Endodontic Practice US - November/December 2015 Issue - Vol8.6 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews November/December 2015 – Vol 8 No 6

PROMOTING

EXCELLENCE

Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans

Cleaning the third dimension Drs. Gilberto Debelian and Martin Trope

ENDODONTICS

Posterior composites and new bulk-fill materials Dr. Ron Jackson

Practice integrity, part 1: fulfilling the promise Dr. Joel Small

Practice profile

Dr. Albert (Ace) Goerig

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

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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@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 6

et me tell you about the Father of Our Specialty — Dr. Louis I. Grossman (1902–1988). At the time that I met him, I was 24 years old. In many ways, I was too young to fully appreciate the man who was to be my mentor for the next 2 years as an Endodontic gradstudent at the University of Pennsylvania. Looking back, I did not have the maturity to really understand how extraordinary he was. I can’t tell you much about his personal life because he rarely shared that with us. I want to tell you about what I observed about his professional life — his approach to Endodontics. To this date, I’m still fascinated and instructed by his imagination, curiosity, and desire to do better Endodontics. I met Dr. Grossman when he was 70 years old. He was almost 50 years my senior at the time. One may have thought that with age, Dr. Grossman might have become dogmatic and closed-minded. At that stage in his life, he certainly could have been forgiven for being so, but he wasn’t! To the contrary, when I asked him if I could try finishing cases without obtaining a culture, he said, “Give it a try.” (Actually, back then, we needed two negative cultures before we could obturate.) When I asked him if I could try treating patients in one appointment — same answer. “Just be prepared to justify why you think it will work, and document your results.” As I think back, I remember a sly smile on his face whenever he gave me an answer to such inquiries. It was as if he were thinking, “Find out for yourself what works … I already know!” Some of you may have had the chance to meet Dr. Grossman, but you may not have had the chance to know him as such an intellectually spirited guy. What he taught my classmates and me was to always be thinking how we could do something better, to try new ideas, and not to accept the status quo. There was not much new in Endodontics in the 1970s and 1980s. Yes, we spent a lot of time discussing which obturation technique worked better (cold lateral versus warm vertical), but there was not much new and very little to get excited about. In contrast, the 1990s were an exceptional and exciting time in Endodontics — rotary instrumentation was introduced, and surgical operating microscopes (SOMs) really changed the game. The last decade has given us new technologies such as CBCT and bioceramics. How excited Dr. Grossman would have been to see how advanced material science in the form of premixed nanoparticle sealer technology had upped the game. Imagine Dr. Grossman’s thrill at seeing a series of 3D images that could confirm his suspicion that a tooth had a vertical root fracture or that he could see a mid-root perforation — the result of an internal resorption. The use of CBCT for the diagnosis and treatment of Endodontic disease has added immensely to our ability to accurately see what was only recently obscure and hidden. Or better yet, can you imagine if he had the chance to use rotary instrumentation? What he might be thinking and doing? Do you think he would have been slow to embrace these advanced technologies? Let me assure you that that would not have been the case! Sealers/cements that use 21st-century nanotechnology (EndoSequence® BC Sealer™, Brasseler USA®) are not only innovative; they are more efficient and user-friendly. They exhibit properties that Dr. Grossman could only dream about — they are biocompatible, antibacterial, hydrophilic, stable upon setting (no shrinkage), insoluble in tissue fluids, osteogenic, bond to dentin, and even produce hydroxyapatite upon setting. Can you imagine, in view of the abundant science and research confirming bioceramic technology, that he would still be using or advocating the use of eugenol or resin-based sealers? Yet many of our colleagues are still using root canal sealers/cements based on 50-year-old technology. No one was more aware of the limitations of these early “traditional” sealers than Dr. Grossman. He was clear when he spoke or wrote about the sealers/cements of his day: They were less than ideal but the best that was available at the time. So now you have the opportunity to use advanced material science and technology to do a better job. If you have not embraced new techniques and/or technology because you have forgotten to question why you are doing what you are doing, just think of Dr. Grossman, the Father of Our Specialty, and consider what he might be doing if he were fortunate enough to be practicing today. Dennis Brave, DDS, is a Diplomate of the American Board of Endodontics and is a member of its College of Diplomates. In addition to having served as the managing partner of an Endodontic specialty group practice for over 25 years, Dr. Brave has been a prolific author and international lecturer on Endodontics. Among his many accomplishments, Dr. Brave is proud to be a co-founder of Real World Endo, holds multiple dental patents, including the VisiFrame, and was the first of his colleagues to be named “Baltimore’s Best Endodontist” by Baltimore magazine. Formerly having served as an associate clinical professor at the University of Pennsylvania’s School of Dental Medicine, and having a clinical appointment at The Johns Hopkins Hospital, he now serves as an advisor to Endodontic Education Seminars for Real World Endo.

