H. Korzen offers insight to ensure proper completion of the endodontic instrumentation.............26

Corporate profile

Mani, Inc. — From our hands to yours, “The Best Quality in the World, to the World” Mr. Kazuaki Kato offers insight into Mani’s history and high standards

ON THE COVER Inset image on cover is an intact nerve removed from an upper molar. Photo courtesy of Dr. Reid Pullen.

4 Endodontic practice

Volume 8 Number 4

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TABLE OF CONTENTS

Abstracts The latest in endodontic research

Continuing education Nonsurgical retreatment and perforation repair in a maxillary first molar

Dr. John Rhodes discusses treatment for a technically challenging condition

Dr. Kishor Gulabivala presents the latest literature, keeping you up-todate with the most relevant research ....................................................... 40

Practice development How to achieve influence online Dr. Julian Webber discusses a new online resource for endodontic patients and the digital environment for endodontists...................................44

Endospective No pressure, no diamonds Dr. Rich Mounce offers some gems on reaching goals................................. 46

Practice management

Continuing education 34 Relationship between clinical and histopathologic findings of 40 periapical lesions Drs. Francisco Javier JimĂŠnez Enriquez, Jorge Paredes Vieyra, and Fabian Ocampo Acosta discuss the clinical and histopathological findings of periapical inflammatory lesions treated by endodontic surgery

6 Endodontic practice

Increase case acceptance by becoming a patient-centered practice and offering flexible payment options Marla Merritt discusses how to make treatment more affordable................47

Volume 8 Number 4

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PRACTICE PROFILE

Reid V. Pullen, DDS His badge of honor: to protect and serve endodontic patients

What can you tell us about your background? I grew up in southern California playing football, baseball, and basketball and didn’t have an artistic bone in my body. I played football at the University of California, Davis, and graduated with a BS in Biology in 1995. I then attended University of Southern California (USC) Dental School and graduated in 1999. I completed a 1-year Advanced Education in General Dentistry in the Army Dental Corps in Landstuhl, Germany, in 2000 and served in the Army as a dentist from 1999-2002. I then spent 2 years in private practice as a general dentist in Yorba Linda, California, which I found to be an extremely valuable experience. I decided to follow a desire that had been growing for the last few years and applied to endodontic residencies and attended the Long Beach VA Endodontic Residency from 2004-2006. I opened my own endodontic practice in 2007 in Brea, California, and have been working hard ever since to be better and to grow the practice. I also have three perfect kids and a wonderful wife and like to work out, eat, and read.

When did you become a specialist, and why? I became an endodontist strictly for the fame and money. No, really, I first became interested in endodontics while in the Army. I was scared of maxillary molar root canals, and after learning the basics, I was let loose to perform endo. After some success and many mistakes, I started realizing that it was pretty fun, and that I could actually do it. I liked the complexity of each treatment and also loved how cool you look while using a microscope.

Is your practice limited solely to endodontics, or do you practice other types of dentistry? My practice is limited solely to endodontics. 8 Endodontic practice

Dr. Pullen working: “I sometimes stand, sometimes sit”

Why did you decide to focus on endodontics? I entered the Army planning to be an oral surgeon. I changed my mind numerous times over the next 3 years, exploring periodontics and pediatric dentistry. The military was a great place to learn about the different specialties, and all of the specialists were extremely open and willing to help in any way they could. I settled on endodontics thanks to my friend Adam Colombo, an endodontist in Kansas City, who encouraged me to perform more root canals. I realized that it was a very complicated and cool procedure with immediate payoff. So yes, I learned how to do root canals on our American soldiers, and I had a lot of geographic success. In other words, I left Germany before I could see any of my endodontic failures.

Do your patients come through referrals? Yes, the majority of my patients come through referrals, but over the last year, I have learned that a lot of patients came to us because of our Yelp reviews. At the time I knew very little about Yelp but have realized how important online reviews can be. I now ask our patients to tell their general dentist what a great experience they had in our office and to write a favorable Yelp review. I also tell them if they didn’t like us to keep quiet.

How long have you been practicing endodontics, and what systems do you use? I completed the endodontic residency in 2006. For a year and a half I was an endodontic journeyman and finally settled down and opened a practice in Brea, California, in 2007. I absolutely love the WaveOne® reciprocating file (soon WaveOne® Gold) and the ProTaper Next® Volume 8 Number 4

PRACTICE PROFILE

(Dentsply Tulsa Dental Specialties) shaping files. I have multiple NiTi file disorder and use an array of NiTi files including TRUShape™, ProTaper Gold® and Vortex Blue® (Dentsply Tulsa Dental Specialties). All of these files are absolutely amazing by themselves or used in a hybrid technique. I like using different file systems because it keeps things interesting and fresh, and it allows me to master more techniques. I also feel it makes me a better teacher and lecturer because I am more experienced on each file technique. I also have multiple sealer disorder and use Endosequence BC Sealer™ bioceramic sealer and bioceramic gutta-percha points (Brasseler USA®), Pulp Canal Sealer™ EWT (SybronEndo), and ThermaSeal Plus Ribbon Sealer® with GuttaCore® (Dentsply Tulsa Dental Specialties).

What training have you undertaken? Besides dental school and residency, I continue to attend as many quality continuing education classes as possible. I have taken an implant course and still love to listen and learn techniques from other endodontists. I usually pick up a few gems from each lecture I attend and can immediately apply them to my clinical practice.

Who has inspired you? Dr. Stephen Davis, my Endodontic Resident Director at Long Beach VA, was a great teacher and loved to ask hard questions. All of my co-residents at the Long Beach VA were fantastic and were always trying to make each other better. Dr. Gary Carr was very influential in setting up an ergonomic office with highquality technology. He also inspires all of us to be excellent. Dr. Cliff Ruddle has always been a great teacher and very inspiring to young endodontists trying to find their way. Dr. Adam Colombo (endodontist), my good Army buddy, encouraged me to apply to endodontics and to stay healthy in that endeavor. My extremely talented associate, Dr. Paula Elmi, makes me better every day and continues to push me to be excellent. My wonderful parents and sisters always loved me and expected excellence with no excuses allowed. Lastly, my loving wife always encourages me to be my best and allows me to vent when I have rough days.

What is the most satisfying aspect of your practice? I love when patients tell us that was the most painless, easy root canal they have ever had. (Of course, this is not always the case.) We also try to infuse a little humor into the procedure, and a few patients have told us Volume 8 Number 4

Dr. Pullen’s office in Brea, California Endodontic practice 9

PRACTICE PROFILE that was the funniest dental experience they have ever had. My endodontic assistants are all very funny and really help lighten things up especially with a fearful patient. Also, I love when a case turns out well, and I know in my heart that I did everything I could to be excellent. Now I just have to figure out how to do that every time.

Professionally, what are you most proud of? Two things: first, becoming a Diplomate of the American Board of Endodontics in 2013, and second, setting up a new practice from scratch. It was a lot of work and stress but has been immensely gratifying.

What do you think is unique about your practice?

What has been your biggest challenge? Finding the right staff that can all get along day in and day out. Endodontics is a very hard field, and it is especially hard on the assistants. I now have a phenomenal staff: Stephanie, Trish, Lizz, and Natalie. These are four of the best staff members I could ever ask for.

What would you have been if you didn’t become a dentist? Cop. My personality seems to fit that field. I always ask my cop friends to tell me stories so that I can live vicariously through them.

What is the future of endodontics and dentistry?

I am proud of the technology in my practice. I have TDO, which is the best endodontic software on the market. TDO allows me to print out or email beautiful patient reports and to provide seamless digital radiography, CBCT images, and pictures taken through the microscope to each patient’s file. It is a very thorough and well-constructed endodontic software created to give a complete digital office. I use OPMI PROergo (Zeiss) microscopes with the assistant scope and cameras, so I can take pictures and video and document information, especially cracks and fractures, in the patient charts. I have a LightWalker® laser (Fotona) and use photoninduced photoacoustic streaming (PIPS®) on all my cases. This is laser-enhanced chemical debridement, which is accomplished by placing the PIPS laser tip just into the access and using photons to cause a tidal wave of aggressive acoustic streaming to move solution throughout the entire root canal system. I also have a limited-focus CBCT (Carestream) that I find invaluable in my diagnosis and retreatment and surgical planning.

I think the future of endodontics is very exciting. With the advent of Sonendo® and PIPS and the new irrigation paradigms that are coming out, the field of endodontics will be changing for the better. The nickeltitanium files are also getting easier and safer. WaveOne and WaveOne Gold (coming out soon) reciprocating files allow the clinician to treat an entire canal system with one file in a very efficient, predictable, and safe manner. Even though the technology is making it easier for general dentists to perform endodontics, I still think the endodontic community will be busy for many years to come. Root canals are still difficult!

Extracting teeth in Haiti

Best kids in the world — Haiti Orphanage

10 Endodontic practice

What are your top tips for maintaining a successful specialty practice? 1. Perform the best treatment possible, and try not to hurry through a case. When in doubt, use two visits to complete the nonsurgical root canal treatment (NSRCT). 2. Call all of your patients the next day. This is a huge practice builder because the patient sees how much you care and often tells the referring dentist that you called to check on them. 3. Use new nickel-titanium files on new cases. I can’t remember the last time I have separated a new nickel-titanium shaping file. 4. Invest in technology (CBCT, PIPS, PROergo microscopes). 5. Hire great staff members, and form a loyal team (easy to say, hard to do). Take them all out to happy hour and sushi or to a ballgame every now and then. This builds relationships and only serves to improve office morale.

What advice would you give to budding endodontists? Buy the best equipment. If you are opening your own practice, I 100% HIGHLY recommend using The Digital Office (TDO) as your office software. This is a huge practice builder, and Dr. Gary Carr and the TDO group give excellent support and are always

Volume 8 Number 4

What are your hobbies, and what do you do in your spare time? I like most to be with my wife and three kids. I have coached my kids in baseball, basketball, soccer, and football. Recently, I coached an all girls’ 4th grade flag football team in an all boys’ league. We won three games, and I was surprised to see how tough and competitive the girls were. The boys feared us! I also enjoy working out, martial arts, surfing, playing golf, and reading. I recently spent a week at an orphanage in Haiti performing tooth extractions. It was a very difficult experience to see the suffering and poverty that exists in Haiti. Many of the adults whom I treated had never seen a dentist. I came to learn that the Haitian people are extremely resilient and adaptive. Also, these last few years, I have started teaching and giving lectures and hands-on workshops around the country. It has been a lot of fun, and I have learned a lot through this process. EP

Top 10 favorites 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

PROergo microscope from Zeiss TDO (The Digital Office) software The 90003D CBCT and digital sensors (Carestream) LightWalker® laser from Fotona (photon-induced photoacoustic streaming) WaveOne®/WaveOne® Gold reciprocating nickel-titanium shaping file (Dentsply Tulsa Dental Specialties) ProTaper Next® nickel-titanium shaping files (Dentsply Tulsa Dental Specialties) ProMark® Apex Locator (Dentsply Tulsa Dental Specialties) ProMark® rotary/reciprocation motor (Dentsply Tulsa Dental Specialties) New ProTaper Next® X2 gutta percha (Dentsply Tulsa Dental Specialties) EndoSequence BC Sealer™ bioceramic sealer and bioceramic coated cones (Brasseler USA) EndoPro270 cordless heat plugger (Brasseler USA)

Top right: “The Karate Kid” (Dr. Pullen surfing) Bottom left: Dr. Pullen and his family enjoying Kauai Bottom right: Supporting the CSUF Center for Autism Volume 8 Number 4

Endodontic practice 11

PRACTICE PROFILE

friendly. I recommend buying a good CBCT machine because what you can see, you can do. If you don’t know something is there, then it will be tough to find and treat. Work hard, and learn as much as you can. For the first 3 years, try not to work fast but smart, and when in doubt, place calcium hydroxide.

CORPORATE PROFILE

Mani, Inc. — From our hands to yours, “The Best Quality in the World, to the World” Mr. Kazuaki Kato offers insight into Mani’s history and high standards

stablished in 1956 in Takenzawa, Japan (north of Tokyo), by our Founder, Masao Matsutani, Mani is a manufacturer and supplier of medical instruments to over 120 countries worldwide. We are very proud of our long history of research, innovation, and manufacturing quality. Our singular goal is “Contributing to people’s happiness in the world through developing, manufacturing, and delivering the product that can help doctors and patients.” In addition, we strive to improve the quality of people’s lives by providing “The Best Quality in the World, to the World.” More than a slogan, this is our passion at every level of Mani (Figure 1). Mani has a storied history. Highlights among many innovations since our founding include producing the world’s first “18-8” stainless steel surgical needle in 1961. In 1991, Mani introduced the world’s smallest drilled eyeless needle (27μm) for trial and developed a skin stapler for medical use in the same year. In 2013, Mani developed state-of-the-art metal skeletons for stent grafts. To date, Mani holds 310 patents (including 221 non-Japanese patents) and has 148 patents pending (including 126 nonJapanese patents). Mani meets and exceeds the highest manufacturing and quality assurance standards and is ISO 13485, and MDD 93/42/EEC (CE Marking — EC Medical Device) certified, among other certifications. Mani has received numerous awards since our founding, including the coveted Porter Prize in 2008, which recognizes outstanding Japanese companies. A truly global company, the surgical, ophthalmic, eyeless (needles), and dental divisions of Mani have consolidated subsidiaries in Vietnam, Myanmar, Laos, and the People’s Republic of China. Mani has been traded on the First Section of the Tokyo Stock

Kazuaki Kato is Senior Director, Dental Products Department at Mani, Inc.

12 Endodontic practice

Figure 1: Mani Headquarters, Kiyohara Factory, Utsunomiya, Japan

Exchange since 2012. Mani dental products are sold and represented worldwide through a group of carefully chosen dealers selected for their clinical and product knowledge. A market leader in many parts of the world, Mani is not yet well-known in North America. We seek to make Mani Dental a “household” name in North America with the introduction of our existing products (listed below) as well as with our exciting new anatomy-based NiTi rotary instrumentation system, Mani Silk. Mani Silk was launched at the American Association of Endodontics meeting in Seattle in May of 2015. Heat treated in the apical 10 mm of its cutting flutes, Mani Silk features a teardrop cross section, providing a smooth tactile feel, a feature which prevents the “screwing in” effect common with other instrumentation systems. Anatomy-based, Mani Silk has “Simple” packs for relatively straight and uncomplicated canals, “Standard” packs for canals of moderate curvature and calcification, and “Complex” packs for canals of severe curvature and calcification. Mani Silk was designed to provide a safe, predictable, and efficient instrument system that is both simple to learn and simple to use. Each pack has three files and can be

Figure 2: Mani Silk NiTi Instrumentation System

Figure 3: Clinical case instrumented with the Complex Pack configuration of the Mani Silk NiTi Instrumentation System

Volume 8 Number 4

Our singular goal is “Contributing to people’s happiness in the world through developing, manufacturing, and delivering the product that can help doctors and patients.”

used either “Crown Down” or “Step Back.” We believe the “Silky Smooth Feel” and predictable results from using Mani Silk are a winning combination for both the specialist and general dentist alike. We encourage you to try Mani Silk. Aside from Mani Silk, Mani offers an unmatched variety of stainless steel hand files, including K, H, Reamer, “K Flex” type — Flexile, .05 tapered — Flare, stiff — D Finders, flexible yet cutting — RT, among many other varieties. The hand file line also includes a complete offering of nickeltitanium options. Many of the above instruments are available in medium sizes (12, 17, 22, 27, etc.) and also safe-ended options. In addition to its rotary and hand files, Mani manufactures posts, gutta-percha removal instruments (GPR files), Gates Glidden Drills, Peeso Reamers, NiTi Flare Finger Spreaders, NiTi Pluggers, Stainless Steel Finger Spreaders and Finger Pluggers, micro K, H, and micro Flare files (.05 tapered) among other micro-endodontic file designs and products. Mani also sells a wide variety of accessories to sterilize and store burs and endodontic files. Aside from the endodontic products above, additional dental products include diamond, carbide, surgical, finishing, and polishing burs, sutures, and surgical needles. Our aim is to always develop the highest quality product possible and improve each product in successive generations. Toward Volume 8 Number 4

this goal, twice each year, we hold a conference called “The best quality in the world or not?” where we perform various tests on Mani products compared with our competition. A ranking chart is then created to see if our products are ranked the highest. If a product fails to reach the top rank, engineers are required to put together an action plan to improve the product so as to be ranked number one by the time of the next conference. In addition, we place a high value on skilled work performed by human hands. Although optical and mechanical quality control systems are installed to achieve efficiency and ensure quality, we do not rely solely on mechanical inspections. We believe that inspections carried out using the five human senses are key to ensuring “The Best Quality in the World, to the World.” For example, we supply more than 10,000 types of surgical needles, which are used on different parts of the human body by surgeons with various tactile preferences. Additionally, we manufacture over 2,000 types of dental instruments, all of which are subjected to human visual inspections in the production process. In essence, no product leaves our factories without having been inspected both mechanically and visually by a human being. Aside from world-class, patient-centered product development, and state-of-the-art manufacturing, Mani is deeply committed

Figure 4C: Mani staff being given gifts at the Iowa AGD Mastertrack class (left to right): Mr. Koichi Arakawa, Mr. Akihiro Shiozaki, Mr. Hiroyuki Ogiwara, and Mr. Daiki Kawaguchi

to clinical education and advancement of the specialty of endodontics both in North America and across the world. Mani has sponsored and participated in numerous hands-on courses in the United States. For example, among other courses, Mani was proud to be a part of the 2014 Iowa Academy of General Dentistry™ (AGD) Mastertrack endodontic course given by Dr. Richard Mounce and will be helping Dr. Mounce again with the 2015 Nebraska AGD Mastertrack endodontic course. Events such as these are one of the many ways that Mani obtains direct customer feedback to both understand our customers’ needs and help identify needed future products to move the specialty forward. In addition to the above commitment to our customers, we exhibit at all of the major trade shows in North America, including, but not limited to, the American Association of Endodontists, Greater New York Dental Meeting, Chicago Midwinter Meeting, and the CDA (North and South) meetings. We encourage you to visit with our representatives at these meetings to get to know us better. And finally, the Mani team is a company made up of individuals dedicated to a common goal: helping improve the quality of people’s lives globally. Regardless of the country worked in, Mani employees are selected for their honesty, manual dexterity, and desire for continuous improvement. Such crucial personal qualities ensure that both Mani’s labor and product quality are of the highest standard. Given our proud history and constant effort to improve our products, we can truly and humbly say from our hands to yours, “The Best Quality in the World, to the World.” Thank you. For more information about Mani and Mani Silk, we welcome you to visit http:// www.mani.co.jp/en/. EP This information was provided by Mani, Inc.