Endodontic practice 1

INTRODUCTION

November/December 2015 - Volume 8 Number 6

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MESSAGE FROM THE PUBLISHER

When inspiration meets reality Dear Readers: With this issue of Endodontic Practice US, I am delighted to introduce a new series of articles that have the potential to change the course of your life. I know this to be true because over the years, the author of these articles, Tony Robbins, has impacted me both professionally and personally. This story begins when I was in my 20s. At that time, life’s challenges were daunting, and the road ahead seemed not only to be winding, but filled with potholes and roadblocks. Also, I was searching for a career path that would also be my life’s passion. It was then I discovered peak performance strategist and bestselling author Tony Robbins. Listening to his motivational tapes in my car on the way to and from work was often the only positive voice that I would hear all day. “Human beings have the awesome ability to take any experience of their lives and create a meaning that disempowers them or one that can literally save their lives.” His insights catapulted me to achievement of my professional aspirations, as well as personal fulfillment. I remember wishing that I could attend one of Tony’s seminars in person. Fast-forward 25 years later. As a successful publisher and entrepreneur, I had the opportunity to attend CEREC® 30, an educational event sponsored by one of our long-term clients, Sirona Dental, Inc. I was beyond excited that Tony was going to be a featured speaker at this event! It was a surreal moment when I had the opportunity to stand up in front of upwards of 6,000 attendees and ask a question of my mentor, Tony Robbins, peak performance strategist and bestselling author, who wasn’t even aware of the impression he had made on me over the years. It was with Lisa Moler, publisher and CEO of MedMark, LLC, at CEREC 30 even more incredible when he was gracious enough to schedule a personal interview with MedMark for our magazines. This brings me to good news for our readers. I am so proud and honored that Tony Robbins and Tom Zgainer, founder and CEO of America’s Best 401k, will be authoring a Financial Focus column for our publications in 2016. This column will discuss what to look for in a 401k plan, show how fees can erode 401k savings, and will also discuss the fiduciary responsibility of plan sponsors and the serious ramifications of non-compliance with The Employee Retirement Income Security Act of 1974 (ERISA). This federal law sets minimum standards for most voluntarily established pension and health plans in private industry to — Tony Robbins provide protection for individuals in these plans. Sadly, many plan sponsors do not live up to their duties, and as a result, the savings of all the participants in their plan may be subjected to needless and excessive fees. Tony said, “The abuse is mind-boggling.” At MedMark, we pride ourselves on educating the dental community on new techniques, the latest products, and creative practice management methods. Now, Tony Robbins and Tom Zgainer will share their expertise to protect and help grow your retirement savings. At our interview, Tony Robbins and I discussed living in the moment and letting go of the ghosts of the past. He once said, “In life, you need either inspiration or desperation.” It was in times of desperation that I found inspiration in his powerful insights. Now, I am honored that it’s my turn to be a catalyst, through this new Financial Focus column, for our readers to have more control over their financial success in retirement. All the best,

“In life, you need either inspiration or desperation.”

Tom Zgainer, founder and CEO of America’s Best 401k, with Lisa Moler at CEREC 30 4 Endodontic practice

Volume 8 Number 6

FINANCIAL FOCUS

Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans MedMark is proud to launch a new column that will help dental professionals make important decisions about retirement plans

isa Moler, publisher and CEO of Robbins’ knowledge has been widely recognized. He was named to the Worth Power MedMark, LLC, recently experienced one of the pinnacle events of her career at 100 as No. 49 on the list of the world’s most the CEREC® 30 conference in Las Vegas. powerful players in global finance. Working with America’s Best 401k, She had the privilege of holding an in-person business owners can alleviate their fiduciary meeting with peak performance strategist and responsibility while providing their employees bestselling author, Tony Robbins, and Tom with a plan that does not sacrifice perforZgainer, founder and CEO of America’s Best mance for lower fees. The company has 401k. These two visionaries discussed the worked with numerous dental practice changing landscape of employer-sponsored retirement plans andknow the information that owners to help them drastically reduce the You can’t where you are going business owners need to adhere to the investment fees associated with their plans, if you don’t know where you are. Department of Labor regulations. helping clients save an average of 57%. This topic was discussed at the event At the meeting with Robbins and Zgainer, is also highlighted in Tony Robbins’ Lisayour Moler discussed Stepand 1. Send us your fee disclosure (also called abest408b2) from existing provider. Ifthe you changing don’t where landto locate it, call us and we will direct you.the Keep in mind7that scape Department of 401k Labor space, regularlywhat requires plan pracselling book, MONEY: Master Game: of the dental sponsors to benchmark their plan so this will fulfill your fiduciary obligation. Simple Steps to Financial Freedom. After titioners across the country need to know 401k’s unique, lowin your order toon meet DOL member regulations, and the destination Best is a financially secure retirement, is 401k course? A of our team Stepseeing 2. If theAmerica’s will walk through your complimentary comparison so you can see the impact that costyou approach firsthand, Tony“side-by-side” Robbins feepair’s mission to save America’s retirement. higher fees will have on your account balance over time. became a partner in the business, and the “If you offer your employees a run-ofSteppair 3. Take the to switch America’s Best 401k. There is noplan, conversion fee a and our team the-mill 401k there’s good chance set action out onand a make mission helptoAmericans makes the conversion process painless. The quicker you make the change, the quicker your savings begin. across the country rescue their retirement. you are vulnerable to Department of Labor

YOUR NEXT STEPS

Volume 8 Number 6

AmericasBest401k.com

oversight, which has become more aggressive in recent months,” Zgainer said. Robbins adds, “Small business owners often have no idea that they are the fiduciaries for their plan. That means that they have to benchmark that plan annually or they have to pay penalties, with average penalties that can reach $600,000. We can help these people meet their responsibilities in this area.” In as little as 60 seconds, dentists and other business owners can access the company’s free Fee Checker (americas best401k.com/medmark), which can help them meet their fiduciary obligation and ensure their retirement plans are for the sole benefit of their employees. When a dentist sponsors a retirement plan, he/she takes on new responsibilities in addition to being a doctor and a business owner. They also need to meet their fiduciary obligation and fulfill their trustee responsibility. Robbins and Zgainer’s advice can lead to employees keeping more of what they’ve saved, and enjoying a longer, more-secure retirement. America’s Best 401k has assembled a team of world-class retirement plan experts across design, administration, recordkeeping, and actuarial disciplines to offer an alternative to expensive, complex plans. Working with America’s Best, business owners can alleviate their fiduciary responsibility while providing their employees with a plan that doesn’t sacrifice performance for lower fees. For information, contact America’s Best 401k at 855-905-4015 or info@americas best401k.com. Readers of Endodontic Practice US will be able to share more of this exciting and informative conversation with Robbins and Zgainer through a series of interview articles that will appear in upcoming issues. EP Endodontic practice 5

TABLE OF CONTENTS

Practice profile Albert (Ace) Goerig, DDS, MS

A successful, fulfilled, and debt-free life

Financial focus Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans .........................................................5

Event recap CEREC速 30

Clinical 18

An unforgettable extravaganza of unsurpassed hands-on learning and first-class entertainment....................21

The contradictions of modern endodontic techniques and their solutions Dr. Barry Musikant examines the techniques and solutions of two instrumentation systems, using the literature and illustrated cases 6 Endodontic practice

Volume 8 Number 6

NOW YOU DON’T HAVE TO CHOOSE BETWEEN SAFETY AND EFFICIENCY

Introducing the file system that’s compatible with both reciprocation and rotary

TABLE OF CONTENTS

Continuing education Cleaning the third dimension Drs. Gilberto Debelian and Martin Trope explain how a finishing file can contact areas that round files cannot while maintaining the original shape of the canal...................................... 22

Continuing education

Posterior composites and new bulk-fill materials

Technology spotlight

Dr. Ron Jackson assesses the research behind posterior composites and new bulk-fill materials

Resolve to save more teeth .......................................................32

Abstracts The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-todate with the most relevant research .......................................................34

Practice management Transitioning employees after a practice purchase Paul Edwards offers five effective postpurchase policies.............................38

Product profile

Small talk

Don’t choose between the safety of reciprocation or the efficiency of rotation: Get both with the Endo-Eze® Genius™ files and EVOS™ motor

Practice integrity, part 1: fulfilling the promise

Dr. Carlos Spironelli Ramos discusses newly debuted products by Ultradent .......................................................42

Product spotlight

Product profile

Mani Gutta Percha Removal (GPR) instruments: opening the path

EndoSequence® BC Sealer™ and Root Repair Material (BC-RRM™).................................40

Dr. Rich Mounce reviews a technique for removal of GP during endodontic retreatment..................................... 44

8 Endodontic practice

Dr. Joel Small discusses a strategy to create and maintain long-term success ........................................................46

Endospective Reflections on a referral-based endodontic practice Dr. Rich Mounce offers some tips for professional growth......................... 47

Industry news................. 48

Volume 8 Number 6

Remove up to 36% less dentin with superior overall shaping*. Aid disinfection by disrupting polymicrobial biofilms and significantly reducing bacteria*.* Contact up to 75% of walls along the entire canal*. Create a predictable apical shape with up to 32% less transportation*.

Call to learn more or request a demo today.

Preserving What Matters.

The inner green area indicates the unprepared canal. TRUShape 3D Conforming Files conform to natural canal anatomies for a more conservative shape (red area). The file’s unique S-shape creates an innovative envelope of motion within the canal that conforms to unconstrained spaces while respecting constrained spaces.

Traditional ISO files make round shapes, and can unnecessarily remove tooth structure (white line). Image courtesy of Ove A. Peters, DMD, MS, PhD.

* Peters OA, Arias A, Paque’ F. Three dimensional analysis of the root canal geometry of oval canals after preparation with a novel rotary instrument. Submitted for publication. ** Pileggi R, Bruder G, Wallet SM, Sorenson H, Walker C, Neiva KG. Quantitative analysis of a polymicrobial biofilm removal following instrumentation with a new file system. Submitted for publication.

1-800-662-1202 For the latest information consult

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PRACTICE PROFILE

Albert (Ace) Goerig, DDS, MS A successful, fulfilled, and debt-free life

What can you tell us about your background? My great-grandparents came to Washington on the Oregon Trail in the 1850s. I was born in Seattle, Washington. After my mother divorced my father when I was 3 years old, we moved to Spokane, Washington, where my mother and my two other brothers lived with her grandmother in an 800-square-foot house. When I was in high school, we moved to Las Vegas, Nevada, when the town was only around 60,000 people. After graduating from Las Vegas High School, I went to Utah State University on a pole-vaulting scholarship. I joined ROTC where I learned to fly fixed-wing aircraft and looked forward to flying helicopters when I graduated in 1966. I studied engineering but was not the greatest student, and by chance, I visited my cousin, Dr. Jomy Zech, who was a dentist just before my senior year. He told me, “If you don’t like engineering, why don’t you become a dentist?” I asked him, “Don’t you have to be smart?” He said, “No, you just have to have endurance.” I changed majors, and it took me 2 years to get accepted to Case Western Reserve dental school. After my sophomore year, I married my wife and my best friend, Nancy, who had just graduated from nursing school. She helped support us over the last 2 years of school, and we had our first child just before I graduated. We have been married and in love for over 46 years and have five children and seven grandchildren. After graduating, I spent 20 years in the U.S. Army and moved 12 times but totally enjoyed the entire experience. I was trained in endodontics in the Army and spent 15 years as an endodontist and never did fly helicopters in Vietnam. I became a Diplomate of the American Board of Endodontics in 1981. In 1991, I retired from the Army and drove south from Seattle until I ran out of traffic and ended up in Olympia, Washington. There are only two other endodontists in town, and they were booked out 8 weeks. Once I started practicing, the other endodontist told me he was taking 2 weeks off and was sending me all his patients. It is different today; we now have eight endodontists in a town of 100,000, and we book day to day. In reality, 10 Endodontic practice

Albert (Ace) Goerig, DDS, MS

this is a great gift because now we are able to see emergency cases that day, providing incredible service and getting easy cases. Because of my fear of failure, I opened a small practice in an old dental office that had three operatories in 600 square feet. I knew nothing of the business of dentistry or about systems. I worked 5 days a week, 10-hour days seeing 10 to 15 patients a day while only completing three or four treatments. After a year and a half, my accounts receivable over 120 days was a $250,000; I was 9 months behind in my payroll taxes, and I had an overworked team, which led to a lot of unrest. By the way, I was unaware of all these things. Finally, I brought in a practice consultant, who taught me about systems, how to become a leader, and create a vision for my practice as well as teaching me the business of dentistry. During that time, I lost all my team except one and hired new team members that fit into my new vision. We implemented new tracking monitors and an office manager position, and focused on treating only one patient at a time, completing almost all cases in one appointment. I changed my schedule to three 10-hour days and brought in an associate who worked the same. During this

time, my net profit doubled even though I was working half as much. From that time on, I never worked more than 125 days a year and each year take off 10 to 12 weeks. In 1997, I founded Endo Mastery, a coaching program to share with other endodontists what I have learned from my initial practice disaster and to help them change their practice model to a stress-free, fun, profitable, and dynamic practice. In 1994, we doubled our office space by moving into a 1,250 square-foot four-operatory office where we are today. My partner, Mike Behnen joined me in 2003, and my son, David, joined me 2 years ago. I now work in the practice 2 days a week, approximately 90 days a year. Over this next year, we will be expanding our practice space by adding another operatory and a large teaching conference room.