Endodontic practice 13

CORPORATE PROFILE

Figures 4A and 4B: Clinical course with participation by Mani given in Des Moines, Iowa for the Iowa AGD Mastertrack class (lecture and hands-on by Dr. Richard Mounce)

ENDO ESSENTIALS

Measuring success Dr. Roger Levin explains how to audit your management systems

our endodontic practice already has systems — how you schedule patients, procedures for collecting overdue accounts, the way you present cases, techniques for generating referrals, and so on. But are your existing systems serving you well or actually working against you? If you and your staff have not performed a thorough systems audit within the last 3 years, you could probably be bringing in the same revenues — or even more — with less effort and stress.

Tweaks and bottlenecks The problem with most practice systems is that, no matter how effective they may have been when first implemented, they become obsolete over time. Conditions change, and systems that don’t change with them gradually lose both effectiveness and efficiency. When procedural stumbling blocks begin to show up, staff members try to compensate. Improvising stopgap solutions, the team adds new steps, allocates more time, tries taking shortcuts, and settles for less than ideal results. Whatever you call these measures — patches, workarounds, tweaks — they don’t fix systems that are breaking down. If anything, they obscure the problems that need attention and allow bottlenecks to accumulate. Better by far to acknowledge that every system will someday need to be replaced — not tolerated or updated, but redesigned from the ground up.

Start with performance targets To create a new system, define what you want it to accomplish, specifically. For example, think of a scheduling system not merely as placing patients in openings in your schedule but as how your front desk coordinator balances the workload every day. The

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

14 Endodontic practice

objectives are to avoid peaks and valleys, schedule all consults and treatment within 7 days, use scripting and confirmations to keep no-shows and cancellations to less than 1%, etc. Setting targets will not only guide system design but also enable you to gauge the effectiveness of the resulting systems, evaluate the performance of staff, and monitor your progress toward practice goals.

Create each new system stepby-step To design a system, assemble a small team consisting of you and/or your office manager, the staff member(s) who will use the system regularly, and perhaps others who are directly affected by what the system accomplishes. Ignoring the existing protocols as best you can, go through the entire process the system will control, carefully designing each step and allowing for different paths based on various patient responses and other specifics that will be encountered. As you near completion of a prototype, define every step specifically in writing. At this

stage, you may want to test the prospective new system in real situations to see if there are any unanticipated “bugs” to be eliminated.

Prepare detailed documentation

system

Once you’ve finalized a new system, write a detailed description of how to use it, including every step involved. This documentation is very important. It means that if the only team member who knows a system leaves the practice, you won’t be forced to reinvent the step-by-step process. Also, the written description will serve as the basis for thorough staff training —without which even the best system will fail to achieve the desired results. Using the main system documentation as a resource, you should generate two types of additional documents: 1. Training scripts Most of the systems an endo practice relies on involve interactions with patients. Scripting makes it relatively easy for staff Volume 8 Number 4

2. System quick guide This is a simplified checklist of how a system should work. Regular users should refer to this document frequently to ensure that they will not begin drifting back to old

Having the best systems is not a goal; it’s a process.

but also the “whys.” Acquaint staff members with the practice vision and goals — how the performance targets they are responsible for will serve as steppingstones for reaching those goals, and how the systems they use will help them achieve the desired results. Keeping team members in the loop will empower them, increasing the level of both their performance and their job satisfaction.

Be prepared to repeat the whole process habits or leave out any steps. The guide is especially important when introducing a new system or when a new or infrequent user is about to work with the system.

Train team members to excel As discussed previously, team members need to learn exactly what they are expected to do with their assigned systems. Their training should include not only the “how-to’s”

Go through the process described, and you will create new systems that are far more effective and efficient than your old systems. But conditions will continue to change, and your new systems, excellent as they are, will also need to be replaced eventually. Having the best systems is not a goal; it’s a process. Master it, and your endo practice will thrive, whatever changes the future may bring. EP

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Endodontic practice 15

ENDO ESSENTIALS

members to say the right things in order to get the right results. Scripts are not meant to be memorized and followed verbatim. They provide conversational guidelines and key message points for team members who should be encouraged to “translate” scripts into their own words. One of the greatest advantages of using scripting is that it lends itself extremely well to training. Role-playing among staff members enables them to master the systems while they learn their scripts. Their competence and confidence increase quickly with script-based training. This approach also has great value in staff cross-training and, of course, in training new employees.

TECHNOLOGY

Using a bioceramic sealer in conjunction with vertical condensation Drs. Allen Ali Nasseh and Dennis Brave discuss a new low melting point gutta percha

hen Dr. Herbert Schilder wrote his original article in 1967 on the topic of filling root canals in three dimensions, he was attempting to shed light on the important concept of filling the entire canal and using adequate hydraulics to allow movement and displacement of the resorbable and dimensionally unstable sealer with the marginally more stable thermoplasticized gutta percha.1 The goal was to replace the poor quality sealers of his time with gutta percha following the prevalent axiom of his time, which urged practitioners to minimize the sealer interface. Minimizing the Sealer Interface (MSI) as an axiom was a reaction to the poor quality root canal sealers that were available during that era, including, but not limited to, zinc oxide eugenol (ZOE) and resin sealers. Both lateral and vertical condensation use variations of the same theme, condensing solid or thermoplasticized gutta percha to replace the sealer, thus allowing the realization of this axiom. Why gutta percha was deemed better than sealer was based on the poor material properties exhibited by the previous generation of sealers, which if left to pool in the canal, would shrink and wash out over time, leaving a gap. This is why all compaction techniques have tried to address this issue by replacing the soluble sealer with the insoluble gutta

Figure 1: BC 150 Series Gutta Percha points melt at a lower temperature of 150° Celsius compared to the original EndoSequence and BC gutta percha cones that melt at a higher melting point (250° Celsius)

percha, explaining the historical evolution of obturation techniques and the need to move gutta percha through various compaction methods. Recently, as a result of the development of a new generation of sealers (BC Sealer™, Brasseler USA®) that exhibit far superior properties when compared to gutta percha, the entire axiom of MSI has come under question.2 The development of a dimensionally stable, non-soluble, biocompatible, antibacterial, hydrophilic bioceramic sealer with the additional benefit of bonding to dentin has initiated a new era of endodontic obturation, where MSI may no longer be the applicable basis of obturation.3,4

Dennis Brave, DDS, is a Diplomate of the American Board of Endodontics, and a member of the College of Diplomates. He received his DDS degree from the Baltimore College of Dental Surgery, University of Maryland, and his certificate in Endodontics from the University of Pennsylvania School of Dental Medicine. He is an Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas Odontologic Honor Society Member. In endodontic practice for over 25 years, he has lectured extensively throughout the world and holds multiple patents, including the VisiFrame. Dr. Brave was voted one of “Baltimore’s Best” Endodontists by Baltimore Magazine. Formerly an associate clinical professor at the University of Pennsylvania, Dr. Brave has authored numerous articles on endodontics and is a co-founder of Real World Endo® (RealWorldEndo.com). Allen Ali Nasseh, DDS, MMSc, received his dental degree from Northwestern University Dental School in Chicago, Illinois, in 1994 and completed his postdoctoral endodontic training at Harvard School of Dental Medicine in 1997, where he also received a Masters in Medical Sciences (MMSc) degree in the area of bone physiology. He has been a clinical instructor and lecturer in the postdoctoral endodontic program at Harvard School of Dental Medicine since 1997 and the Alumni Editor of Harvard Dental Bulletin. Dr. Nasseh is the President and Chief Executive Officer for the endodontic education company Real World Endo® (RealWorldEndo.com). He is the endodontic advisor to several educational groups and study clubs and is endodontic editor to several peer-reviewed journals and periodicals. He has published numerous articles and lectures extensively nationally and internationally in surgical and nonsurgical endodontic topics. Dr. Nasseh is in private practice (MSEndo.com) in downtown Boston, Massachusetts.

16 Endodontic practice

Up until now, this sealer (BC Sealer) was advocated for a cold, synchronized Master Cone-Master File, Hydraulic Condensation technique generally without the need for additional lateral or vertical compaction deep in the root canal. However, some practitioners who have been using vertical compaction for decades have found it difficult to make the transition to the simpler Bonded Hydraulic Condensation Technique,3,4 preferring to simply adapt BC Sealer into their existing vertical compaction protocol. In response to this need, the manufacturer of BC Sealer has introduced a line of lower melting point gutta-percha cones (Figure 1) that are synchronized with the EndoSequence® and ESX® 0.04 constant taper files. They melt at a lower temperature of 150° Celsius compared to the original EndoSequence and BC gutta-percha cones that melt at a higher melting point (250° Celsius). Since exposing BC Sealer to high temperatures dries out (desiccates) the cement, making it grainy and more difficult to manipulate, reducing the melting point of the Master Cone allows the application of a heated condenser at both a lower temperature and for less time to achieve the burn off effect. The newly released BC GP Points 150 Series (Brasseler USA) (Figure 2) are a work around to allow melting of the master cone Volume 8 Number 4

TECHNOLOGY at 150° Celsius, which prevents drying out the sealer and makes vertical compaction possible. Furthermore, the new BC Gutta Percha Pellets 150 are bioceramic containing gutta-percha pellets that melt at 150° Celsius and are compatible with most thermoplastic heat guns and allow the back fill of a vertically compacted case where BC sealer and 150 BC Cones are used. The clinical technique is as follows. After completing instrumentation using a constant tapered file such as the EndoSequence or ESX 0.04 Taper Master File, the corresponding size BC 150 Gutta Percha Cone is fitted to the root canal,

ensuring proper fit to the full working length (Figures 3A-3B). After pre-fitting the gutta-percha cone, a correct size plugger tip for a digital heat instrument such as the EndoPro 270 (Brasseler USA) is pre-fitted 5 mm-7 mm from the working length. BC Sealer is then deposited on a paper pad, and the Master File is used to coat the canal walls lightly all the way to the apex (alternatively, a small amount is injected only in the coronal portion of the root canal and then carried down using the Master File [Figures 3C-3D]. The direct injection technique is only recommended for practitioners using an Operating Microscope.). Once the canal is coated with BC Sealer, the pre-fitted cone is then seated to the full working length, and its full seating

is confirmed (Figure 3E). The heat source temperature is set to 150° Celsius, and the pre-fitted plugger is then advanced to its pre-fitted location while activating the heat (Figure 3D). After condensing the cone for 10 seconds without heat, the heat is reactivated, and the coronal gutta percha is removed, leaving a 5 mm-7 mm heated apical plug (Figures 3F-3H). The apical plug is then condensed with a pre-fitted plugger (Figure 3I). A BC 150 Gutta Percha Pellet is placed in a heat gun such as the Obtura® II (Obtura Spartan Endodontics), and the canal is backfilled through injection of 3 mm aliquots of gutta percha followed by compaction (Figure 3J). This process is repeated until the root canal is backfilled all the way to the orifice of the root canal. If post space is needed, backfilling may not be

Figure 2: The combination of BC GP 150 series and its associated 150 series BC GP Pellets allow vertical compaction at lower temperature with the thermoplastic gun of choice C.

Figures 3A-3F: Following instrumentation with a constant tapered rotary file, the constant tapered corresponding size BC GP 150 series is pre-fitted to the full working length. Sealer is then deposited and carried to the full working length with the help of the Master File. After the canal is coated, the cone is fully seated in each canal 18 Endodontic practice

Volume 8 Number 4

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TECHNOLOGY G.

necessary. Any remaining BC sealer is easily removed using a 10-second burst of ultrasonics and water (or a moist cotton pellet/ paper point if ultrasonics are not available). The tooth is then restored as planned (Figure 3K). The clinical video of this case/technique in this case is also available for viewing.5 While a close examination of the sealer properties of BC Sealer can lead to the inevitable conclusion that a one cone obturation technique (Synchronized Hydraulic Condensation) is all that is required to achieve optimal obturation results, some practitioners with years of experience in thermoplasticized techniques have felt the desire to combine bioceramics with heat. Since excessive heat can dry out the bioceramic sealer, a new line of lower temperature gutta-percha and backfilling pellets have been introduced to avoid applying excessive heat, thus making vertical compaction using BC sealer a clinically viable technique for those practitioners preferring its use. EP

Figures 3G-3K: The pre-fitted heat source is then used to sear off the gutta percha 5 mm-7 mm from the apex. Following compaction of the apical segment, 3 mm aliquots of BC 150 Pellets is added to back fill the remains canal

REFERENCES 1. 2. 3. 4. 5.

Schilder H. Filling root canals in three dimensions. Dent Clin North Am. Nov 1967;723-744. Nasseh A., Brave D. Why do we do what we do? A new standard of efficiency in instrumentation and obturation. Dentistry Today. 2014;33(10):112-117. Koch K, Brave D, Nasseh A. bioceramic technology: closing the endo-restorative circle, part I. Dentistry Today. 2010;29(2):100-5. Web site. http://www.dentistrytoday.com/endodontics/1100-sp-1133691715. Accessed June 15, 2015. Koch K, Brave D, Nasseh A. bioceramic technology: closing the endo-restorative circle, part II. Dentistry Today. 2010:29(3):98, 100, 102-105. Web site. http://www.dentistrytoday.com/endodontics/2588bioceramic-technology-closing-the-endo-restorative-circle-part-2. Accessed June 15, 2015. Nasseh, A. Vertical condensation with BC Sealer! [video]. RealWorld速Endo.com. 2015. https://realworldendo.com/videos/vertical-condensation-with-bc-sealer. Accessed June 15, 2015.

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Volume 8 Number 4

TECHNOLOGY

Ni-Ti goes Gold 10 clinical distinctions Dr. John West specifically evaluates the new ProTaper Gold®: a 1-year clinical performance retrospective

i-Ti file systems have come and gone. Mostly gone. Since the introduction of the first files around 1993,1 industry, scientists, dental companies, and clinicians have all been looking for the magic file. While there is no magic Ni-Ti shaping file per se, the new ProTaper Gold® (PTG) Shapers and Finishers (DENTSPLY Tulsa Dental Specialties [DTDS]) are making endodontic shaping magic particularly in canals that are calcified or curved to varying degrees (Figure 1).2,3 Why? It is true that PTG files produce predictable and safe results, but their true magic is in the positive and energizing experience of actually producing the result. It is a bold and audacious statement, however, to say that PTG is magic; so-claimed accomplishments must be backed up with evidence: scientific evidence, market evidence, and clinical evidence. This paper is a report on the proof of clinical evidence. I have divided this article into the 10 critical performance distinctions for evaluating Ni-Ti systems in the practice of clinical endodontics.4

No. 1: Predictability If you are reading this article, you yearn to do endodontics better and easier. If there were ever a lure of my writings over the years, it has never been about cheapest or fastest. In every article I have ever written, my goal has been to focus on value and performance.5-11 John West, DDS, MSD, is founder and director of the Center for Endodontics in Tacoma, Washington. He graduated from the University of Washington Dental School and received his MS degree and endodontic certificate at Boston University, where he was awarded the Alumni of the Year Award. He is an educator and clinician, and his focus is interdisciplinary endodontics. He has authored several textbook chapters and is an editorial board member for the Endodontic Practice US, Practical Procedures in Aesthetic Dentistry, and the Journal of Microscope Enhanced Dentistry. He can be reached at 800-9007668, via email at johnwest@centerforendodontics.com, or visit centerforendodontics.com. Disclosure: Dr. West is the co-inventor of ProTaper®, ProGlider™, WaveOne®, and Calamus® systems (DENTSPLY Tulsa Dental Specialties).

Volume 8 Number 4

Figures 1A-1C: 1A.The essence of ProTaper Gold® (PTG) series: SX, S1, S2 Shapers and F1, F2, F3 Finishers. 1B. The three precisely and progressively designed Shapers are used in a brush/follow motion in order to first remove access dentinal triangles and coronal restrictive dentin. 1C. The three specifically and regressively designed tapered Finishers are used in a follow/brush motion in order to prepare predictable and consistent shapes for easy 3D cleaning/disinfection and predictable 3D obturation

As dentists, we are self-selected. The Hippocratic Oath of “Do No Harm” means that we are trained to make things better, not worse, and not a just a little better. We are not trained to see how much we can get away with but rather how much we can get. Predictability is about how much we can get. Predictably is about past tense — how well did I do in the last 20 years? And, predictability is also about the future — how well will I do in the next 20 years? Predictability is about increasing the probability of success. It is also the knowingness and confidence that if we do certain things, we will get certain results. As dentists, our greatest fear is when we don’t know how a procedure is going to turn out. We have all had that sick feeling of a casting not fitting or breaking an endodontic file in a tooth. We are built to embrace successful performance. The clinical proof of the ProTaper® success story is the most critical distinction of all: sustainable and transferrable predictable predictability (Figures 2A-2D). How do you make the top-selling file system in the world better? Simple. Make the predictability of performance even better by maintaining existing geometries and introducing new metallurgy so that the clinician (not the file) has even more control! By adding advanced metallurgy to ProTaper Universal (PTU), a new era of predictability and safety has been born: PTG has redefined the endodontic shaping experience. PTG is the system that changed the file. Learn more about the performance of ProTaper Gold® at

TulsaDentalSpecialties.com and JohnWestEndo.com. Take-home message ProTaper Gold produces consistently predictable shapes for predictable cleaning and obturation that is easier and safer than ever before.12 Predictable endodontics requires precision performance that, in turn, gives dentists the desired confidence before treatment and the control during their clinical endodontic procedural mechanics.