Is your practice endodontics?

limited

Our practice is solely limited to endodontic procedures and microsurgery. We believe that all specialists’ practices need a profit center, and that is why we do not do implants, which would compete with the other specialties that do implants. Volume 8 Number 6

While in dental school, I had a great endodontic mentor, Dr. Jefferson Jones, who took a special interest in me and was a master endodontic teacher. This was followed up by another mentor in my Army internship, Dr. Fred Seymour, whom I wrote my first endodontic article with in the JADA.

How long have you been practicing, and what systems do you use? I have been a practicing endodontist for over 40 years. I have always been a persistent learner. In those days, we only had Kerr hand files, gutta percha, silver cones, and NaOCl. We are blessed today to have the equipment necessary to provide us with efficient and predictable results. Because of my Army influence, I have always done

one-appointment endodontics, which has consistently given me high-quality results with less postoperative problems. In 1993, Dr. John McSpadden introduced me to his new nickel-titanium engine files, which changed all of our lives in endodontics. During that same year, Dr. Schick put one of the first digital radiography units in my office. And we were the first endodontic practice in our area to use microscopes and to have a CBCT scan unit, which is now becoming the standard of care for endodontists. We have multiple file systems in our office to include those from EndoMagic!™, EdgeEndo® files, and DENTSTPLY Tulsa Dental Specialties products. All nickel-titanium files work well, but the operator must stick to a specific sequence of files that give a predictable result with little or no breakage. Once the operator gets to the apical foramen,

it should not take more than 10 to 15 minutes to completely instrument all canals up to at least a size 40 with any of these systems. The real difficulty in the endodontic procedure is to find all of the canals and be able to get to the apical foramen with the size 10 file. This is a blessing for endodontists because this is why general dentists refer. The real secret to this is to use a specific file that can get you down calcified cases quickly. DENTSPLY Tulsa Dental Specialties has the PathFile®, but I have used the EndoMagic! number 15 traditional file from EndoSolutions™ to move down calcified canals.

What training have you taken? We are always learning in our office. Ever since my residency, I have attended almost every AAE Annual Session. We also have access to the a AAE live Learning Center,

Partners in Northwest Endodontic Specialists Michael J. Behnen, DDS, graduated cum laude from Xavier University in Cincinnati, Ohio, with a Bachelor of Science degree. He received a doctoral degree from Indiana University School of Dentistry, Indianapolis, Indiana, in 1992. He was selected for a U.S. Army Endodontics Residency, Fort Gordon, Georgia, in conjunction with the Medical College of Georgia, graduating in June 2000. For 3 years, Dr. Behnen was the endodontic mentor for the Army’s Advanced General Dentistry residency program at Fort Lewis, Washington. He presented at the International Association of Dental Research Annual Meeting and is published in the Journal of Endodontics. Dr. Behnen served in the U.S. Army Dental Corps for 11 years. He had multiple assignments, including endodontic mentor and clinic chief. As a member of the active-readiness Army, he was deployed as a dental officer to Somalia, Haiti; Guantanamo Bay, Cuba; Camp Hovey, Korea; as well as to Kuwait for Operation Iraqi Freedom. He is a Member of American Dental Association, Washington State Dental Association, Thurston Mason County Dental Society (Past President), American Association of Endodontists, and Washington State Association of Endodontists. Dr. Behnen lives in Olympia, Washington, with his wife, Katherine. He enjoys fishing, snow skiing, bicycling, and weight training. David C. Goerig, DDS, MS, was raised in Olympia, Washington. He attended Olympia High School and Western Washington University before being accepted to the University of Pacific Dental School, where he earned his Doctor of Dental Surgery Degree and Bachelors in Applied Science Degree in 2009. After 2 years in practice, Dr. Goerig completed his Master of Science in Endodontics Degree at the University of Minnesota in 2013. During his academic career, Dr. Goerig served as president of his dental school class, chaired several committees, and volunteered for many outreach programs, including a dental mission to Peru. He continues this tradition of service by volunteering with the Union Gospel Mission in Olympia and being active in organized

Volume 8 Number 6

Drs. Mike Behnen, Ace Goerig, and David Goerig

dentistry. He is a member of the American Dental Association, Washington State Dental Association, and the Thurston-Mason Counties Dental Society. He is a specialist member of the American Association of Endodontists and the Washington State Association of Endodontists. As a father of three boys, Dr. Goerig is proud to once again plant his roots back in the Olympia community and raise his family in the great Pacific Northwest. He enjoys camping, fishing, skiing, and introducing his boys to all of the fun activities the Pacific Northwest has to offer.

Endodontic practice 11

PRACTICE PROFILE

Why did you decide to focus on endodontics?