No. 2: Safety In sports, it is referred to as “bending but not breaking.” If the new PTG’s most important critical distinction is improved predictability, then the critical distinction of safety ranks a close second. The more flexible PTG proudly produces greater torsional resistance and less cyclic fatigue, which is the same safety focus that inspired the successful Ni-Ti reciprocation files. In addition, a progressive series of rotary files allows less work required per file versus a single file having to do all the work. The great news is rotary has become remarkably safer (Figures 2E-2I). Take-home message PTG’s advanced metallurgy has discovered the perfect mix of safety, flexibility, and predictability in shaping. Today we are experiencing a newfound level of confidence because PTG enables files to effortlessly crawl along the smooth walls of existing glide paths. Endodontic practice 21

TECHNOLOGY

Figures 2A-2I: 2A. Pretreatment image of severely curved and calcified MB canal in maxillary right first molar. 2B. PTG F2 safely shaping canal to the physiologic terminus. 2C. Conefit. 2D. Backpacked root canal system demonstrating Schilder’s fourth mechanical objective: Flow, meaning the position of the apical portal of exit position is maintained without internal or external transportation. 2E. Pretreatment of mandibular second molar with abrupt apical mesial canal curvature. 2F. Original anatomy maintained using PTG. (Courtesy of Dr. Jordan West, Tacoma, Washington). 2G. Pretreatment of maxillary first molar. 2H. Pack image. 2I. Eight-month recall, which is the longest documented PTG posttreatment result. Attachment apparatus healed, and lamina dura is again present. The patient is asymptomatic. (Courtesy of Dr. Jordan West, Tacoma, Washington)

No. 3: Efficiency PTG is less efficient, making it more efficient. How can that be? The Merriam-Webster Dictionary defines efficiency as the “ability to do something or produce something without wasting materials, time, or energy.” One of the three hallmarks of ProTaper® has always been the quality of efficiency. ProTaper® was the first popular “cutting file” in the marketplace. When originally introduced, Ni-Ti shaping files had blades with flat edges called radial lands, but their efficiency waned. Now fast-forward 20 years to 2015; PTG clinicians are experiencing a softer and at first seemingly less efficient metal that instead serendipitously fosters a profoundly greater sense of smoothness, friendliness, and ease. The net result is that PTG is actually more efficient due to its effortless shaping capacity, leaving clinicians energized versus sometimes emotionally exhausted at the end 22 Endodontic practice

of their endodontic shaping, cleaning, and obturation procedures. In addition, PTG offers an economy of files that equally distribute the shaping workload. PTG metallurgy has such a profound ability to “follow” the shaped funnel of each proceeding file that clinicians have an unexpected and positive experience. There is a feeling of “file acceptance.” The sense is that the previous instrument has “paved the way” for the next file. To make your own unbiased and subjective test of the efficiency distinction for yourself, compare your current preferred Ni-Ti system with PTG. Put them head-to-head. Author Eckhart Tolle may have said it best: “Awareness is the greatest agent of change.” Take-home message The softer and more flexible PTG is experientially super-efficient. It does not make mistakes. This efficiency attribute is

achieved because the file does the shaping for the dentist by easily following down a canal versus more indiscriminately cutting down a canal! The dentist does not have to do the work; the flexible PTG design does it for you instead.

No. 4: Versatility “ProTaper Gold is synonymous with ‘versatility’ because it takes away the fear factor,” explains Dr. Jordan West. PTG offers the greatest versatility of any Ni-Ti file system in the world. I will prove my point. There are no problems in endodontics — only situations requiring smart thinking, smart strategy, and smart instruments. PTG is the most versatile Ni-Ti system in the world because it is smart. The original ProTaper sequence of Purple, White, Yellow, and often Red and Blue as needed, allows the clinician to progressivity shape in such a way that each successive instrument has equal and Volume 8 Number 4

TECHNOLOGY

yet minimal shaping to do (Figure 1A). Therefore, regardless of nature’s natural anatomy, the color sequence is constant and makes “what to do next” a no-brainer! Some clinicians are discovering that there are certain cases where a single Shaper may be sufficient to remove restrictive dentin followed by a single appropriate Finisher or the sequence of Finishers as needed. The big thing to me is when I don’t have to think about if the file is performing, I can think about all the other things that matter, such as irrigation, patency, restraint, conefit, 3D obturation, patient comfort, my comfort, dental assistant comfort, and all the rest of the endodontic parts that matter.

Take-home message PTG is the world’s most versatile Ni-Ti system. In certain cases it can be used as a single file or a series of files. What does this mean to you and me? More options, more choices, more control!

No. 5: Simplicity Simplicity has always been the hallmark of PTU and continues as the hallmark of PTG. The mindset is the same: Purple, White, Yellow, Red. Dentists who have enjoyed the predictability of ProTaper have always felt that the thinking and planning was already done for them by dedicated engineers and designer clinicians who wanted to produce consistent results. PTG makes sequencing as simple as it has ever been with the added critical distinction of exceptional rotary safety. Take-home message The PTG shaping technique requires little or no learning curve. There is nothing as simple as Purple, White, Yellow, and Red as needed. The sequence has never changed; only the safety and performance. Remember, this is a shaping system that can be immediately implemented into your practice today.

No. 6: Maximally appropriate endodontics So what is meant by the phrase “minimally invasive endodontics”? Prior to natural or traumatic canal calcific metamorphosis, nature makes the width of root canals from between one-fifth to onethird the width of the root at its coronal extent (Figures 3A-3F). The purpose of endodontic shaping is to produce funnel-shaped preparations that reproduce this coronal dimension and connect the coronal dots with the dots measuring the apical constriction. PTG’s Finishers reproduce original nature’s canal Volume 8 Number 4

Figures 3A-3H: 3A. Note: ToothAtlas.com reveals natural width of central is about one-third the width of the root while the DB canal of the maxillary molar is about one-fifth the width of the root. The shaping width goal of endodontics is simply to give nature back her original dimensions. I call this “Maximally Appropriate Endodontics.” The ferrule location that matters is not even mesial-distal; it is buccal-lingual. Shaping width claims of various Ni-Ti systems should be evaluating CBCT buccal and lingual remaining tooth, not mesial-distal! 3B. Animation of aging or calcifying DB canal that needs to be shaped to between one-fifth to one-third the width of the coronal portion of the canal. 3C. Arrow points to the two apical dots that represent the minimal physiologic constriction. 3D. Appropriate coronal PTG shaping width indicated by dots needs to be connected with the apical dots for proper funnel-shaped canal. 3E. Dots connected demonstrating outline of desired “Maximally Appropriate” funnel shape. 3F. Animated proper DB shape. 3G. Pretreatment of maxillary left first molar. 3H. Three “Maximally Appropriate”conefits. (Figures 3B-3F courtesy of Advanced Endodontics.)

shapes: not too big and not too small, but just right (Figures 3G-3H). Because PTG can be pre-curved, and due to shorter handles, dentists can more easily slide into the mesial endodontic accesses of patients with restricted openings and therefore design the most tooth conserving accesses possible. Take-home message PTG shapes are actually more appropriate than ever before. The coronal shapes produced from PTG are essentially just like Mother Nature makes. These shapes create cleaned contents and produce perfect preparations for the 3D endodontic seal. Until minimally invasive means not invasive at all, maximally appropriate is not only appropriate, but meets the desired finishing criteria for endodontic predictability.13

No. 7: Confidence PTG looks different and feels different. The feeling of confidence is what it’s all about. The feelings of easy, safe, and effortless are

qualities that are hard to prove. However, these priceless feelings are unmistakable and profound. In my years of measuring endodontic performance, it was not until PTG that someone like Dr. Jordan West observed that rotary shaping has been transformed from “fear to fun, especially in wicked curves” or Dr. Jason West’s remark after his almost 15 years of endodontics that PTG is a “game changer.” Endodontist Dr. Tom McClammy, who will soon be opening his advanced endodontic training center in Scottsdale, Arizona reports: “When PTU was released for clinical use, I remember coining the term ‘Nickel-Titanium Nirvana.’ PTU has been my go-to file in most clinical applications for well over a decade. Now with the ever-changing advancements in metallurgy and technology, PTG is in our hands. Wow! The term Gold speaks for itself, but the performance of PTG clinically is off the charts. We still have the shaping efficiency and now the superior flexibility to safely negotiate the multiplanar curvature of Endodontic practice 23

TECHNOLOGY

Figures 4A-4H: 4A. Pretreatment image maxillary right first and second molar. 4B. Exquisite PTG finishes of two in a row. (Courtesy of Dr. Tom McClammy, Scottsdale, Arizona). 4C. Pretreatment image of mandibular right first molar. 4D. Elegant PTG shapes. (Courtesy of Dr. Scott Doyle, Minneapolis, Minnesota). 4E-4F. PTG shapes and elegant obturations. (Courtesy of Dr. Wyatt Simons, San Clemente, California). 4G-4H. Curved canals need curved shapes. The premolar and molar were both safely and predictably prepared with PTG

root canal systems. Nature seldom makes a straight line and never makes two of the same. With PTG, we are experiencing the golden age of shaping canals in three dimensions safely, securely, accurately, and with all the minimally invasive techniques at our fingertips. Nothing could be sweeter (Figures 4A and 4B).” Take-home message How PTG feels in your hands is what it’s all about. How it feels makes all the difference. To me, the indomitable confidence factor is priceless and has made all the work to make PTG come true truly worth it. Oh, and it might take a few canals to get used to the lighter feel of shaping, but just a few!

No. 8: Challenging anatomy: calcified, abrupt, long, and multiple curves The recently innovated PTG flexibility enables the Shaping and Finishing files to literally “crawl” down not only the most calcified canals but also the most curved canals (Figures 4C-4D). This may sound corny, but the more calcified and the more curved or 24 Endodontic practice

multiple curved a canal is, the greater sense of success and enjoyment to the clinician. However, I still find the mechanical glide path file ProGlider® (DTDS) can be a confidence builder in expanding the glide path width of particularly long, narrow, and curved canals for safe rotary or reciprocation shaping. Put this newfound level of confidence in your own words, and share it with your colleagues in the spirit of collaboration. Rising endodontic star Dr. Wyatt Simons shares his newly discovered increased confidence this way: “I wanted to send you a quick note to let you know how amazing I have found the ProTaper Gold files to perform. Dare I say, a game changer! I am shocked to report how much the ProTaper Gold files have impacted my practice. I am doing things I would not dare to attempt with other rotary systems, and the results are awe-inspiring. Instead of ProTaper Gold, I call it ProTaper Butter.” Check out the case in Figure 4E. A highly respected clinician, educator, and inventor, Dr. Simons then adds, “What I mean about ProTaper Gold® being transformative is that I did this case with few to no hand files. Although likely previously

possible, I now have the confidence to tackle any shape with less pathfinding/path establishing. Said differently, if I knew a canal had excessive curvature or forks in the road, I would always shape the canal to a point that I was more comfortable in bringing rotary systems in. With ProTaper Gold, I have no reservations, whether they be curvature, length, splitting, etc. (Figure 4F).” Abrupt apical as well as long canal curvature can present a difficult challenge for any clinician performing endodontics (Figures 4G-4H). The configuration of abrupt apical canals is often blocked or ledged because following skill sets literally cannot be followed! PTG has solved this for me. Here is the technique for treating abrupt apical curvature: create and/or confirm glide path with No. 10 manual file to the radiographic terminus. Then identify actual physiologic constriction length with the apex locator. Curve the apical 1 mm of a PTG F1 with orthodontic bird beak pliers. Confirm coronal restrictive dentin is removed. Next, follow canal either manually or mechanically with PTG F1 to reference length. Flush canal with Stropko™ Irrigator, and fit an F1 newly formulated precision micronized formula PTG gutta-percha cone (DTDS), and pack! That’s it. The rigidity of PTG gutta percha preserves the sharp PTG apical turn. Another advantage of PTG gutta percha is that the intentionally lessened coronal taper prevents false tugback and optimizes clinical dexterity in placing the gutta-percha cone. Finally, PTG gutta percha has an extended heat wave for better compaction into the shaped and cleaned root canal system (Figures 5A-5B). Take-home message The more challenging the case, the safer, more predictable and more precise PTG performs.

No. 9: Blocks, ledges, and transportations Blocks. I used to think that if I could not de-block a dentin or collagen block after thorough and careful irrigation with delicate attempts to disrupt the block, I needed a stiffer Ni-Ti system such as PTU to hopefully follow my way through the block. (A surprise to me!) PTG does what I thought it could not do more predictably, and that is to follow down or through the block. The clinical effect of the softer and more flexible PTG is that the files respect the original blocked path and follow it to the physiologic terminus. Ledges. Again, I thought a more rigid PTU file could more easily remove a ledge or shelf by pre-curving a PTU F1, for example, follow past the ledge, and brush it away. I Volume 8 Number 4

Figures 5A-5D: 5A. The more challenging the root canal system anatomy, the safer, more predictable, and more precise PTG performs. (Courtesy of Dr. Jason West, Tacoma, Washington). 5B. PTG shapes allow sufficient obturation hydraulics to fill portals of exit regardless of size. 5C. Pretreatment of maxillary left central incisor with under-filled root canal system and lesion of endodontic origin. PTG F3 was singular instrument needed to remove gutta percha and shape the root canal for F3 PTG conefit and 3D obturation using vertical compaction of warm guttapercha technique. 5D. Posttreatment and 4-month posttreatment image validating early healing of radiographic endodontic lesion

could not have been further from the truth; and the truth is that PTG more easily follows around a ledge and more efficiently and predictably brushes away the shelf or ledge and once again blend the radicular wall into a continuously tapering funnel. Transportation. Transportation comes in the form of internal and external. Internal transportation simply does not occur if each PTG Finishing file is followed to the physiologic terminus and removed. The Ni-Ti memory of PTG is intentionally lessened, which allows Finishing files to have the capacity to safely rotate at the physiologic terminus for a moment or two though not required or recommended. Take-home message PTG gives new predictability in preventing and correcting endodontic blocks and ledges and preventing external transportations.

No. 10: Nonsurgical retreatment In my original 1-month test of using PTG exclusively, naturally PTG was called upon for removing gutta percha in nonsurgical retreatments. I discovered something that I did not expect — once again PTG was “better, faster, and easier” than using PTU. I was thinking that the “stiffer” PTU would be more efficient to remove solvent impregnated gutta percha. I was wrong! I also learned that the most effective way to remove the failing gutta-percha/sealer obturation attempt was a two-file approach: S2, F1, and in some situations a single Finishing file may be sufficient (Figures 5C-5D). Because of the PTG “softness,” the Shaper and Finisher file geometries more predictably “follow” the softened gutta percha. In addition, PTG, again because of its advanced metallurgy, follows existing radicular walls more easily without “gouging” or exaggerating existing apical blocks. Finally, carrier-based obturator retreatments are also safer and easier because PTG follows alongside the carrier, versus cutting into the carrier, which can prevent Volume 8 Number 4

the possibility of lifting the carrier toward the access for removal. Take-home message ProTaper Gold more safely, predictably, and easily removes gutta percha in nonsurgical endodontic retreatments due to progressive taper and increased PTG flexibility (Figure 6).

Closing comments The greatest variable in endodontics is not our preferred Ni-Ti shaping system. My dad, Roy West, a master finish carpenter, who passed away just about a year ago, and who was still coaching me, his grandchildren, and great-grandchildren at 94 years young, always told us, “Do it like anyone else but better than anyone else.” That anyone else is you and I. We are the greatest variable and the greatest determinant. We are our only competition — to be better than we are today. Our knowledge, skill, judgment, willingness, and integrity are the pillar values to make the right clinical choices every day. Timeless principles + breakthrough technologies = predictable performance. Invitation: I humbly invite you to take what I will call the “ProTaper Gold® Challenge.” My personal leap of faith came when I decided to exclusively use and validate PTG for a full month in my private practice. PTG performed more predictably, more efficiently, and more confidently in all 10 critical clinical performance distinctions. I believe that once a dentist experiences ProTaper Gold, that individual will become equally enlightened by the stunningly predictable and safe results. I am willing to bet my reputation as a clinician and an educator on it. But please don’t take my word for it — put PTG to the comparative test, and prove it for yourself. Master endodontist, Dr. Scott Doyle from Minneapolis, Minnesota, did, and he concludes, “The improved flexibility of PTG allows me to shape nature’s wide variety of curved roots with confidence.” Remember what Albert Einstein said: “The only source of knowledge is experience.” EP

Figure 6. Newly introduced PTG gutta-percha cones are precision machined, have advanced NanoFlow technology, consistent quality, and have the added advantage of an extended heat wave allowing a shallower deepest point of compaction in classic vertical compaction of warm guttapercha techniques

REFERENCES 1.

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

Ruddle CJ, Machtou P, West JD. Endodontic canal preparation: new innovations in glide path management and shaping canals. Dent Today. 2014;33(7):118-123.

Ruddle CJ. Shaping complex canals: clinical strategy and technique. Dent Today. 2014;33(11):88-95.

West JD. So many rotary systems, so little time: how do I choose? Endo Tribune. 2008;3:4-8.

West JD. Endodontic predictability: “what matters”? Dent Today. 2013;32(9):108-113.

West JD. Anatomy matters. “Could it all simply be a coincidence?” Part 8. Endodontic Practice US. 2013;6(5):52-55.

West JD. Endodontic update 2006. J Esthet Restor Dent. 2006;18(5):280-300.

West JD. Perforations, blocks, ledges, and transportations. overcoming barriers to endodontic finishing. Dent Today. 2005;24(1):68, 70-73.

West JD. Removing the mystery: Treating multirooted teeth. Dent Today. 2009;28(12):70, 72-73.

10. West JD. Nonsurgical versus surgical endodontic retreatment: “how do I choose”? Dent Today. 2007;26(4):74, 76, 78-81. 11. West JD. The endodontic Glidepath: “Secret to rotary safety.” Dent Today. 2010;29(9):86, 88, 90-93. 12. Hieawy A, Haapasalo M, Zhou H, Wang ZJ, Shen Y. Phase transformation behavior and resistance to bending and cyclic fatigue of ProTaper Gold and ProTaper Universal instruments. J Endod. 2015 epub ahead of print. 13. West JD. Finishing: the essence of exceptional endodontics. Dent Today. 2001;20(3):36-41.

Endodontic practice 25

TECHNOLOGY

ENDODONTIC INSIGHT

The Glide Path — laying the groundwork for proper endodontic instrumentation Dr. Barry H. Korzen offers insight to ensure proper completion of the endodontic instrumentation

n aeronautics, the Glide Path is the approach path of an aircraft when landing, usually defined by a radar beam. Its purpose is to establish a tightly controlled horizontal and vertical “corridor” that will take the incoming aircraft to the proper location at the end of the runway. Have you ever been on a commercial flight where immediately after touchdown all the passengers begin clapping? It’s the response to a job well done by the pilot. To ensure that you get that same “well done” feeling when you complete your endodontic cases, a vital step in the instrumentation process is preparation of the Glide Path to allow all subsequent instruments to move smoothly from the coronal orifice of the canal in an unimpeded progression to the apical constriction. With some cases, once proper access has been created, all that is necessary is to confirm that the canal is ready for cleaning and shaping. But with teeth with large restorations, especially in older patients, it isn’t unusual to find that the natural defense mechanisms (e.g., pulp stones, the formation of reparative dentin creating a narrowing of canals, etc.) that have kicked in while the pulp was trying to recover from long-term irritants have now become an impediment to successful endodontic treatment. And properly establishing the Glide Path, even though time consuming in those difficult-to-treat

A graduate of the University of Toronto Faculty of Dentistry and the Harvard University graduate endodontic program, Dr. Barry Korzen is the Founder of The Endo Academy (www.TheEndoAcademy.com) and Zendo® (www.Zendo-online.com). He was an Associate Professor, Assistant Dean, and former Head of the Discipline of Endodontics at the University of Toronto Faculty of Dentistry. Besides authoring numerous papers, Dr. Korzen has spoken to dental societies and organizations around the world and has delivered lectures at more than 20 universities. He has received fellowships from the American College of Stomatologic Surgeons, the International College of Dentists, and the Pierre Fauchard Academy. Dr. Korzen is a Past-President of both the Canadian Academy of Endodontics and the Ontario Society of Endodontists and has been a longstanding member the American Association of Endodontists.

26 Endodontic practice

Figure 1: Visualizing root curvature

To ensure that you get that same “well done” feeling when you complete your endodontic cases, a vital step in the instrumentation process is preparation of the Glide Path ... cases, will help ensure that proper completion of the endodontic instrumentation is achievable. And just as turbulence can cause an aircraft to veer off its Glide Path, in endodontics the lack of a properly established glide path will often lead to ledge formation, transportation of the natural canal anatomy, and blockage of the canal with dentin debris, or a combination of all three negative consequences. As Dr. John West states in his excellent Dentistry Today article entitled, “The Endodontic Glidepath: ‘Secret to Rotary Safety,’”1 “without the endodontic Glidepath,

the rationale of endodontics cannot be achieved.” Just as the preparation of the Glide Path lays the groundwork for the proper shaping of the canal, proper access preparation is an essential precursor for identifying the canal orifice(s) and the subsequent preparation of the Glide Path. Once the canal orifices have been identified, and before placing a single instrument into the canal, study the pretreatment radiograph carefully. Even though the radiographic and physiologic termini of the canals likely do not correspond exactly, understanding what problems you might encounter when Volume 8 Number 4

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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. 2008 April; 85(1): 180–187. doi: 10.1002/jbm.b.30933 Chmilewsky, F., C. Jeanneau, P. Laurent, M. Kirschfink, and I. About. “Pulp Progenitor Cell Recruitment Is Selectively Guided by a C5a Gradient.” Journal of Dental Research 92.6 (2013): 532-39. Print.

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ENDODONTIC INSIGHT

Figure 2: Canal seems to disappear due to narrowing of canal space or overlapping of the roots on the radiograph

negotiating the canals will help you plan the most efficient technique to overcome these potential impediments to successfully creating an effective Glide Path. These are some questions to ask for that determination: â&#x20AC;˘ Are the roots curved, and if so, to what degree (Figure 1)? â&#x20AC;˘ Does the canal space disappear on the radiograph, and if so, in the apical third or more coronally (Figure 2)? â&#x20AC;˘ Is there a radiolucent lesion, and if so, at the radiographic apex or somewhat removed from the apex (Figure 3)?

Technique Throughout Glide Path preparation and subsequent shaping of the canal, copious irrigation should be maintained. Sodium hypochlorite is the irrigant of choice and is best combined with a carbamide-peroxide and EDTA-containing gel.2 The EDTA chelates calcium salts from calcified areas within the root canal, and due to its effervescent properties, it allows for pulp tissue, dentinal shavings, and debris to be easily removed, facilitating the movement of the instruments down the canal. Initiate the preparation of the glide path using a pre-curved No. 10 stainless steel K-type hand file that matches the canal curvature obtained from the preoperative radiograph (Figure 4). If canal constrictions prevent the No. 10 K-file from easily reaching the estimated working length (EWL), use a No. 08 K-file 28 Endodontic practice

Figure 3: Radiolucent lesion distant from the radiographic apex

along with copious irrigation until it easily reaches the EWL. Because the No. 08 is not as stiff as the No. 10, whatever prevented the No. 10 from reaching the estimated working length initially may distort the No. 08, and you may require a number of instruments to achieve your goal. You may even have to resort to using No. 06 instruments to ensure that you remain within the natural canal and are not creating your own pathway. Try the No. 10 K-file again, and if it reaches the EWL, continue using the No. 10 until it easily reaches the EWL. To facilitate the removal of debris, especially in long and narrow canals, it may be necessary to alternate between the No. 08 and No. 10 files. In narrow canals, meticulously creating the Glide Path has historically been a slow and tedious procedure. Once a No. 10 K-file is worked to the EWL, Z-Pathfinder3 nickeltitanium engine-driven files, which have an innovative design comprised of cutting edges on three different radii that leave a large and efficient area for debris removal, and increased flexibility due to their small diameters (No. 12 and No. 17) and their slight .03 taper, quickly and efficiently complete the preparation of the Glide Path (Figure 5). The Pathfinders are used by slowly progressing apically without pressure. When resistance is encountered, remove the file from the canal, place a small amount of RC Cleaner in the canal, irrigate with sodium hypochlorite, and again progress slowly toward the apex using the Pathfinder file. In most cases the use of the P1 file with its

Figure 4: Pre-curve a No. 10 K-file to match the radiographic appearance of the root

Figure 5: Cross section of the Z-Pathfinder showing the three different radii Volume 8 Number 4

Volume 8 Number 4

ENDODONTIC INSIGHT

.12 apical tip will be sufficient to allow the placement of a No. 15 K-type file to the EWL. If this is not the case, complete the Glide Path preparation with the P2 Pathfinder. Its .03 taper and No. 17 apical tip size will create a canal shape that will permit the effortless placement of the No. 15 K-type file (.02 taper and No. 15 apical tip size) to the EWL, and this is important as the No. 15 is the minimum size apical tip that can be properly verified on a radiograph (Figure 6). Every step in endodontic instrumentation is important in order to achieve the desired end result. However, creating the correct Glide Path for the canal you are treating will make each of the remaining steps in your treatment protocol that much easier to perform, resulting in a cleaner and wellshaped canal that can be ideally obturated. The time you take in preparing the Glide Path will pay dividends, especially when you step away from the chair and know that your job was “well done.” EP

Figure 6: Protocol for efficient Glide Path preparation

REFERENCES 1.

West J. The Endodontic Glidepath: “Secret To Rotary Safety.” Dentistry Today. September 10, 2010. http://www.dentistrytoday. com/endodontics/3478-endodontic-glidepath-secret-to-rotary-safety. Accessed June 16, 2015.

Zendo RC CLEANER. Zendo-online.com. https://zendo-online.com/products/98/Zendo%20RC%20Cleaner. Accessed June 16, 2015.

Zendo. Zendo-online.com. Zug, Switzerland. Accessed June 16, 2015.

Endodontic practice 29

CONTINUING EDUCATION

Nonsurgical retreatment and perforation repair in a maxillary first molar Dr. John Rhodes discusses treatment for a technically challenging condition Introduction This article describes the nonsurgical retreatment of a maxillary first molar (UL6) and the management of a pulp floor perforation.

History A 52-year-old man was referred to an endodontic specialist following an attempt to retreat UL6. Unfortunately, a Gates Glidden bur had broken while attempting to remove gutta percha from the root canals and could not be retrieved. A comprehensive medical history was uncomplicated.

Educational aims and objectives

This clinical article aims to discuss the nonsurgical retreatment of a maxillary first molar (UL6) and the management of a pulp floor perforation.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the indications of failed root filling and chronic periapical (periradicular) abscess. • Realize some possible causes for this condition. • Identify possible treatment for this condition. • Identify some materials and equipment that can lead to easier treatment and more positive treatment outcome. • Discuss management of several specific factors involved in iatrogenic perforation.

Clinical examination Intraoral examination revealed that UL6 was slightly tender to palpation. The tooth was restorable and had a temporary (MO) compomer filling sealing the access. There was no abnormal mobility, no significant or increased periodontal pocketing, or bleeding on probing. Soft tissue examination revealed that there was a buccal sinus tract through which pus could be expressed. Sensitivity testing with Hygenic® Endo® Ice (Coltene) showed that the adjacent teeth were vital. A paralleling periapical radiograph of the UL6 was exposed using a Rinn Holder (Rinn, Dentsply ). The radiograph showed good marginal bone levels. The UL5 and UL7 were minimally restored with no evidence of periapical pathology, and the root canals appeared sclerosed. An unerupted UL8 was present. The UL6 had been root filled with gutta percha, but the canals were under-prepared and under-filled. The second mesiobuccal canal (MBII) had been located. A fractured

Figure 1: The UL6 and buccal sinus tract

Gates Glidden bur was lodged in the distobuccal canal. The inferior border of the maxillary antrum was visible and reached its lowest point between the first and second molars. There was potential radiolucency in the trifurcation and periapically around the MB root; however, this was masked by the proximity of the antrum.

Diagnosis 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, Poole and Dorchester, United Kingdom. He lectures and teaches on endodontics nationally.

30 Endodontic practice

Failed root filling and chronic periapical (periradicular) abscess. The root canal filling had most probably failed as a result of persistent bacterial infection in the root canal.

Figure 2: A paralleling radiograph showing a technically poor and failing root filling UL6 Volume 8 Number 4

1. Root canal retreatment and restoration with a cusp coverage onlay or crown 2. Extraction and nothing 3. Extraction and replacement with an implant The prognosis for root canal retreatment should be good, and the patient could expect the tooth to remain functional for many years. Replacement with an implant may be feasible, but generally, well root-filled and restored teeth appear to function comparably to single tooth implants (Hannahan and Eleazer, 2008; Torebinejad, et al., 2007). Restored natural teeth also tend to be less costly to repair if and when they fail (Pennington, et al., 2009). After discussing all the treatment options, the patient elected to have the UL6 retreated nonsurgically.

Treatment A two-visit strategy was adopted in this case to ensure adequate disinfection of the root canals, allow optimal management of a pulp floor perforation, and confirm healing of the sinus tract before obturation. Profound anesthesia was provided by buccal and palatal infiltration of 4% articaine 1:100,000 adrenaline (Septodont). Single tooth isolation with a latex rubber dam and a number 14 clamp provided a controlled operating field. Using an operating microscope, the existing compomer filling was removed with a long-tapered diamond bur, and the margins of the cavity refined. A cotton wool pellet was removed from the access cavity, and after rinsing with 3% sodium hypochlorite, a preliminary survey of the pulp floor could be carried out under low magnification with the operating microscope. This showed the fractured Gates Glidden bur seated in the distobuccal canal and a moderately large perforation adjacent to the mesiobuccal canal, extending into the furcation. Granulation tissue was visible through the perforation. Gates Glidden burs provide a very efficient means of removing gutta percha and have a fail-safe stress point at the end of the shaft so that if they break, retrieval is easier. If they fracture when embedded in gutta percha, this cools and hardens around the bullet-shaped tip making them more difficult to remove. A simple technique to overcome this involves vibrating the fractured piece with a dry ultrasonic tip; the energy is dissipated as heat, re-plasticizing the gutta percha and Volume 8 Number 4

Figure 3: The pulp chamber floor showing a perforation. There is gutta percha in the MBI and a fractured Gates Glidden bur in the distobuccal canal

Figure 4: Gutt-percha tags on the wall of the palatal canal were removed with micro-openers and chloroform solvent

Figure 5: The pulp floor just prior to perforation repair and placement of calcium hydroxide medicament

allowing removal with Stieglitz forceps. In this case, the fragment of a Gates Glidden bur was vibrated with a Start-X™ tip No. 3 (Dentsply). The remaining bulk of gutta percha in all canals was rapidly removed with a Gates Glidden size 2 and Hedstroem file size 30 (Dentsply). Straight-line access to all canals was then refined. Working length estimations were made with an apex locator (Endo Analyzer, Sybron) and size 10 FlexoFile® (Dentsply Maillefer). A steady zero reading was achieved in all canals despite the perforation. Patency was confirmed and glide paths created in the primary root canals with a ProGlider™ rotary instrument (Dentsply Maillefer; Dentsply Tulsa Dental Specialties), and these were then rapidly tapered using reciprocating WaveOne® primary and large instruments (Dentsply Maillefer; Dentsply

Tulsa Dental Specialties). The canals were kept flooded with sodium hypochlorite and patency recapitulated throughout preparation. The root canals were inspected under high magnification, and any tags of gutta percha on the canal walls removed with an Endo-Explorer (Dentsply Maillefer; Hu-Friedy). A small amount of chloroform was used as a solvent to dissolve any gutta percha lodged in lateral anatomy; this was wicked with sterile paper points. The root canal system was disinfected with a solution of heated 3% sodium hypochlorite (Teepol) irrigant, delivered using a safe-ended needle (Henry Schein®). The needle was pre-bent and kept moving in the root canal to prevent extrusion of irrigant. Disinfection was carried out over approximately 30 minutes. The sodium hypochlorite was agitated with a size 20 Irrisafe™ ultrasonic tip (Satelec Acteon) and Endodontic practice 31

CONTINUING EDUCATION

Treatment options

CONTINUING EDUCATION an EndoActivator® (Dentsply Tulsa Dental Specialties) with a red tip. The solution was replenished every 2 minutes. A final sequence of 40% citric acid (Cerkamed) and 3% sodium hypochlorite completed irrigation. The sodium hypochlorite solution was able to penetrate the perforation site but was not injected into it. The canals were dried with sterile paper points (Dentsply) and non-setting calcium hydroxide placed (Calasept®). Collagen matrix (Hemocollagene, Septodont) was packed through the perforation site to form a matrix onto which Biodentine® (Septodont) was compacted. Once set, the access was sealed with Cavit™ (3M ESPE) and Fuji IX® (GC). One week later, the sinus had healed, the tooth was symptom-free, the canals dry, the integrity of the Biodentine confirmed, and the tooth ready for obturation. Calcium hydroxide inter-appointment medicament was removed with alternate citric acid and sodium hypochlorite irrigation. The canals were then dried and obturated with vertically compacted thermoplasticized gutta percha and AHPlus® sealer (Dentsply) Biodentine was packed into the coronal 3 mm-4 mm of the MBI and MBII canals to ensure that the perforation site was well sealed. (Should the MB root ever need to be resected, this material would provide a good seal.) Once the Biodentine had set, Fuji IX was used to seal the pulp floor. A Palodent®Plus sectional matrix (Dentsply) was placed and the cavity thoroughly washed. The cavity was selectively etched with 30% phosphoric acid and Scotchbond™ (3M ESPE) dual-cure bonding agent applied. A composite core was constructed with flowable bulk-fill composite (Smart Dentin replacement [SDR®] Dentsply) and Ceram-X® mono. A final paralleling radiograph was exposed using a Rinn Holder. This showed a well-oburated root canal system and homogenous coronal seal with no voids. A cusp coverage restoration was to be provided by the referring dentist to help prevent fracture. Reviews will be carried out at 1 year and subsequently at 2 years, and 4 years if required in line with the “Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology” (2006).

Discussion Iatrogenic pulp floor perforation can occur if the operator becomes disorientated when trying to locate canal orifices. The 32 Endodontic practice

Figure 6: The canals irrigated and dried, ready for obturation

Figure 7: Biodentine was packed into the coronal part of the MBI and MBII and across the pulp floor between them

importance of using illumination and magnification during endodontic procedures cannot be overemphasized (Buhrley, et al., 2002; Schwarze, et al., 2002). Perforation repair can be technically challenging, and offering referral if treatment is beyond the expertise of the operator is good practice (General Dental Council Standards for the Dental Team 2013). Management of iatrogenic perforation is dependent on several factors (Fuss and Trope, 1996). Level There is a high risk of microleakage when perforation occurs at crestal bone level. Obtaining adequate coronal seal can be difficult, and direct communication with the oral cavity via the periodontal tissues means the prognosis may be guarded. If bone is present on the external aspect of the perforation, repair is normally feasible.