PRACTICE PROFILE

Dr. Mike Behnen and Catherine

which contains presentations from all the AAE past meetings and is an incredible CE resource. In 1979, I took the 1-week handson warm gutta-percha course taught by Dr. Herbert Schilder. I took the first courses by Dr. Gary Carr on the microscope and ultrasonics. Recently, my son and I both took the microsurgery course taught by Drs. Syngcuk Kim and Samuel Kratchman as well as the CBCT course by Dr. Martin Levin. Both of these are must-take courses. We have also attended the great hands-on courses by Dr. Steve Buchanan and Dr. Cliff Ruddle. But the greatest educational experiences that I ever had were when I visited another endodontist’s office. While still in the Army, I spent many days in Dr. Steve Cohen’s office in San Francisco. In 1985, I saw Dr. Steve Buchanan present the California dental meeting. He showed some of the most incredible endodontic cases I have ever seen, all done with hand files. I called him, and he invited me to watch him in his office and stay at his home. That night in the hot tub after going through a few bottles of good California wine, I was finally able to understand the concept of passive instrumentation, which has made all the difference in hand and engine filing for me. The time I spent with Dr. John McSpadden’s in his office and his home in Chattanooga, Tennessee, learning the specifics of the new nickel-titanium engine files, was incredible. I highly recommend that young endodontists should find other endodontists 12 Endodontic practice

Melissa Garrett, Office Manager

that they admire and visit their office or talk with them at the annual meeting.

Who has inspired you? What is so great about our profession of endodontics is that all our great teachers are so approachable. I remember walking out of the elevator at my first AAE meetings and running into Drs. Al Frank and Dudley Glick. They invited me to sit down and have a drink with them. Besides those I mentioned previously, I would also put in Dr. Gary Carr in the category of those selfless educators, visionaries, and inventors. Without him, we may not have had the microscope or the ultrasonics. Without Drs. John McSpadden or Ben Johnson, we might not have the nickel-titanium engine files. There have been so many great teachers in my life who have taken me under their wings and helped me along my path. I appreciate them all. As endodontists, we are encoded to share with others. It is a great profession. Kendrick Mercer, the founder of Mercer Financial and the Garden Company, has been my greatest mentor, and I still work with him today. He was the one who helped me become financially free as well as personally free. Now I go to the office because I want to, not because I have to. He also helped me discover and let go of the many painful personal issues I carried from my childhood, which allowed me to soften on my ego and become much more peaceful in my life. And as you get older, you realize that it is not

about the money, but as Dickie Fox stated in the movie, “Jerry Maguire,” “It is about personal relationships.” Because we can only live in the moment, you must realize the most important person in your life at that moment is the person you’re with, so why not make it an incredible relationship? We as dentists have the greatest opportunity to connect with and create incredible relationships with our patients, team, and referring doctors. When you are a safe person, at peace with yourself and truly interested in other people, they will share with you at a deeper level, allowing you to make significant differences in your life and theirs.

What is the most satisfying aspect of your practice? Our office is a fun place, where we have an incredible team, no drama, and great doctors who provide the patients with a loving, caring experience that is unsurpassed. It is a stress-free environment where we see patients on time and complete them on time. We have great systems that make the office and schedule run smoothly, and we rarely go home tired. I must admit that we do have those few days and patients that are “special,” but these become the opportunities that allow us to truly excel. Stress in the practice is a function of poor scheduling, the doctors’ ego and perfectionism, and their inability to learn how to be at peace with themselves and circumstances. I’m fortunate to have Volume 8 Number 6

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PRACTICE PROFILE Melissa Garrett, our office manager, who takes care of all the administration of the office, allowing me to treat patients 99% of the time. The following is our vision statement, which describes our office culture. Vision: â&#x20AC;&#x153;We are in a continual process of creating a magical story for our practice that is fun and highly successful and brings each of us personal and professional fulfillment, aliveness, happiness, and freedom. Through people, ideas, and the use of systems, we have a positive, nurturing, and caring environment for both our patients and each team member. It is a place of mutual respect, laughter, clear communication, and teamwork in an atmosphere that is fun, energized, and efficient. We provide a patient experience that is so incredible that they hesitate to leave our office for fear of entering into a harsher world. Our office has a reputation of being so gentle, safe, and caring that we draw the best patients from all of the best doctors in our area. We enjoy every day to the fullest but live in each moment. Our office flows effortlessly and is filled with pride, a sense of ease, and a calmness that allows us to provide excellence in endodontic treatment that is unsurpassed.â&#x20AC;?

more than 130 days per year. With all that time off, we have more time for family, are much more refreshed, love our practice more, are more profitable, and provide a higher level of care. Another way our practice is unique is that we do not have a retirement plan but a debt-reduction plan. Money that used to be given to team members for retirement is now given to them to put toward debt reduction, which actually provides over 100% return on their money while providing them with 3 times as much money at retirement. I have a meeting each year with the entire team and their spouses to show them how they all could be completely debt-free, including their house, within 5 to 10 years. Since I began this program 5 years ago, I have three people completely out of debt, and everyone else is just paying off their house and will be debt-free within 7 years.

The real gift I give them is changing them from spenders to savers. I developed a free website, Doctorace.com, to show other offices what I teach my office team. I find I have a much happier team when money is not an issue in the family. I have also encouraged members of our team to attend 3to 4-day personal growth seminars where they address personal issues that hold them back from having peace in their life. The office pays for all the seminars and for the time they are there. When they come back home, they find that their relationships are much stronger, or they have the ability and courage to make changes.

What has been your biggest challenge? My biggest challenge has been to get the word out to all doctors that they can have their practice just the way they

Professionally, what are you most proud of? That I am able to develop and teach simplified systems that help endodontists and their teams move to higher levels of success, excellence, financial freedom, and peace. Whether it is teaching at the AAE, endodontic residency programs, my Endo mastery courses, or my website debtreduction seminar at Endomastery.com, or Doctorace.com, I know these systems change lives.