Figure 8: The completed composite core

Figure 9: A final radiograph shows well-obturated canals and homogenous coronal seal with core material Volume 8 Number 4

Size The larger the perforation, the greater the surface area that will need to be sealed. Time It is preferable to seal a perforation as soon as possible to prevent microleakage and bacterial contamination. During retreatment, the existing material, any obstructions, and missed canals should be prepared and disinfected as efficiently as possible and at the first visit (Van Nieuwenhuysen, 1994). When retreating teeth that have been obturated with gutta percha, most of the filling material can be removed mechanically. Gates Glidden burs are extremely efficient, and once a glide path has been established, tapering the canal with NiTi instruments will remove most of the remainder. Material lodged in fins and isthmuses will need to be removed using a solvent (Ferreira JJ, Rhodes JS, and Pitt Ford TR, 2001). Mechanical preparation will reduce the bacterial load in an infected root canal (Byström and Sundqvist, 1981), but sodium hypochlorite in a concentration of at least 1% is required to kill the majority of bacteria in a contaminated canal system (Byström and Sundqvist, 1983). Bacteria aggregate as biofilms on the root canal wall. These bacteria are surrounded by matrix and can be difficult to remove. Irrigants used during endodontic treatment, therefore, have to be agitated to disrupt biofilm (Ahmad M, Pitt Ford TJ, Crum LA, 1987). 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, et al., 2011). The concept of a two-visit strategy using a chemo-mechanical approach has been adopted since the 1980s. Dressing the canals (after preparation and disinfection) with calcium hydroxide for 7 days was shown to be effective at producing bacteriafree canals (Byström, Claesson, Sundqvist, 1985; Sjögren, et al., 1991). Universal use of a two-visit approach has been questioned Volume 8 Number 4

as calcium hydroxide and sterile saline slurry limits but does not totally prevent regrowth of endodontic bacteria (Peters 2002). A systematic review of the literature reported that multiple visits with calcium hydroxide treatment did not improve clinical outcome, and there was a minimal level of evidence for considering one versus two appointments in nonsurgical endodontics (Hargreaves 2006). Many endodontists have therefore adopted a single-visit approach for many cases with no significant postoperative difficulties nor reduced prognosis (Ng, et al., 2011). Contrary to this, a two-visit strategy was adopted in this case to allow setting of the perforation repair material and confirm healing of the sinus tract before obturation. Calcium silicate cements such as Biodentine and MTA have excellent sealing abilities and have many reported uses in endodontics (Parirokh and Torabinejad, 2010). The excellent performance of MTA in surgical endodontics is well published (Chong BS, Pitt Ford TR, and Hudson MB, 2003). Long-term follow-up case studies have demonstrated that MTA can be predictably used as a repair material for furcal perforation (Pace R, Giuliani V, Pagavino G, 2008). Biodentine contains tricalcium silicate with additives such as powder and a liquid containing calcium chloride to speed up setting. Calcium silicate materials have excellent biocompatibility and are able to induce calcium-phosphate precipitation at the periodontal ligament interface allowing bony healing (Tay, et al., 2007; Torabinejad and Parirokh, 2010). With a reduced setting time compared to MTA, Biodentine is perhaps more user-friendly for perforation repair (Wongkornchaowalit N, Lertchirakarn V, 2011). Definitive restoration of root-filled molar teeth with loss of marginal ridges should encompass cusp coverage to reduce the risk of tooth fracture under masticatory forces. (Whitworth JM, Walls AWG, and Wassell RW, 2002; Sorensen JA and Martinoff JT, 1984). In this case, the final restoration was to be completed by the referring dentist.

Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of magnification on locating the MB2 canal in maxillary molars. J Endod. 2002;28(4):324-327.

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.

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.

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

Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root- end filling materials in endodontic surgery. Int Endod J. 2003;36(8):520-526.

Ferreira JJ, Rhodes JS, Pitt Ford TR. The efficacy of guttapercha removal using ProFiles. Int Endod J. 2001;34(4):267–74.

Conclusion

25. 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.

This article highlights the diagnosis and management of nonsurgical retreatment, instrument removal, and perforation repair with micro-endodontic techniques and Biodentine. EP

REFERENCES 1.

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

10. Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod Dent Traumatol. 1996;12(6):255-264. 11. General Dental Council. Standards for the dental team. September 2013. https://www.gdc-uk.org/Dentalprofessionals/ Standards/Pages/standards.aspx. Accessed June 26, 2015. 12. Hannahan JP and Eleazer PD. Comparison of success of implants versus endodontically treated teeth. J Endod. 2008;34(11):1302–1305. 13. Hargreaves KM. Single-visit more effective than multiple-visit root canal treatment? Evid Based Dent. 2006;7(1):13–14. 14. 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. 15. Pace R, Giuliani V, Pagavino G. Mineral trioxide aggregate as a repair material for furcal perforation: case series. J Endod. 2008;34(9):1130-1133. 16. 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. 17. Pennington MW, Vernazza CR, Shackley P, Armstrong NT, Whitworth JM, Steele JG. Evaluation of the cost-effectiveness of root canal treatment using conventional approaches versus replacement with an implant. Int Endod J. 2009;42(10):874-883. 18. 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. 19. 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. 20. Schwarze T, Baethge C, Stecher T, Geurtsen W. Identification of second canals in the mesiobuccal root of maxillary first and second molars using magnifying loupes or an operating microscope. Aust Endod J. 2002;28(2):57-60. 21. 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. 22. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal coverage: a study of endodontically treated teeth. J Prosthet Dent. 1984;51(6):780-784. 23. Tay FR, Pashley DH, Rueggeberg FA, Loushine RJ, Weller RN. Calcium phosphate phase transformation produced by the interaction of the Portland cement component of white mineral trioxide aggregate with a phosphate-containing fluid. J Endod. 2007;33(11):1347-1351. 24. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review – part II: Leakage and biocompatibility investigations. J Endod. 2010;36(2):190-202.

26. Van Nieuwenhuysen JP, Aouar M, D’Hoore W. Retreatment or radiographic monitoring in endodontics. Int Endod J. 1994;27(2):75-81. 27. Whitworth JM, Walls AW, Wassell RW. Crowns and extracoronal restorations: endodontic considerations: the pulp, the root-treated tooth and the crown. Br Dent J. 2002;192(6):31520, 323-327. 28. Wongkornchaowalit N, Lertchirakarn V. Setting time and flowability of accelerated Portland cement mixed with polycarboxylate superplasticizer. Journal of Endodontics. 2011;37(3):387-389.

Endodontic practice 33

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Location Perforations that have damaged the root canal orifice can be more difficult to seal. In this case, there was dentin around the periphery of the MB canal, and the perforation was positioned away from any isthmus between the MBI and MBII.

CONTINUING EDUCATION

Relationship between clinical and histopathologic findings of 40 periapical lesions Drs. Francisco Javier Jiménez Enriquez, Jorge Paredes Vieyra, and Fabian Ocampo Acosta discuss the clinical and histopathological findings of periapical inflammatory lesions treated by endodontic surgery

he goal of endodontic treatment is to prevent or cure apical periodontitis (AP) caused by infection of the root canal systems of the affected teeth (Ørstavik and Pitt Ford, 1998) or due to persistence of the primary infection or emergence of infection after treatment (Kuc, Peters, and Pan, 2000). Periapical lesions are the most frequently diagnosed apical odontogenic pathologies in human teeth. The condition is generally described as apical periodontitis. The etiologic factor is the presence and colonization of microorganisms within the pulp canal system (Ørstavik and Pitt Ford, 1998; Kuc, Peters, and Pan, 2000; Nair, et al., 1990). Bacterial stimulus cells cause intercellular mediators, humoral antibodies, and effector molecules to be released into the periapical tissues, as shown by Nair, Henry, and Cano Vera (2005). When bacteria colonize only in the apical ramifications of the root canal or outside the root canal or when pathosis is sustained by a periapical foreign body, the surgical procedure effectively removes the infected site and enhances the chances of healing (Nair, et al., 1990). Apical ramifications, lateral canals, and isthmuses connecting main root canals have all been shown to harbor bacterial cells, which are also frequently organized in biofilmlike structures (Nair, Henry, and Cano Vera, 2005; Ricucci, Siqueira, and Bate, 2009; Ricucci, Siqueira, 2010). In their natural habitats, microorganisms almost invariably live as members of metabolically integrated communities commonly attached to surfaces

Dr. Francisco Javier Jiménez Enriquez is an oral surgeon and professor of oral surgery and anatomy at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico. Dr. Jorge Paredes Vieyra is an endodontist and professor of endodontics and pulp therapy at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico. Dr. Fabian Ocampo Acosta is director of the histopathology department at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico.

34 Endodontic practice

Educational aims and objectives

This clinical article aims to demonstrate the importance of the histopathological evaluation for a proper diagnosis of periapical pathosis.

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: • Identify some etiologic factors of apical periodontitis. • Recognize some mechanisms to the development of apical periodontitis. • Realize some of the reasons for prolonged debate about the management of large periapical lesions. • Identify some classifications for periapical lesions of endodontic origin. • See some of the criteria used to evaluate the success of the periapical surgery for this study.

to form biofilms (Costerton, 2007). The biofilm provides microorganisms with a series of advantages and skills, including establishment of a broader habitat range for growth; increased metabolic diversity and efficiency; protection against competing microorganisms, host defenses, antimicrobial agents, and environmental stress; and enhanced pathogenicity (Marsh, 2005). In situ investigations using optical and/or electron microscopy have allowed observations of bacteria colonizing the root canal system in primary or persistent/secondary infections as sessile biofilms covering the dentinal walls (Nair, 1987; Siqueria, Roças, and Lopes, 2002; Molven, Olsen, and Kerekes, 1991; Carr, Schwartz, Schaudinn, 2009). Peters, Wesselink, and Moorer reported that poor endodontic treatment allows canal reinfection, which may often lead to treatment failure (1995). Clinical signs and symptoms as well as radiographic evidence of periradicular lesions are usually associated with endodontic failure. When root canal therapy is performed according to accepted clinical principles and under aseptic conditions, the success rate is generally high. The host response is further characterized by bone resorption and an extraradicular infection resulting in radiolucency. An acute apical periodontitis or periapical abscess is associated with clinical signs of inflammation and pain. Frequent indications for endodontic surgery have been suggested, though contemporary practice proposes that

endodontic surgery should be achieved only if conventional endodontic retreatment will not remove potential areas of canal infection such as in an uninstrumented portion of a canal or will have the potential to irreversibly injury the tooth; for example, root fracture following to post removal, or if previous retreatment has not resulted in healing (Love and Firth, 2009). Apical periodontitis is one of the most common pathological conditions within alveolar bone. Apical periodontitis consists of an inflammation and destruction of the tissues around the root of the teeth caused by etiological agents of endodontic origin (Love and Firth, 2009; Nair, 2006). It is usually a sequel of an endodontic infection that turns the dental pulp into a necrotic tissue infected by autogenous oral bacteria. This infection usually occurs through dental hard tissue damage resulting from caries, clinical procedures, or trauma, and provokes an inflammatory process that stimulates the proliferation of the cell rests of Malassez in the periodontal ligament, as reported by Nair (2006). The development of apical periodontitis can occur due to different mechanisms, such as accumulation of osmotic fluid in the lumen, proliferation of epithelial cell rests of Malassez, or molecular mechanisms (Nair, Sjögren, and Sundqvist, 1998). As a result, clinicians often make clinical and radiographic diagnoses, and the removed periapical tissues are seldom submitted for histopathological analysis Volume 8 Number 4

The debate There has been a prolonged debate about the management of large periapical lesions, with some authors suggesting that they can be treated successfully by only surgical means and others proposing that they will heal after nonsurgical root canal treatment (Friedman, 2005). Periapical surgery attempts to contain any microorganisms within the canal by sealing the canal apically. (At the same time the periapical lesion, if present, can be curetted and histologically investigated.) The objective of this surgical procedure is to optimize the conditions for periapical tissue healing and regeneration of the attachment apparatus. There are a number of classifications for periapical lesions of endodontic origin based on etiology, symptoms, or histopathological features; for example, the World Health Organization classification leans toward a Volume 8 Number 4

clinical classification (World Health Organization, 1995). Studies show that a periapical granuloma is the most common periapical lesion of endodontic origin; the diagnosis is based on the presence of connective tissue, blood vessels, and inflammatory cells and may also be called chronic apical periodontitis when chronic inflammatory cells feature or secondary acute apical periodontitis when polymorphonuclear leukocytes are present (Nair, 1997; 2006). The purpose of the present study was to relate the clinical and histopathological findings of periapical inflammatory lesions treated by endodontic surgery with the results of histopathological investigation of the same lesions. We hypothesized that the results of histopathological findings related with clinical diagnostic of periapical inflammatory lesions are caused by periapical granulomas.

Material and methods This study design was an evaluation of a consecutive clinical sample of patients with persistent periapical pathosis who were seen by an endodontist at the University Autonomous of Baja California, School of Dentistry, Tijuana, Mexico. The subjects’ review committee approved the study, and all the participants were treated in accordance with the Helsinki Declaration (World Health Organization, 1996). A clinical follow-up study was carried out between January 2012 to June 2014; 40 patients with chronic periapical lesions were treated with endodontic surgery after informed consent of each patient had been obtained after explaining the clinical procedures and risks involved and clarifying all questions raised by the patients. Periapical pathosis was defined as a radiolucent lesion related with a root-filled tooth with either an extending periapical lesion as seen on a radiograph; an unhealed periapical lesion of 5 or more years’ duration post-endodontic treatment (Ørstavik, 1996); or a tooth with a periapical radiolucent lesion with clinical signs and symptoms of periapical pathosis of endodontic origin such as pain, swelling, or sinus tract. Data were collected using a protocol for each patient and stored in an automated database. The data were coded for later statistical processing. The inclusion criteria for treatment planning for endodontic surgery were: • Periapical disease affecting permanent teeth subjected to endodontic treatment, with the presence of pain or inflammation, and repeated failure of root canal treatment

• Periapical disease causing pain or swelling and involving permanent teeth subjected to endodontic treatment with bridge abutments or teeth with posts presenting extraction difficulties • Where retreatment is impossible owing to fractured instruments, ledges, blockages, and filling material impossible to remove • An evaluation that any root canal obstacles could not be bypassed or removed to allow full conventional instrumentation of the root canal system. • With failure of orthograde retreatment where the prognosis of nonsurgical retreatment is unfavorable or impractical (such as an extensive coronal restoration) • Where biopsy is needed • Symptomatic gutta-percha overfilling or foreign bodies impossible to remove over an orthograde approach, radiolucencies larger than 8 mm to 10 mm in diameter Exclusion criteria were patients not meeting inclusion criteria or failure to obtain patients’ authorization. The material for this study consisted of sequential biopsies of roots or root tips together with adhering surrounding apical tissue. Specimens were part of the histologic collection of one of the authors. The material comprised 40 roots from 40 human teeth. Endodontic surgery was not carried out in the acute phase or during exacerbation of a chronic periapical abscess.

Surgical technique All surgical procedures were carried out by an experienced oral surgeon; endodontic surgery was carried out under local anesthesia. Surgical approach was gained using a complete or partial Newman flaps, and sufficient bone was removed using surgical burs with irrigation to allow curettage of the periapical lesion. After flap elevation and osteotomy, the periapical lesion and the root end were located. After root-end resection using a fissure bur, the resected root tip and the pathological tissue were curetted out. The intent was to collect the pathological tissue attached to the cut root tip. However, in most cases, the soft tissue and the cut root tip were collected separately. All patients with clinical findings of acute inflammation such as fistula, swelling, or abscess received antibiotic therapy 2 hours before the surgery (amoxicillin 875 mg with clavulanic acid 125 mg or clindamycin 300 mg in case of penicillin allergy). Strict aseptic Endodontic practice 35

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(Wang, Cheung, and Ng, 2004). Clinical and radiological evaluations alone cannot properly identify the type of lesion in the apical area (Cotti, et al., 2003; Ricucci, Mannocci, and Ford, 2006). Sjögren, Hagglund, and Sundqvist report that many factors are involved in the healing process of a periapical defect following endodontic surgery (1990). Among these, the two layers of the periosteum are very important because they may act both as a source of osteocompetent cells and as a barrier against the infiltration of epithelial cells into the healing site. However, in large defects, the periosteum is often damaged by the infective process (Pecora, et al., 2001). Most persistent lesions remain asymptomatic (Lin, et al., 1991; Salehrabi and Rotstein, 2004; Yu, et al., 2012). Friedman’s study (2002) introduces the concept of asymptomatic function. In addition to the groups “healed,” “healing,” and “non-healed,” the American Association of Endodontists has added the group “functional” to endodontic treatment outcomes (American Association of Endodontists, 2005). The concept of asymptomatic function or functional as a defined treatment outcome has implications for retreatment decision-making. The assumption is that all persistent radiographic lesions represent persistent inflammatory lesions (Brynolf, 1967; 1970). Matsumato and colleagues showed that the prognosis for the surgical treatment of large periapical lesions was not as good as that of small lesions (Matsumato, et al., 1987). Some authors consider the size of the periapical lesion as a preoperative prognostic factor (Molven, Olsen, and Kerekes, 1991; Wang, Cheung, and Ng, 2004).

CONTINUING EDUCATION conditions were followed to avoid bacterial contamination during surgery. The periapical lesion was eliminated and placed in formalin (10%). Osteotomy was carried out using round 0.27 mm tungstencarbide drills (Jota, Switzerland) mounted in a handpiece, and abundant irrigation with sterile physiological saline. The minimum apical resection necessary to access the apex was made, with subsequent apical curettage. The cavity for root-end filling was prepared with ultrasound, Piezon Master (EMS, Electro Medical Systems, Switzerland) and non-diamond ultrasound tips adapted to the different root and anatomic variants. All other necessary clinical procedures were performed, such as root-end resection and root-end filling, and the flap sutured. Patients were given standard postoperative instructions and review appointments. Magnifying glasses of 2.6 magnification Orascoptic™ (Acuity™ System, KaVo Kerr Group) were used to facilitate the procedure. Filling material was introduced and condensed (SuperEBA™, Harry J. Bosworth Company) within the retrograde cavity, in all cases.

Tissue processing All biopsies were taken during the endodontic surgery and immediately fixed in 10% formaldehyde solution with a surgical specimen/fixator volume ratio of 1:10. Samples were embedded in paraffin using an automated tissue processor (Autotechnicon Processor; Bayer Healthcare, LLC) and then prepared for histopathological diagnosis. Microtome serial sections (6 to 8 microns) were later made with a Minot rotation microtome (Minotome; IEC). Sections were de-paraffinized and systematically stained with hematoxylin eosin, and a cover slip placed. The histologic sections were examined under a Bx45 microscope (Olympus, Nishi-Shinjuku, Shinjuku-ku, Tokyo) by two experienced oral pathologists, and a histopathological diagnosis was made as a result by consensus. The specimens were classified, according to agreed criteria (35) as radicular cyst, scar tissue, or granuloma; it was also highlighted if the granuloma was a mixed form (being classified as epithelized granuloma or granuloma with fibrous tissue). A diagnosis of periapical granuloma was made based on the histological findings of granulation tissue with inflammatory cells; no distinction was made between the presence of chronic inflammatory cells (chronic apical periodontitis) or acute inflammatory cells (secondary acute periodontitis). A cyst was identified when epithelium was seen 36 Endodontic practice

to line a lumen, no distinction was made between a true cyst or bay (pocket) cyst; a scar was defined as dense relatively acellular fibrous connective tissue; and an abscess was defined as a collection of pus (dead and dying neutrophils).

Radiographic study Periapical radiographs were taken before surgery and after 2 years. The images obtained were calibrated (Clini View Version 5.1 program Instrumentarium Imaging, Tuusula, Finland) before being analyzed using the Micro Image Pro®Plus image analyzing system, (Media Cybernetics, Inc.), measuring the area (cm2) of the lesion.

Prognostic assessment healing classification The following criteria were used to evaluate the success of the periapical surgery. The clinical criteria of Mikkonen and colleagues considering: • Success — when there is no pain, swelling, or fistula • Uncertain healing — radiographic evidence of bone destruction and presence or not of symptomatology • Failure — when there are bone destruction, root resorption, and symptomatology (1983) The radiographic criteria of Rud, Andreasen, and Jensen (1972): • Complete healing — complete bone regeneration, normal, or slight increase in width of periodontal periapical space, but less than double the width of the unaffected radicular areas • Incomplete healing — reduced radiolucency, characterized by signs of bone healing around the periphery of the rarefaction • Doubtful healing — reduced radiolucency with one or more of the following characteristics: the radiolucency was greater than twice the width of the periodontal space, it was bordered by a structure such as hard lamina, it had a circular or semi-circular periphery, or was located symmetrically “cone-like” around the apex as an extension of the periodontal space • Radiographic failure — there were no changes, or there was an increase in radiolucency (1972) The clinical and radiographical criteria of Von Arx and Kurt to determine overall evolution: • Success — when bone regeneration was ≥90% and the pain and clinical scales were 0 (on a scale of 0 to 3)

• Improvement – when bone regeneration was between 50% and 90%, and the pain and clinical scales were 0 • Failure – when bone regeneration was less than 50%, or there were clinical symptoms (1999) Finally, it was evaluated if the tooth was functional (remained in place) or not (Friedman, 2003).

Statistical analysis The data were coded for later statistical processing using the SPSS version 20 for Windows. Descriptive statistics were calculated for the relevant variables; specifically, means, maximum, and minimum relationships were studied using analysis of variance (ANOVA) with subsequent Tukey testing and calculation of Pearson’s correlation coefficient. The hypothesis tests were conducted at the 0.05 level of significance.

Results The study comprised 40 patients, 26 women (65%), and 14 men (35%) at a mean age of 43.54 years (range, 18 to 69 years) with 40 biopsy samples (Table 1). The outcomes demonstrated that 40 cases were sent to the Laboratory of Oral Pathology, Facultad de Odontología Tijuana with a clinical diagnosis of periapical inflammatory lesions. A possible diagnosis of periapical granuloma was hypothesized, after the histopathological analysis (Table 1); all cases were diagnosed as Granuloma (62.5%), Cyst (20%) and Abscess (17.5%). Our results showed that UR2 had a high percentage of periapical lesion corresponding to periapical granuloma associated with overfilled canals (Table 1). The distribution of periapical lesions by age (Table 3) were high in patients with 40-50 years old with diagnostic of granuloma (66.6%). According to the lesion’s size and patient’s age (Table 2 and 3), these were identified as periapical Granulomas in the group of 40-50 years of age (66.6%) with a size of >1.0 – <2 cm (37.5%).

Table 1: Distribution of the periapical lesions Endodontic lesions

n (%)

Granuloma

25 (62.5%)

Cyst

8 (20%)

Abscess

7 (17.5%)

Total

40 (100%) Volume 8 Number 4

Discussion The most common periapical lesions of endodontic origins are periapical abscess, granuloma, and cysts (Figures 1-3), all these periapical pathoses, with different treatment and prognostic implications considered clinically suggestive of apical periodontitis, and they must be confirmed by histopathological examination (Gulabivala and Briggs, 1992; Nohl and Gulabivala, 1996). Because microorganisms are the essential etiological agents of primary apical periodontitis (Kakehashi, Stanley, and Fitzgerald, 1965) and also the major cause of posttreatment apical periodontitis (Nair, et al., 1990; Molander, et al., 1998; Siqueira and Rôças, 2004), the cherished goal of treatment of the disease has been a total elimination of the intraradicular infection and prevention of reinfection. These observations are fully in accordance with similar findings reported before by Sundqvist and colleagues (1998). According with Pellegrino, patients with posttreatment apical periodontitis are faced with contrasting alternatives, including nonsurgical or surgical management intended to cure and retain the affected tooth (Pellegrino, 1994). All the samples examined in the present study were obtained during endodontic surgery by the first authors using strict clinical inclusion and exclusion parameters from teeth with persistent apical pathology. The incidence of periapical cysts among periapical lesions varies from 6% (Block, 1976) to 55% (Priebe, Lazansky, and Wuehrmann, 1954). In the present study, more than half of the periapical lesions analyzed had a final diagnosis of periapical granuloma cyst (53%), and periapical cyst represented 20% (n=8) of the cases. This study did not examine the cystic lesions to determine whether they were a true cyst or a bay/periapical pocket cyst

Figure 1: Periapical granuloma Volume 8 Number 4

Table 2: Relationship between age and size of the periapical lesions Age

0.5 cm n (%)

>0. 5 - <1 cm n (%)

>1.0 - <2 cm n (%)

Total n (%)

18-28 years

1 (20.0%)

2 (40.0%)

5 (100.0%)

29-39 years

0 (0.0%)

6 (75.0%)

2 (25.0%)

8 (100.0%)

40-50 years

5 (31.2%)

6 (37.5%)

16 (100.0%)

51-61 years

2 (33.3%)

6 (100.0%)

62-72 years

2 (40.0%)

1 (20.0%)

2 (40.0%)

5 (100.0%)

10 (25.0%)

16 (40.0%)

14 (35.0%)

40 (100.0%)

Total p=0.595

Table 3: Distribution of periapical lesions by group of age Age

Granuloma n (%)

Cyst n (%)

Abscess n (%)

Total n (%)

18-28 years

3 (60.0%)

1 (20.0%)

5 (100.0%)

29-39 years

7 (63.6%)

4 (36.3%)

0 (0.0%)

11 (100.0%)

40-50 years

10 (66.6%)

2 (13.3%)

3 (20.0%)

15 (100.0%)

51-61 years

2 (40.0%)

1 (20.0%)

2 (40.0%)

5 (100.0%)

62-72 years

3 (75.0%)

0 (0.0%)

1 (25.0%)

4 (100.0%)

25 (62.5%)

8 (20.0%)

7 (17.5%)

40 (100.0%)

Total p=0.566

Table 4: Differences between quality of root canal and patient’s age Age group

Short n (%)

Overfill n (%)

Fractured Instrument [n (%)]

Total n (%)

18-20 years

3 (60.0%)

1 (20.0%)

5 (100.0%)

29-39 years

3 (27.3%)

5 (45.5%)

3 (27.3%)

11 (100.0%)

40-50 years

5 (33.3%)

9 (60.0%)

1 (6.7%)

15 (100.0%)

51-61 years

2 (40.0%)

3 (60.0%)

0 (0.0%)

5 (100.0%)

62-72 years

0 (0.0%)

4 (100.0%)

0 (0.0%)

4 (100.0%)

5 (12.5%)

40 (100.0%)

Total

13 (32.5%)

22 (55.0%)

p=0.327

Figure 2: Periapical cyst

Figure 3: Periapical abscess Endodontic practice 37

CONTINUING EDUCATION

There was no difference between men and women, and the fourth and fifth decades of life were the most affected (Table 3). Relation between age and the quality of the root canal treatment showed no statistical relevance (Table 4).

CONTINUING EDUCATION because in the majority of cases root apices were not included in the biopsy material, and the material often was not able to be removed in total. As such, a true representation of the type of cyst could not be reliably made (Nair, 1998). Matsumato and colleagues reported that the prognosis for the treatment of large periapical lesions was not as good as that of small lesions (1987). Harrison and Juroski (1992) state that if the lesion is small, then all the pathologic tissue can easily be removed; however, if the lesion is large, then it is more likely that curettage will be incomplete and thus unsuccessful. On the other hand, Rahbaran, Gilthorpe, and Harrison suggest that the lesion size has no significant influence on the success of treatment (2001). Likewise, Strindberg (1956) and Sjögren and colleagues (1990) found no significant differences in healing frequency between lesions initially larger or smaller than 5 mm. It is clear that the prognosis for a periapical lesion depends on its origin, type, and radiographic size, and the ultimate success of endodontic surgery is dependent on a myriad of factors. These include the quality of the orthograde root canal filling, the apical root-end filling, size of the periapical destruction, experience of the operator, the type of periapical pathology, use of antibiotics, status of the coronal restoration, and the method of preparing the apical root-end cavity (Carr, 1992; Maddalone and Gagliani, 2003). The patient’s systemic condition to the history of the individual teeth, case selection, surgical materials, and techniques, and the surgeon’s interpretation of the short and long-term clinical and radiographic findings are other points to consider (Gutmann and Harrison, 1991). An accurate histopathological diagnosis was only possible when the lesion was removed as a whole, and if a serial sectioning or step-serial sectioning was performed. According to Nair and colleagues, this is possible because in a routine histological report, the presence of an epithelialized lesion is reported as a radicular cyst, but often this report is inappropriate (1996).

Conclusion The outcomes of the present study show a high number of periapical granulomas among periapical cysts and confirms that periapical granulomas and cysts are the most common periapical lesions of endodontic origin associated with persistent periapical pathosis. However, other studies have shown a different perspective in the diagnosis of periapical cysts, and more prospective studies 38 Endodontic practice

are necessary for better clarification of these data. Moreover, this study highlights the importance of the histopathological evaluation for a proper diagnosis of periapical pathosis. EP

29. Nair PN. Apical periodontitis: a dynamic encounter between root canal infection and host response. Periodontol 2000. 1997;13:121-148.

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30. Nair PN. New perspectives on radicular cysts: do they heal? Int Endod J. 1998;31(3):155-160. 31. Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39(4):249-281. 32. Nair PNR, Pajarola G, Schroeder HE. Types and incidence of human periapical lesions obtained with extracted teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(1):93-102.

American Association of Endodontists. Approved definitions of endodontic outcome. Colleagues for Excellence. Chicago, IL: 2005.

33. Nair PNR, Sjögren U, Kahnberg KE, Krey G, Sundqvist G. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: a longterm light and electron microscopic follow-up study. J Endod. 1990;16(12):580-588.

Block RM, Bushell A, Rodrigues H, Langeland K. A histopathologic, histobacteriologic, and radiographic study of periapical endodontic surgical specimens. Oral Surg Oral Med Oral Pathol. 1976;42(5):656-678.

34. Nair PN, Sjögren U, Sundqvist G. Cholesterol crystals as an etiological factor in non-resolving chronic inflammation: an experimental study in guinea pigs. Eur J Oral Sci. 1998;106(2 pt 1);644-650.

Brynolf I. A histological and roentgenological study of the periapical region of human upper incisors. Odonto Revy. 1967;18(suppl 11):1-176.

35. Nohl FS, Gulabivala K. Odontogenic keratocyst as periradicular radiolucency in the anterior mandible: two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(1):103-109.

Brynolf I. Roentgenologic periapical diagnosis. II. One, two or more roentgenograms? Sven Tandlak Tidskr. 1970;63(5):345-350.

Carr GB. Microscopes in endodontics. J Calif Dent Assoc. 1992;20(11):55-61.

36. Orstavik D. Time-course and risk analyses of the development and healing of chronic apical periodontitis in man. International Endodontic Journal. 1996;29(3):150-155.

Carr GB, Schwartz RS, Schaudinn C, Gorur A, Costerton JW. Ultrastructural examination of failed molar retreatment with secondary apical periodontitis: an examination of endodontic biofilms in an endodontic retreatment failure. J Endod. 2005;35(9):1303-1309.

Costerton JW . The Biofilm Primer. Berlin: Springer-Verlag Berlin Heidelberg; 2007.

Cotti E, Campisi G, Ambu R, Dettori C. Ultrasound real-time imaging in the differential diagnosis of periapical lesions. Int Endod J. 2003;36(8):556-563.

Friedman S. Prognosis of initial endodontic therapy. Endod Topics. 2002;2:59-88.

10. Friedman S. Etiological factors in endodontic post-treatment disease: apical periodontitis associated with root filled teeth. Endod Topics. 2003;6:1-2. 11. Friedman S. The prognosis and expected outcome of apical surgery. Endod Topics. 2005;11(1):219-262. 12. Gulabivala K, Briggs PF. Diagnostic dilemma: an unusual presentation of an infected nasopalatine duct cyst. Int Endod J. 1992;25(2):107-111. 13. Gutmann JL, Harrison JW. Surgical Endodontics. Boston, MA: Blackwell Scientific Publications; 1991: 338-384. 14. Harrison JW, Jurosky KA. Wound healing in the tissues of the periodontium following periradicular surgery. III. The osseous excisional wound. J Endod. 1992;18(2):76-81.

37. Orstavik D, Pitt Ford TR. Essential Endodontology: Prevention and Treatment of Apical Periodontitis. Malden, MA: Blackwell Science; 1998. 38. Pecora G, De Leonardis D, Ibrahim N, Bovi M, Cornelini R. The use of calcium sulphate in the surgical treatment of a ‘through and through’ periradicular lesion. Int Endod J. 2001;34(3):189. 39. Pellegrino ED. Patient autonomy and the physician’s ethics. Annals of Royal College of Physicians and Surgeons of Canada. 1994;27(3):171-173. 40. Peters LB, Wesselink PR, Moorer WR. The fate and the role of bacteria left in root dentinal tubules. Int Endod J. 1995;28(2):95-99. 41. Priebe WA, Lazansky JP, Wuehrmann AH. The value of the roentgenographic film in the differential diagnosis of periapical lesions. Oral Surg Oral Med Oral Pathol. 1954;7(9):979-983. 42. Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units of a teaching dental hospital: A retrospective study. Oral Surg Oral Med Oral Pathol. 2001;91(6):700-709. 43. Ricucci D, Mannocci F, Pitt Ford TR. A study of periapical lesions correlating the presence of a radiopaque lamina with histological findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(3):389-394. 44. Ricucci D, Siqueira JF Jr. Fate of the tissue in lateral canals and apical ramifications in response to pathologic conditions and treatment procedures. J Endod. 2010;36(1):1-15.

15. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germfree and conventional laboratory rats. Oral Surg Oral Med Oral Pathol. 1965;20:340-349.

45. Ricucci D, Siqueira JF Jr, Bate AL, Pitt Ford TR. Histologic investigation of root canal-treated teeth with apical periodontitis: a retrospective study from twenty-four patients. J Endod. 2009;35(4):493-502.

16. Kuc I, Peters E, Pan J. Comparison of clinical and histologic diagnoses in periapical lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(3):333-337.

46. Rud J, Andreasen JO, Jensen JE. A follow-up study of 1,000 cases treated by endodontic surgery. Int J Oral Surg. 1972;1(4):215-228.

17. Lin LM, Pascon EA, Skribner J, Gängler P, Langeland K. Clinical, radiographic, and histologic study of endodontic treatment failures. Oral Surg Oral Med Oral Pathol. 1991;71(5):603-611.

47. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod. 2004;30(12):846-850.

18. Love RM, Firth N. Histopathological profile of surgically removed persistent periapical radiolucent lesions of endodontic origin. Int Endod J. 2009;42(3):198-202.

48. Siqueira JF Jr, Rôças IN. Polymerase chain reaction-based analysis of microorganisms associated with failed endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):85-94.

19. Maddalone M, Gagliani M. Periapical endodontic surgery: a 3-year follow-up study. Int Endod J. 2003;36(3):193-198. 20. Marsh PD. Dental plaque: biological significance of a biofilm and community life-style. J Clin Periodontol. 2005;32(suppl 6):7-15. 21. Matsumoto T, Nagai T, Ida K, Ito M, Kawai Y, Horiba N, Sato R, Nakamura H. Factors affecting successful prognosis of root canal treatment. J Endod. 1987;13(5):239-242. 22. Mikkonen M, Kullaa-Mikkonen A, Kotilainen R. Clinical and radiologic re-examination of apicoectomized teeth. Oral Surg Oral Med Oral Pathol. 1983;55(3):302-306. 23. Molander A, Reit C, Dahlén G, Kvist T. Microbiological status of root-filled teeth with apical periodontitis. Int Endod J. 1998;31(1):1-7 24. Molven O, Olsen I, Kerekes K. Scanning electron microscopy of bacteria in the apical part of root canals in permanent teeth with periapical lesions. Endod Dent Traumatol. 1991;7(5):226-229. 25. Molven O, Olsen I, Kerekes K. Scanning electron microscopy of bacteria in the apical part of root canals in permanent teeth with periapical lesions. Endod Dent Traumatol. 1991;7(5):226-229. 26. Nair PN, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after ‘‘one-visit’’ endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(2):231-252. 27. Nair PN, Sjögren U, Krey G, Sundqvist G.Therapy-resistant foreign body giant cell granuloma at the periapex of a root-filled human tooth. J Endod. 1990;16(12):589-595. 28. Nair PNR. Light and electron microscopic studies of root canal flora and periapical lesions. J Endod. 1987;13(1):29-39.