What do you think is unique about your practice? All practices need something to differentiate themselves such as one-appointment endodontics, using nitrous oxide, seeing the patient that day and completing the treatment that day, providing an incredible WOW experience for the patient, caring and loving doctors and team members, plus much more. Compared to other endodontic practices that I have seen, we are unique in a few ways that we take care of our team and the amount of doctor time-off. Dr. Joe Camp many years ago taught me never to work more than 2 days in a row. In our office, each doctor only works 3 days a week with a day in between. Our goal is to never work 14 Endodontic practice

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PRACTICE PROFILE want it. And the second challenge is to help them understand that true personal freedom begins with becoming debt-free. The problem is that our culture teaches that you have to work hard for a living, and you will always be in debt, which is not true. They can go to my Endo mastery website under resources for a free presentation on exactly how this is done.

What would you have become if you have not become a dentist? A career Army officer and pilot in the combat engineer corps.

What is the future of endodontics and dentistry? I believe the future of dentistry and especially endodontics is very positive, but we must be aware of the threats to our profession. Over the past few years, the business of dentistry and endodontics has changed and will continue to change. It has become more insurance-driven, allowing the insurance companies to take advantage of fearful dentists and keep fees low. In my state of Washington, the largest insurance provider WDS, reduced its fees by 15% (reducing net profit by 30% to 50%), and we have not had a rate increase in 7 years. Corporate dental offices grow at 5% a year and are filled with young dentists who are burdened by school debt with high-interest rates preventing them from opening their own practices. To slow this progression, we need to be very active in organized dentistry and politics. Every year, our office sponsors a practice management consultant to put on the day course for our referring dentists to help them become more efficient, profitable, and debt-free, so they go to work because they want to, not because they have to, and to become less reliant on insurance. The more successful our referring doctors become, the more successful we become. I also work closely and donate with those in our state legislators who support dentistry and who will protect us from the overreach of these insurance companies.

What are your top tips for maintaining a successful practice? We all can have the practice of our dreams, and this always begins with a great vision. The vision sets the culture of the practice. The foundation of a great practice is providing incredible customer care and compassion for the patient while providing excellence in endodontics. To support you on your path, you must have a team you love to 16 Endodontic practice

Nancy and Ace Goerig

I am proud that I am able to develop and teach simplified systems that help endodontists and their teams move to higher levels of success, excellence, financial freedom, and peace.

work with and that are totally committed to your vision. There is no room in the practice for those who stir the pot or cause drama. Because I believe the doctor needs to be at the chair 98% of the time, our office is run by Melissa Garrett, an exceptional office manager who has been with me for over 15 years and has the tools and monitors to manage the practice. She is responsible for all hiring and firing as well as meeting our goals each month. I only do that which is required by law and have empowered my team to do everything else. Our doctors meet with the office manager and marketing coordinator 2 hours at the beginning of each month to review the practice and marketing monitors. We also have a 2- to 3-hour monthly team meeting. You need to provide the highest quality endodontic treatment result possible. It is sad that this is less appreciated by the referring doctor as compared to seeing the patient that day. To ensure that your best

doctors keep referring, you have to provide high-quality results while exceeding the patientâ&#x20AC;&#x2122;s expectations at every opportunity. I have had hundreds of endodontists and their teams that are in my coaching program visit me in my practice, and I have the opportunity to show them what is possible. This is very exciting, and I always seem to do better when people are watching. You must have a strong marketing program to include a dedicated marketing coordinator and monitors that track your effectiveness. You must commit at least 1% to 3% of your collections to marketing efforts. The most important marketing tool we have is to see the referring doctorsâ&#x20AC;&#x2122; patients that day and complete them that day, so we always leave space on the schedule each day for those emergency/ treatment patients. Never say anything negative about other dentists or their work. It is our responsibility to point out to our patients things we see on the X-ray, but I never criticize any dentist or the work. Criticism negatively affects the patientâ&#x20AC;&#x2122;s perception of all dentistry and dentists without serving a purpose. I may just tell the patient that sometimes the filling material loses its seal, or that many of these canals are calcified and difficult to get down. This philosophy has done much to strengthen our relationship with our referring doctors. Although few have taken me up on my offer, I have invited all dentists in our community to visit our office and help them with their endodontic technique. Have a philosophy of giving. We work very closely with the Union Gospel Mission in Olympia and provide free endodontic care for those street people in need. We also provide free or discounted care for those whom our referring doctors request that we do. We also provide free endodontic care for all referring doctors and their teams. I am a big supporter of the AAE Foundation and am a platinum donor. This becomes a lot easier when you are debt-free. The secret to a successful practice is to incorporate great systems into the culture of your practice. Examples of systems that you need to create may range from the scripts that you use to answer the phones, to working with insurance companies in obtaining payments, to the way we bring patients through the office and care for them, to the systematic way we do our clinical treatment, to our marketing efforts plus many other systems. The AAE Live Learning Center is an excellent source for this practice management education. I would highly Volume 8 Number 6

a student until your school debt is paid off. Refinance your highinterest school loans down to 3% to 4%. If you plan to open your own practice, then you must learn the business of dentistry and get a mentor or coach to help you set up strong systems to make your practice fun and profitable. This is an exciting time for you to enjoy the process.

What advice would you give a budding endodontist?

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

The greatest challenge that faces the budding endodontist is the staggering debt that they carry. They need to have a systematic approach of eliminating all school debt within 5 years. This means they have to learn to be much more efficient in the way they do endodontics. If they are not planning to open their own practice initially, I recommend they find an associate position in an office where the endodontist routinely completes 6 to 8 cases a day with exceptional clinical results. Learn from these doctors. Live like

Top 10 favorites 1. 2. 3. 4.