49. Siqueira JF Jr, Rôças IN, Lopes HP. Patterns of microbial colonization in primary root canal infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(2):174-178. 50. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498-504. 51. Strindberg LZ. The dependence of the results of pulp therapy on certain factors - an analytical study based on radiographic and clinical follow-up examinations. Acta Odontol Scand. 1956;14(suppl 21): 1-174. 52. Sundqvist G, Figdor D, Persson S, Sjögren U. Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85(1):86-93. 53. von Arx T, Kurt B. Root-end cavity preparation after apicoectomy using a new type of sonic and diamond-surfaced retrotip: a 1-year follow-up study. J Oral Maxillofac Surg. 1999;57(6):656-661. 54. Wang Q, Cheung GS, Ng RP. Survival of surgical endodontic treatment performed in a dental teaching hospital: a cohort study. Int Endod J. 2004;37(11):764-775 55. World Health Organization. Application of the International Classification of Diseases to Dentistry and Stomatology. 3rd ed. Geneva: World Health Organization; 1995: 66-67. 56. World Health Organization. Declaration of Helsinki. British Medical Journal. 1996;313(7070):1448-1449. 57. Yu VS, Messer HH, Yee R, Shen L. Incidence and impact of painful exacerbations in a cohort with post-treatment persistent endodontic lesions. J Endod. 2012;38(1):41-46.

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Nonsurgical retreatment and perforation repair in a maxillary first molar

Relationship between clinical and histopathologic findings of 40 periapical lesions

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ENRIQUEZ

Replacement with an implant may be feasible, but generally, well root-filled and restored teeth appear to function _______ single tooth implants. a. comparably to b. much better than c. much worse than d. more effectively than Restored natural teeth also tend to be ________ if and when they fail. a. more costly to repair b. less costly to repair c. more complicated to repair d. impossible to repair A two-visit strategy was adopted in this case to __________. a. ensure adequate disinfection of the root canals b. allow optimal management of a pulp floor perforation c. confirm healing of the sinus tract before obturation. d. all of the above The importance of using _______ during endodontic procedures cannot be overemphasized. a. a composite core b. illumination c. magnification d. both b and c There is a high risk of ________ when perforation occurs at crestal bone level. a. bur fracture b. granulation tissue accumulation c. microleakage d. poor esthetics If bone is present on the external aspect of the perforation, repair is normally _______. a. feasible

Volume 8 Number 4

b. unfeasible c. not recommended d. risky 7.

10.

It is preferable to seal a perforation ________ to prevent microleakage and bacterial contamination. a. with cotton wool pellets b. as soon as possible c. and plasticize the gutta percha d. none of the above A solution of ____ EDTA or citric acid as a final rinse is used to remove smear and has a positive benefit on outcome in retreatment cases. a. 0.2% b. 10% c. 17% d. 28% Dressing the canals (after preparation and disinfection) with calcium hydroxide for ___ days was shown to be effective at producing bacteria-free canals. a. 3 b. 5 c. 7 d. 10 (Many endodontists have adopted a single-visit approach, however,) Contrary to this, a two-visit strategy was adopted in this case to ____________. a. allow setting of the perforation repair material b. confirm healing of the sinus tract before obturation c. recheck for the disinfection d. both a and b

Periapical lesions are the ______________ apical odontogenic pathologies in human teeth. a. most frequently diagnosed b. most frequently misdiagnosed c. the least frequently diagnosed d. most untreatable Bacterial stimulus cells cause __________ to be released into the periapical tissues, as shown by Nair, Henry, and Cano Vera. a. intercellular mediators b. humoral antibodies c. effector molecules d. all of the above

Apical ramifications, lateral canals, and isthmuses connecting main root canals have all been shown to _______, which are also frequently organized in biofilm-like structures. a. have antibacterial-like cells b. harbor bacterial cells c. create non-connective tissue d. cause a tangle of blood vessels

An acute apical periodontitis or periapical abscess is associated with clinical signs of _______. a. numbness b. inflammation c. pain d. both b and c

Apical periodontitis is one of the _____ pathological conditions within alveolar bone. a. most unusual b. most untreatable c. most common d. least diagnosable

It is usually a sequel of an endodontic infection that turns the dental pulp into a necrotic tissue infected by autogenous oral bacteria. This infection usually occurs through dental hard tissue damage resulting from ________ and provokes an inflammatory process that stimulates the proliferation of the cell rests of Malassez in the periodontal ligament, as reported by Nair. a. caries

b. clinical procedures c. trauma d. all of the above 7.

Matsumato and colleagues showed that the prognosis for the surgical treatment of large periapical lesions was ______ as that of small lesions. a. not as good b. comparable to c. better than d. not as measurable

Studies show that a(n) _____ is the most common periapical lesion of endodontic origin; the diagnosis is based on the presence of connective tissue, blood vessels, and inflammatory cells and may also be called chronic apical periodontitis when chronic inflammatory cells feature or secondary acute apical periodontitis when polymorphonuclear leukocytes are present. a. periapical granuloma b. sessile granuloma c. osmotic lumen d. epithelial granulosis

Periapical pathosis was defined as a radiolucent lesion related with a root-filled tooth with either an extending periapical lesion as seen on a radiograph; an unhealed periapical lesion of ______ duration post-endodontic treatment; or a tooth with a periapical radiolucent lesion with clinical signs and symptoms of periapical pathosis of endodontic origin such as pain, swelling, or sinus tract. a. 6 months’ b. 2 years’ c. 3 years’ d. 5 or more years’

10.

It is clear that the prognosis for a periapical lesion depends on its ___________, and the ultimate success of endodontic surgery is dependent on a myriad of factors. a. origin b. type c. radiographic size d. all of the above

Endodontic practice 39

CE CREDITS

ENDODONTIC PRACTICE CE

ABSTRACTS

The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research Pulp treatment for extensive decay in primary teeth Smail-Faugeron V, Courson F, Durieux P, Muller-Bolla M, Glenny AM, Fron Chabouis H. Cochrane Database of Systematic Reviews. [Update of Cochrane Database Syst Rev, 2003] (2014) 8:CD003220 Abstract Aim: In children, dental caries is among the most prevalent chronic diseases worldwide. Pulp interventions are indicated for extensive tooth decay. Depending on the severity of the disease, three pulp treatment techniques are available: direct pulp capping, pulpotomy, and pulpectomy. After treatment, the cavity is filled with a medicament. This was an update of a Cochrane review first published in 2003. The previous review found insufficient evidence regarding the relative efficacy of these interventions, combining one pulp treatment technique and one medicament. The aim was to assess the effects of different pulp treatment techniques and associated medicaments for the treatment of extensive decay in primary teeth. Methodology: The Cochrane Oral Health Groupâ&#x20AC;&#x2122;s Trials Register (to 25 October 2013) was searched, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 25 October 2013), EMBASE via OVID (1980 to 25 October 2013), and the Web of Science (1945 to 25 October 2013). The OpenGrey for Grey Literature and the U.S. National Institutes of Health Trials Register, and the World Health Organization (WHO) Clinical Trials Registry Platform for ongoing trials were searched. There were no restrictions placed on the language or date of publication when searching the electronic databases. Eligible studies were randomized

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.

40 Endodontic practice

controlled trials comparing different pulp interventions combining a pulp treatment technique and a medicament in children with extensive decay involving dental pulp in primary teeth. Two review authors independently carried out data extraction and risk of bias assessment in duplicate. The authors of randomized controlled trials were contacted for additional information, if necessary. The primary outcomes were clinical failure and radiological failure, as defined in trials, at 6, 12, and 24 months. Data synthesis was performed with pairwise meta-analyses using fixed-effect models. Statistical heterogeneity was assessed using by I(2) coefficients. Results: 47 trials (3,910 randomized teeth) were included compared to three trials in the previous version of the review published in 2003. All trials were single center and small sized (median number of randomized teeth: 68). Overall, the risk of bias was low in only one trial with all other trials being at unclear or high risk of bias. The overall quality of the evidence was low. The 47 trials examined

53 different comparisons: 25 comparisons between different medicaments/techniques for pulpotomy, 13 comparisons between different medicaments for pulpectomy, 13 comparisons between different medicaments for direct pulp capping, and two comparisons between pulpotomy and pulpectomy. Regarding pulpotomy, 14 trials compared mineral trioxide aggregate (MTA) with formocresol (FC). MTA reduced both clinical and radiological failures at 6, 12, and 24 months, although the difference was not statistically significant. MTA also showed favorable results for all secondary outcomes measured; although again, differences between MTA and FC were not statistically significant (with the exception of pathological root resorption at 24 months and dentin bridge formation at 6 months). MTA showed favorable results compared with calcium hydroxide (CH) (two trials) for all outcomes measured, but the differences were not statistically significant (with the exception of radiological failure at 12 months). When comparing MTA with ferric Volume 8 Number 4

Correlation between clinical and histologic pulp diagnoses Ricucci D, Loghin S, Siqueira JF Jr. Journal of Endodontics. (2014) 40(12):1932-9 Abstract Aim: Clinicians routinely face conditions in which they have to decide whether the dental pulp can be saved or not. This study evaluated how reliable the clinical diagnosis of normal pulp/reversible pulpitis (savable pulp) or irreversible pulpitis (nonsavable pulp) is when compared with the histologic diagnosis. Methodology: The study material consisted of 95 teeth collected consecutively in a general practice over a 5-year period and extracted for reasons not related to this study. Based on clinical criteria, teeth were categorized as having normal pulps, reversible pulpitis, or irreversible pulpitis. The former two were grouped together because they represent similar conditions in terms of prognosis. Teeth were processed for histologic and histobacteriologic analyses, and pulps were categorized as healthy, reversibly inflamed, or irreversibly inflamed according to defined criteria. The number Volume 8 Number 4

of matching clinical/histologic diagnosis was recorded. Results: The clinical diagnosis of normal pulp/reversible pulpitis matched the histologic diagnosis in 57 of 59 (96.6%) teeth. Correspondence of the clinical and histologic diagnosis of irreversible pulpitis occurred in 27 of 32 (84.4%) cases. Infection advancing to the pulp tissue was a common finding in teeth with irreversible pulpitis but was never observed in normal/reversibly inflamed pulps. Conclusions: Findings using defined criteria for clinical and histologic classification of pulp conditions revealed a good agreement, especially for cases with no disease or reversible disease. This means that the classification of pulp conditions as normal pulps, reversible pulpitis, and irreversible pulpitis has high chances of guiding the correct therapy in the large majority of cases. However, there is still a need for refined and improved means for reliable pulp diagnosis.

Root canal therapy reduces multiple dimensions of pain: a national dental practice-based research network study Law AS, Nixdorf DR, Rabinowitz I, Reams GJ, Smith JA Jr, Torres AV, Harris DR, National Dental PBRN Collaborative Group. Journal of Endodontics. (2014) 40(11):1738-45 Abstract Aim: Initial orthograde root canal therapy (RCT) is used to treat dentoalveolar pathosis. The effect RCT has on pain intensity has been frequently reported, but the effect on other dimensions of pain has not. Also, the lack of large prospective studies involving diverse groups of patients and practitioners who are not involved in data collection suggest that there are multiple opportunities for bias to be introduced when these data are systematically aggregated.

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Endodontic practice 41

ABSTRACTS

sulfate (FS) (three trials), MTA had statistically significantly fewer clinical, radiological, and overall failures at 24 months. This difference was not shown at 6 or 12 months. FC was compared with CH in seven trials and with FS in seven trials. There was a statistically significant difference in favor of FC for clinical failure at 6 and 12 months, and radiological failure at 6, 12, and 24 months. FC also showed favorable results for all secondary outcomes measured, although differences between FC and CH were not consistently statistically significant across time points. The comparisons between FC and FS showed no statistically significantly difference between the two medicaments for any outcome at any time point. For all other comparisons of medicaments used during pulpotomies, pulpectomies, or direct pulp capping, the small numbers of studies and the inconsistency in results limit any interpretation. Conclusions: There was no evidence to identify one superior pulpotomy medicament and technique clearly. Two medicaments may be preferable: MTA or FS. The cost of MTA may preclude its clinical use, and therefore, FS could be used in such situations. Regarding other comparisons for pulpectomies or direct pulp capping, the small numbers of studies undertaking the same comparison limits any interpretation.

ABSTRACTS Methodology: This prospective observational study assessed pain intensity, duration, and its interference with daily activities among RCT patients. Sixty-two practitioners (46 general dentists and 16 endodontists) in the National Dental Practice-Based Research Network enrolled patients requiring RCT. Patient-reported data were collected before, immediately after, and 1 week after treatment using the Graded Chronic Pain Scale. Results: The enrollment of 708 patients was completed over 6 months with 655 patients (93%) providing 1-week follow-up data. Before treatment, patients reported a mean (+standard deviation) worst pain intensity of 5.3 + 3.8 (0-10 scale), 50% had “severe” pain (>7), and mean days in pain and days pain interfered with activities were 3.6 + 2.7 and 0.5 + 1.2, respectively. After treatment, patients reported a mean worst pain intensity of 3.0 + 3.2, 19% had “severe” pain, and mean days in pain and days with pain interference were 2.1 + 2.4 and 0.4 + 1.1, respectively. All changes were statistically significant (P < .0001). Conclusions: RCT is an effective treatment for patients experiencing pain, significantly reducing pain intensity, duration, and related interference. Further research is needed to reduce the proportion of patients experiencing “severe” postoperative pain.

Prevalence of persistent pain 3 to 5 years post primary root canal therapy and its impact on oral health-related quality of life: PEARL Network findings Vena DA, Collie D, Wu H, Gibbs JL, Broder HL, Curro FA, Thompson VP, Craig RG, PEARL Network Group. Journal of Endodontics. (2014) 40(12):1917-21 Abstract Aim: The frequency of persistent pain 3 to 5 years after primary root canal therapy and its impact on the patient’s perceived oral health-related quality of life was determined in a practice-based research network. Methodology: All patients presenting to participating network practices who received primary root canal therapy and restoration for a permanent tooth 3 to 5 years previously were invited to enroll. Persistent pain was defined as pain occurring spontaneously or elicited by percussion, palpation, or biting. The patient also completed an oral healthrelated quality of life questionnaire (Oral Health Impact Profile-14). Results: Sixty-four network practices enrolled 1,323 patients; 13 were ineligible; 12 did not receive a final restoration; and 41 42 Endodontic practice

RCT is an effective treatment for patients experiencing pain, significantly reducing pain intensity, duration, and related interference. were extracted, leaving 1,257 for analysis. The average time to follow-up was 3.9 + 0.6 years; 5% (63/1257) of the patients reported persistent pain, whereas 24 of 63 (38%) exhibited periapical pathosis and/or root fracture (odontogenic pain). No obvious odontogenic cause for persistent pain was found for 39 of 63 (62%). Teeth treated by specialists had a greater frequency of persistent pain than teeth treated by generalists (9.3% versus 3.0%, respectively; P < .0001). Sex, age, tooth type, type of dentist, and arch were not found to be associated with nonodontogenic persistent pain; however, ethnicity and a preoperative diagnosis of pulpitis without periapical pathosis were. Patients reporting pain with percussion tended to experience pain with other stimuli that negatively impacted quality of life including oral function and psychological discomfort and disability. Conclusions: These results suggest that a small percentage (3.1%) of patients experience persistent pain not attributable to odontogenic causes 3 to 5 years after primary root canal therapy that may adversely impact their quality of life.

Results: Two hundred and five patients (229 teeth) were available for follow-up (74% recall rate). The overall success rates were 80.5% (95% confidence interval [CI], 74.586.5) of teeth in the MTA group (137/170) and 59% (95% CI, 46.5-71.5) of teeth in the CH group (35/59). Multivariate analyses (generalized estimating equation logit model) indicated a significantly increased risk of failure for teeth that were directly pulp capped with CH compared with MTA (odds ratio = 2.67; 95% CI, 1.36-5.25; P = .001). Teeth that were permanently restored >2 days after direct pulp capping had a significantly worse prognosis irrespective of the pulp capping material chosen (odds ratio = 3.18; 95% CI, 1.61-6.3; P = .004). Conclusions: The results of this study indicate that MTA provides better long-term results after direct pulp capping compared with CH. Placing a permanent restoration immediately after direct pulp capping is recommended.

Treatment outcome of mineral trioxide aggregate or calcium hydroxide direct pulp capping: long-term results

Venkatesh S, Ajmera S, Ganeshkar SV. Journal of Endodontics. (2014) 40(11):1758-63

Mente J, Hufnagel S, Leo M, Michel A, Gehrig H, Panagidis D, Saure D, Pfefferle T. Journal of Endodontics. (2014) 40(11):1746-51 Abstract Aim: This controlled, historic cohort study project continues a previously reported trial aiming to assess treatment outcome of direct pulp capping with mineral trioxide aggregate (MTA) versus calcium hydroxide (CH). Potential prognostic factors were re-evaluated on the basis of a larger sample size and longer follow-up periods. Methodology: Clinical and radiographic outcomes of 229 teeth treated with direct pulp capping between 2001 and 2011 were investigated 24 up to 123 months post-treatment (median = 42 months). Pre-, intra-, and postoperative information was evaluated and statistically analyzed using a logistic regression model as well as generalized estimating equation logit models.

Volumetric pulp changes after orthodontic treatment determined by cone-beam computed tomography

Abstract Aim: The purpose of this study was to observe and evaluate three-dimensional pulp cavity changes during orthodontic treatment. Methodology: Eighty-seven patients formed the study sample and were divided into an experimental group (48 patients) and a control group (39 patients). Conebeam computed tomographic (CBCT) records were obtained before the start of the treatment (T0) and after space closure for the experimental group, whereas for the control group CBCT images were obtained approximately 17-18 months (T1) after obtaining the first image (T0). CBCT data were reconstructed with surface and volume rendering software (Mimics; Materialise, Leuven, Belgium), and the volumetric images were modified to display the teeth from various orientations. Six anterior teeth were segmented and their pulps isolated. Paired t-test was used to check for statistical significance. Volume 8 Number 4

Direct pulp capping after a carious exposure versus root canal treatment: a cost-effectiveness analysis Schwendicke F, Stolpe M. Journal of Endodontics. (2014) 40(11):1764-70 Abstract Aim: Excavation of deep caries often leads to pulpal exposure even in teeth with sensible, non-symptomatic pulps. Although direct pulp capping (DPC) aims to maintain pulpal health, it frequently requires follow-up treatments like root canal treatment (RCT), which could have been performed immediately after the exposure, with possibly improved outcomes. The long-term costeffectiveness of both strategies was quantified and compared. Methodology: A Markov model was constructed following a molar with an occlusally located exposure of a sensible, non-symptomatic pulp in a 20-year-old male patient over his lifetime. Transition probabilities or hazard functions were estimated based on systematically and nonsystematically assessed literature. Costs were estimated based on German healthcare, and cost-effectiveness was analyzed using Monte Carlo microsimulations. Results: Despite requiring follow-up treatments significantly earlier, teeth treated by DPC were retained for long periods of time (52 years) at significantly reduced lifetime costs (â&#x201A;Ź545 versus â&#x201A;Ź701) compared with teeth treated by RCT. For teeth with proximal instead of occlusal exposures or teeth in patients > 50 years of age, this costeffectiveness ranking was reversed. Although sensitivity analyses found substantial uncertainty regarding the effectiveness of both strategies, DPC was usually found to be less costly than RCT. Conclusions: Both DPC and RCT were suitable to treat exposed vital, nonsymptomatic pulps. DPC was more cost-effective in younger patients and for occlusal exposure sites, whereas RCT was more effective in older patients or teeth with proximal Volume 8 Number 4

exposures. These findings might change depending on the healthcare system and underlying literature-based probabilities.

The effect of rubber dam usage on the survival rate of teeth receiving initial root canal treatment: a nationwide population-based study Lin PY, Huang SH, Chang HJ, Chi LY. Journal of Endodontics. (2014) 40(11):1733-7 Abstract Aim: The aim of the present study was to investigate whether rubber dam usage affects the survival rate of initial RCT using a nationwide population-based database. Methodology: A total of 517,234 teeth that received initial RCT between 2005 and 2011 met the inclusion criteria and were followed until the end of 2011. Univariate and multivariate Cox proportional hazards models were used to estimate the effects of rubber

dam usage on the risk of tooth extraction after initial RCT. Results: Of the 517,234 teeth, 29,219 were extracted, yielding a survival rate of 94.4%. The survival probability of initial RCT using rubber dam after 3.43 years (the mean observed time) was 90.3%, which was significantly greater than the 88.8% observed without the use of rubber dams (P < .0001). After adjusting for age, sex, tooth type, hospital level, tooth scaling frequency per year after RCT, and systemic diseases, including diabetes and hypertension, the tooth extraction hazard ratio for the RCT with rubber dams was significantly lower than that observed for RCT without rubber dams (hazard ratio = 0.81; 95% confidence interval, 0.79-0.84). Conclusions: The use of a rubber dam during RCT could provide a significantly higher survival rate after initial RCT. This result supports that rubber dam usage improves the outcomes of endodontic treatments. EP

Endodontic practice 43

ABSTRACTS

Results: The difference in the pulp volume was statistically significant at P < .05 for all the anterior teeth in the experimental group and at P < .05 for the right canine, P < .05 for the right and left lateral incisors, and P < .05 for the left central in the control group. Conclusions: Orthodontic treatment in the experimental group produced a significant decrease in the size of the pulp, which was statistically significant.

PRACTICE DEVELOPMENT

How to achieve influence online Dr. Julian Webber discusses a new online resource for endodontic patients and the digital environment for endodontists

t the end of 2014, the Harley Street Centre for Endodontics’ website launched Rootipedia, an online glossary of common endodontic and dental terminology. It was compiled as an online resource for patients but also intended to have an impact on website optimization. Hundreds of people visited the website in response to the launch, and this prompted me to reflect on the effects of the digital world on endodontics. Most of us tend to see the Internet as a marketing tool. A website today is as essential as a brass plate and a brochure used to be in the 20th century! But the integration of media that can be achieved online means that the digital environment is equally about helping the business operate successfully. As in many places in the United States as well, the endodontic community is a small one, and competition among specialists in central London is friendly. If you look at the websites of London’s top 20 specialist practices, for instance, we are all saying similar things but in different ways. Our mission, to quote the title of Dale Carnegie’s book from the 1930s, is to “Win friends and influence people” — although endodontists have their sights on two distinct groups of people: referring dentists and new patients. The evolution of my practice into the digital sphere has been influenced by another American, the endodontist Dr. Gary Carr. What’s remarkable about his role is that he has also been a lifelong professional mentor. When he established his company, The Digital Office (TDO), I sat up and took notice. In 2002, I was one of the first U.K. endodontists to decide to buy into his TDO Julian Webber, BDS, MS, DGDP, FICD, currently practices at the Harley Street Centre for Endodontics on Harley Street in London. He was the first U.K. dentist to receive a Master’s in endodontics from a university in the U.S. Dr. Webber lectures extensively in the U.K., as well as providing workshops and hands-on courses. He is the editor-in-chief of Endodontic Practice in the U.K. To find out more about Rootipedia, an online glossary for endodontic and dental terminology, visit the website at www. roottreatmentuk.com/html/rootipedia.

44 Endodontic practice

management software. There are now more than 1,500 of us worldwide, and we belong to the TDO community: www.tdo4endo.com. The TDO software, which backs up directly to servers in the U.S., stores all our records, images, accounts, and policies, making it possible for me to operate a completely paperless practice. This is probably the greatest advantage of the digital environment for me.

Functionality Dentists who refer to the Harley Street Centre for Endodontics are given a login so they can access the records and images of their patients, which can be viewed within 15 minutes of the patient’s appointment. Another advantage of the system is that it allows contemporaneous data capture, so all of the staff can be working within it at the same time. For the past 2 years, I have been using the TDO app on my iPhone. This makes it possible for me to call up patients’ records and look at their notes and speak to their dentist, no matter where I am in the world. For someone who travels a lot, this is hugely reassuring. My website incorporates the TDO software, but the front end was designed and built by Jon Kempner of Kiosx. His parents had run a dental practice, and he understands the patient-facing function of the website. As a result, my website has been built as an educational resource rather than as a business generator. Kempner understands that most of my patients come to the clinic via referral. The website is there as a credibility checker, so new patients can read

about root canal treatment, find out the location of the clinic, and the costs of treatment. There are, of course, patients who find me via the website, but they are the minority.

Digital dreams So what does 2015 hold, and how will I be extending my activities in the digital sphere? My priority is to keep adding information and news to my website because this still has a positive impact on ranking. Initially, I was wary of social media, but I have to admit that I have come to enjoy Twitter greatly and use it at home and abroad as a way of connecting with friends and colleagues. By tweeting links to my website, I help optimize my site. When Rootipedia was launched, Twitter helped get the word out. LinkedIn was also useful. This is another example of the integration of platforms through digital media, and I’m keen to explore more. Social media is about building relationships, and the best endodontics is provided when you have a good relationship with your referring dentists and their patients. But remember that no matter how professional your technology and media strategy are, a personal touch can only be achieved offline. I’m hoping that when patients read Rootipedia or any of my other online resources, my blog, the Saving Teeth Awareness Campaign, and my tweets, they are encouraged to take the step of making an appointment to have their root canal treatment. Hopefully, all online communications reflect the high standards to be found in the specialist practice and a taste of what is to come when the patient finally steps into the operatory. EP Volume 8 Number 4

BEFORE TDO

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ENDOSPECTIVE

No pressure, no diamonds Dr. Rich Mounce offers some gems on reaching goals

“I

t is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.” —Theodore Roosevelt, 1910

Over the years, more than a few times, clinicians and non-clinicians alike have told me how much they would like do something (personally or professionally), and subsequently, then have given me all the reasons why they can’t. A commonality in these conversations is that the individual cannot connect every dot between starting the endeavor and finishing with dazzling success. Because they won’t take the first step or alternatively only take safe baby steps, little of substance is achieved. In essence, these people know what they want, but the doing is stalled by doubt, fear, apathy, and a lack of inertia. Pressure makes diamonds. Nothing worth having comes easily. No pressure means no diamonds. Wouldn’t the world be a better place if we would individually and collectively assess our strengths, weaknesses, passions, opportunities, and formulate a plan, moving forward as

Rich Mounce, DDS, has lectured and written globally in the specialty of endodontics. He owns MounceEndo, an endodontic supply company also based in Rapid City, South Dakota (605-7917000). He can be reached at RichardMounce@ MounceEndo.com, MounceEndo.com. Twitter: @MounceEndo

46 Endodontic practice

though no force on heaven and earth could stop us? I believe so. Aside from the gains of achieving our goals, we avoid the pain of inaction. I was once an avid cave diver. When first diving, I had no idea that technical (cave) diving existed. One thing led to another, and what began as a quest to dive competently on shipwrecks led me into cave diving. Training was difficult, but quitting was never an option. I knew if I quit, it could easily become an excuse for quitting in other realms of my life. Perseverance paid off, as the most beautiful things I have seen in my life are in the caves I explored with my dive guide Brian Kakuk in the Bahamas (BahamasUnderground.com). Ultimately, pushing through the barriers was more than worth it. Forming MounceEndo.com, my endodontic supply company, had much the same origin. We set out initially to have four individual products; we are now dealers for seven vendors and sell thousands of endodontic products, some globally. One initial phone call has led to a successful business that is growing exponentially and become an abundant blessing. If you could do anything in your practice and personal life, without limits, what would they be? What is stopping you? Can

people achieve what they set their minds to? Perhaps naively and optimistically, I believe, the answer is almost universally, “yes.” God gave us great gifts, often only waiting to be used. Failure is guaranteed if we don’t try. And should we fail, I agree with Teddy Roosevelt, at least we have the satisfaction of knowing we did our best, unlike the critics. How is this done? Reflection, a blank piece of paper, dreaming without limits and writing down all the steps needed to move forward, and taking the first one — never easy, but immeasurably better than the alternatives. The journey is never straight, and abundant opportunities will present themselves disguised in the form of problems and challenges along the way. Once challenges are met, confidence, capability, and strength grow. How easy was your first root canal? Where are you now? Could you not use this same approach to achieve your purpose? I challenge you to find your bliss one step at a time — take the first one with resolve, confidence, and expectancy. You have greatness in you. Be an example to those around you, especially your children, so show them what gifts and dreams you have in you by taking the first step. I welcome your feedback. EP Volume 8 Number 4

Marla Merritt discusses how to make treatment more affordable

oes your practice offer flexible payment options to your patients? Most do not. As a result, the dental industry as a whole is missing out on hundreds of thousands of dollars in recommended but unaccepted cases each year. Recently, I have visited with several orthodontic and dental practices. The purpose of

Marla Merritt, Director of Marketing and Sales for OrthoBanc, LLC, has over 22 years of experience in the promotion and sales of risk management services and payment solutions. Her background includes 12 years working for an Equifax affiliate in Chattanooga, Tennessee, where she helped banks, credit unions, and other industries implement risk assessment models into their lending policies. Ms. Merritt is currently with OrthoBanc where she leads the teams that are responsible for sales/marketing, customer setup, training, and customer service. OrthoBanc currently serves over 2,000 providers and has managed payments for over 1.3 million responsible parties. Ms. Merritt secured EXHIBITOR Magazine’s Sizzle Award and also its All-Star Award for two of her highly successful, city-themed trade-show marketing campaigns.

Volume 8 Number 4

my visits has been to discuss the financial policies and fee presentation procedures in these practices. It has been an eye-opening exercise. Here is what I have observed while in dental practices: Treatment Coordinator: Mr. Patient … Here is the treatment you need, and the total price will be about $5,500. Here is the information for a company that will provide you with financing. If you do not qualify, payment in full will be due at the time of treatment. Patient: I know that I need this done. Can we work out some sort of office payment plan? Treatment Coordinator: I’m sorry. We don’t offer an office payment plan, but here is the information you will need to see if you qualify for financing. At this point, the patient often walks out the door with sticker shock. Many will never come back to that practice again. Many will shop around to see if they can get a better price or a more flexible payment option.

Others will determine that they just can’t afford treatment. What I have observed in orthodontic practices, however, has been a much different story. Those fee presentations go something like this: Treatment Coordinator: Mr. Patient … We look forward to working with you and giving you an even more beautiful smile. We typically ask for $1,000 up-front and then let you pay $225 per month interest free for 20 months. Does this work for you? Patient: Not really. I will have to think this over and get back with you. Treatment Coordinator: What part of this doesn’t work? Is it the up-front cost? How much do you think you could afford to pay up-front? We can work with you. At this point, the Treatment Coordinator and the patient engage in dialogue where they work together to come up with something that works for both parties. Practices that are very good at this dialogue are often Endodontic practice 47

PRACTICE MANAGEMENT

Increase case acceptance by becoming a patientcentered practice and offering flexible payment options

PRACTICE MANAGEMENT able to secure an appointment to begin treatment. The July 1995 issue of Dental Economics magazine carried the headline “Cash or Credit? A Flexible Policy Maximizes Your Cash Flow.” As far back as 20 years ago, consultants were pointing out that it is important for a dental practice to offer flexible payment plans — yet most practices still maintain a “cash only” policy. Let’s explore why this is still happening. Practices that offer only third-party financing or cash up-front (known as a “cash only” practice), enjoy a 100% collection rate and maintain very low accounts receivable. On the surface, this seems like the perfect solution. However, if we dig a little deeper, the picture looks quite different. First of all, these practices are giving up as much as 10% of their treatment fees to these thirdparty finance companies when patients choose this over true “cash” up-front. Many practices will inflate fees to account for this, making treatment even more out of reach for numerous patients. Another thing that happens to these “cash only” practices is that they leave behind tens of thousands of dollars in unscheduled production each year. Patients walk away. Many of these are patients who need treatment, who want treatment, and who could afford treatment if only they were offered more flexible payment options. I am not telling you anything that you didn’t already know. Most specialty dentists realize that being a “cash only” practice creates low case acceptance and a dependency on insurance, but the alternative leaves them even more apprehensive. “I am not going to offer payment plans because I do not want to take the risk of having delinquent payments or nonpayment. Also, taking on patient delinquency opens me up to poor compliance, lawsuits, and a referral pipeline of other nonpaying patients.” This is the argument that I have heard from many dentists. For 20 years, dental practices have chosen what they consider to be the lesser of two evils. By having a “cash only” practice, they have avoided the headaches involved with offering office payment plans and chasing down missed payments. They have also missed the opportunity for higher case acceptance and increased profitability. Is there a third choice? Is there a solution that allows for high case acceptance and production, a great collection rate, an efficient schedule, and a high rate of the right kind of patient referrals? 48 Endodontic practice

Now more than ever before, it is important to build a patient-centered reputation. Offering a flexible payment policy that makes your treatment affordable is a key factor in building that reputation.

Dental Consultant, Paul Zuelke, recently said, “Stable people with excellent credit can be trusted to keep their financial agreements and should be allowed, when necessary, low and even $0 down payments with fairly longterm payment plans.” There are two important things to notice about this statement. First of all, Zuelke refers to “stable people with excellent credit.” How do you assess if a person is stable and has excellent credit? Fortunately, technology makes that one easy. Credit grades and payment plan recommendations can be obtained in a matter of seconds using an office computer and the Internet. Check out www.getzacc.com to learn a little more about how this can work in your practice. The next key point I want to highlight is Zuelke’s mention of “when necessary.” The reason I want to dwell on these two words is because the assumption is that you know when a flexible payment plan is necessary. In my observations, dental practices are not delving into these important conversations with responsible parties to determine what they can reasonably afford up-front and as a monthly payment. When handled properly, these conversations can be the key to great case acceptance. It is critical, first of all, to have a system in place that allows you to quickly identify the maturity, stability, and credit worthiness of any person. Second, it is important that you have a well-trained, pleasant Treatment Coordinator that will work with patients to determine a payment plan that is appropriate for both parties. Once you have these two things in place, you can design payment plans that work for your low-risk patients. You will begin to enjoy increased case acceptance, a more predictable flow of monthly income for your practice, and improved profitability.

Before I conclude this article, I want to address two other concerns often expressed to me by dentists who consider offering flexible payment options. The first concern is in response to my comparison of dental and orthodontic practices. The argument can be made that the risk is inherently less in an orthodontic practice because the patient is making payments while receiving ongoing treatment. This is a very valid point, and it is the reason that utilizing a credit assessment tool is so important for a dental practice. People who have a good credit rating can be counted on to pay all their bills, including their dental bills. These are the people who have earned the opportunity for a flexible payment plan. The second concern that I often hear relates to what happens after a payment plan is established. Many practices operate with a staff that is at capacity and cannot take on the added burden of managing monthly payment plans. To address this concern, I strongly recommend electronic drafting for all monthly payments. There are a variety of sources that can handle electronic payment drafting. Check out www.dentalbanc.com to learn about a drafting company that also follows up with responsible parties if a payment fails for any reason. In the last 12 months, dental practices have observed a decline in the number of patients that have dental insurance. It is forecasted that there will be an additional 50% decline in the next 3-5 years due to the Affordable Care Act. Now more than ever before, it is important to build a patientcentered reputation. Offering a flexible payment policy that makes your treatment affordable is a key factor in building that reputation. EP Volume 8 Number 4

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