My beautiful wife, Nancy My incredible children Melissa, my superstar office manager My incredible team who are totally committed to our vision 5. My referring doctors and their patients 6. My mentors and coaches 7. Learning to be at peace by letting go of ego 8. Nickel-titanium engine files 9. Digital radiography and my Kodak 9000 3D Cone Beam CT scanner 10. The Pacific Northwest

When I was younger, I loved to snow ski, fish, scuba dive, and take photographs. I do these things today but at a little lower intensity. I spent 6 years in Germany with the U.S. Army, and my family and I traveled and camped throughout Europe. For the past 23 years, I’ve only been in the office around 125 days a year, which has allowed me a lot free time. There’s been many family trips, but I’ve always loved to do one-on-one adventures with each one

of my children. These adventures may be a week’s horse riding and camping trip with my 12-year-old daughter into the High Sierras or fly fishing in Idaho with my son, David, or flying to Papua New Guinea and spending 2 weeks on a dive boat with my daughter, Catherine. Now it is more traveling with my wife, Nancy, spending time with my grandchildren, and large family vacations. EP

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Endodontic practice 17

PRACTICE PROFILE

recommend that you get a coach and work with that person for a year. Even though I have coached hundreds of endodontists for over the past 18 years, I have had multiple coaches come into my office to work with our team and me to include some of my own Endo mastery coaches. If you are not growing every year, you are declining and need someone to observe, challenge, and excite yourself and your team to move to higher levels of productivity and excellence.

CLINICAL

t’s not a contradiction until you realize it is. Greater tapered rotary nickel-titanium (NiTi) shaping has produced a mechanical standard for cleansing and shaping canals. It is only recently that research is documenting the weakening of the root via the removal of excess dentin, particularly in the mesiodistal plane due to the use of greater tapered instruments and the creation of dentinal microcracks in the process of shaping the canals with instruments in rotation, whether continuous or interrupted.1-24 Dentinal microcracks should come as no surprise given the long and detailed documentation of metallic defects and frank separations that occur in the instruments. One is simply a reflection of the other following Newton’s laws of opposite and equal effects — that removal of excess dentin and the propensity to create microcracks where the dentin is thinnest and most subject to stresses is worth pondering. Rotational instrumentation combined with greater tapered instruments needlessly first inflicts a weakening of the root structure followed by damage to the integrity of the remaining dentin. To date, an answer to these “side effects” has not been required because dentists were not aware that they occurred. As this information is dispersed more widely, one response is a form of rationalization that admits to the problem but quickly states that the advantages of these systems outweigh the disadvantages.

Barry L Musikant, DMD, is a 1969 graduate from the University of Pennsylvania and a partner in the largest endodontic practice in Manhattan, New York City. His 35-plus years of practice experience have crafted him into one of the top authorities in endodontics. Dr. Musikant is a fellow of the American College of Dentistry and International College of Dentists. A domestic and international lecturer, author of numerous articles, Dr. Musikant is a member of the American Dental Association, American Association of Endodontics, Academy of General Dentistry, the Dental Society of NY, First District Dental Society, Academy of Oral Medicine, Alpha Omega Dental Fraternity, and the American Society of Dental Aesthetics. Disclosure: Dr. Musikant is co-founder of Essential Dental Systems (EDS), a dental products manufacturing company located in South Hackensack, New Jersey.

18 Endodontic practice

The basis of this defense is to maintain the status quo, support rotating greater tapered shaping in its present mode or, at most, make some minor changes in technique. Perhaps the rationalizations stem from an apparent lack of alternatives. While this possibility might indeed be used, the same research that has illuminated greater tapered rotating instrumentation has also described techniques that neither lead to excess removal of dentin nor the introduction of dentinal microcracks, with the added benefit that instruments not inducing dentinal defects will themselves not be subject to separation.

Present conflicts The answers to the present conflicts associated with “modern” endodontic techniques reside in the alternatives that deserve much further elaboration. Even prior to the use of greater tapered rotating instrumentation, creating a glide path with K-files has often proved problematic. The K-file instrument (Figure 1) designed with 30 predominantly horizontal flutes along its 16 mm of working length is known to frequently impact debris in the apical third, resulting in loss of length and the potential for canal distortion as the dentist attempts to reclaim that length. In fact, a combination of poor results tied to major bouts of hand fatigue were a major impetus for the creation of greater tapered NiTi instrumentation. Typically, a dentist does not separate the glide path made with the manual use of K-files from the subsequent use of greater tapered NiTi instrumentation. Yet, if we wish to enhance our effectiveness, relieved vertically fluted reamers (SafeSiders® [Essential Dental Systems], Figure 2) must substitute for K-files at the earliest stages of glide path creation. These reamers, designed with half the number of flutes along the same 16 mm of working length, have a flute orientation twice as vertical as those on a K-file. Unlike K-files that are all used manually, only the first and thinnest modified reamer required to negotiate to length is used

manually. Once at the apex, the reamer is attached to a 30º reciprocating handpiece (Figure 3) oscillating at 3,000-4,000 cycles per minute. The vertical flutes on the reamer immediately shave dentin away with the first clockwise stroke. Having half the number of flutes to start with, the relieved reamers engage the dentin far less than the 30 flutes on a K-file, consequently encountering far less resistance to full apical negotiation. Oscillating at 3,000-4,000 cycles per minute, these instruments quickly enlarge the canal space, so the next instrument reaches the apex with minimal resistance. The vertical flute orientation gives these instruments the ability to glide through any debris present rather than impacting it apically. A cutting tip limited to a 30º-45º arc of motion will pierce rather than impact tissue, again reducing the incidence of loss of length so common with K-files. Using all the instruments in the 30º reciprocating handpiece eliminates hand fatigue and virtually eliminates the chances of instrument separation. Remember that an instrument not vulnerable to breakage is compatible in shaping canals without inducing dentinal defects — 02 tapered relieved stainless steel reamers are remarkably flexible through a 15 or 20, far more than their K-file counterparts. Furthermore, a highly tortuous canal is first negotiated and then enlarged with the thinnest most flexible instrument required. At these dimensions, stainless steel is more than flexible enough to negotiate and widen canals without distortion. What is less understood is that a thin stainless steel relieved reamer oscillating at 3,000-4,000 cycles per minute will enlarge the canal to a dimension significantly greater than itself. This must be true because an 08 tipped reamer will encounter minimal resistance after the canal has been shaped with an 06 tipped reamer that initially met significant resistance. We see this fact clinically every day we practice. Two more important observations have been made. As each larger relieved reamer Volume 8 Number 6

CLINICAL

Figure 1: K-file instrument designed with 30 predominantly horizontal flutes

Figure 3: The placement of a SafeSider instrument into a 30º reciprocating handpiece

Figure 2: A relieved vertically fluted SafeSider instrument

Figure 4: The lateral flow of cement when spun off of a bi-directional spiral

Figures 5A-5B and 6A-6B: Before and after radiographs using techniques described in this article

oscillates through the length of the canal, the pathway is being more clearly defined, allowing subsequent and slightly less flexible instruments to faithfully follow the increasing established pathway. Once the dentists are fully confident that the instruments will remain intact, they will apply them more vigorously against the buccal and lingual walls of lateral canals. This is in sharp contrast to the use of greater tapered rotary systems where they are used most safely in a centered position with little potential to effectively shape and cleanse these lateral extensions. Most pulpal anatomy is not conical in shape. It is most often highly oval and sheathlike being consistently thin in the mesiodistal plane (with the exception of palatal roots) and several times wider in the buccolingual plane. A system that encourages dentists to remain centered is not designed to handle Volume 8 Number 6

these situations that are more the rule than the exception.

Endo systems The use of modified reamers employed in the 30º-45º reciprocating handpiece virtually eliminates hand fatigue, dentinal microcracks, and separated instruments while creating a glide path in three dimensions far more quickly than the manual approach necessary with the use of K-files. With the glide path shaped to a 20, the final shaping in the majority of cases creates an apical preparation of 30, a dimension considered the minimum for effective irrigation and a maximum taper of 04. To go from the 20 preparation to a 30/04 preparation requires only two more instruments — the TangoEndo® Shaper (30/02) and the Tango-Endo® Finisher (30/04) (Essential Dental Systems). These instruments, unlike the SafeSiders,

are used in a latch-type reciprocating handpiece that also oscillates at 3,000-4,000 cycles per minute. The Tango-Endo System has a flute design that is significantly more efficient in working the lateral extensions of canals as compared to the SafeSiders, something that is important when attempting to remove tissue ensconced in the thin isthmuses. For the dentist’s safety, the highly efficient TangoEndo System was designed to be latch-type instruments used in the Tango-Endo reciprocating handpiece. If these instruments had a manual hand-type handle, which could be used manually, there would be a chance of extensive engagement and over-torquing the instrument in the canal. The two systems — the SafeSiders, providing the glide path without hand fatigue, and the Tango-Endo System, providing a fully shaped canal that preserves dentin in Endodontic practice 19

CLINICAL the thinner mesiodistal plane — work synergistically to atraumatically shape canals in a way that reflects their original anatomy in larger form. The canal is now ready to be obturated using a single Tango-Endo gutta-percha cone where the cone is thoroughly coated with epoxy resin cement (EZ-Fill®, Essential Dental Systems), and the canals are flooded with cement using the bi-directional spiral (Figure 4) as the applicator. Without question, the cement creates an effective seal. The gutta-percha point is nothing more than a carrier and a driver of the cement. The advantages of a passive single point room temperature technique include: 1. Minimal stresses being transferred to the root the way they are when lateral, vertical, and thermal condensation techiques are used. 2. No shrinkage. In fact, there is approximately 1.75% expansion as the room temperature cement and gutta percha warm to body temperature. 3. A cement visocosity that flows better than the most thermoplasticized gutta percha available and then does not shrink. A single point technique is obviously dependent upon the properties of the cement. EZ-Fill is an epoxy resin cement that has the following advantages: 1. It is a polymer that is highly resistant to hydrolytic degradation. 2. It is the most flowable of cements penetrating deeply into the dentinal tubules. 3. It is highly radiopaque. 4. It is highly antibacterial. 5. It bonds chemically and physically to the both the gutta percha and the canal walls. 6. If expressed over the apex, the macrophage digest it over 3 to 6 months. Many root canal cements claim to be biocompatible and bone inductive, but their primary quality must be to provide a good long-term seal without producing prolonged irritation. Epoxy resins are a known quantity as a superior seal in endodontics with research going back over 60 years on their favorable properties.

Case presentations I am presenting two cases that illustrate the ability of the two instrumentation systems working in concert to produce non-distorted shaping while also having the ability to penetrate the most calcified of cases. Note the small 20 Endodontic practice

degree of taper that preserves tooth structure in the coronal third. The fillings are quite radiopaque because while thin in the mesiodistal plane, they extend the full length of the pulpal space in the wider buccolingual plane. What we have succeeded in doing is enlarging the original canal anatomy in both planes and only to the degree necessary to remove the pulp tissue and a more or less uniform layer of circumferential dentin. Aside from the initial thin reamer that was first negotiated to the apex, all instrumentation was done with the reciprocating handpiece oscillating at 3,000-4,000 cycles per minute, virtually removing all hand fatigue. Confined to a 30º-45º arc of motion, the

instruments too are virtually free of separation, which in turn gives the dentist the confidence to use these instruments vigorously in the buccal and lingual planes. By replacing rotation continuous or interrupted with 30º-45º reciprocation, using relieved reamers rather than K-files and limiting the maximum taper in most cases to an 04, we maintain the integrity of the instruments and the roots they are treating, reducing costs significantly while maintaining conditions that are more consistent with long term success. The goal is to remove enough tooth structure, but no more than that. We have shown the means to accomplish this goal in a timely and effective manner. EP

REFERENCES 1. Abou El Nasr HM, Abd El Kader KG. Dentinal damage and fracture resistance of oval roots prepared with single-file systems using different kinematics. J Endod. 2014;40(6):849-851. 2. Adorno CG, Yoshioka T, Suda H. The effect of root preparation technique and instrumentation length on the development of apical root cracks. J Endod. 2009;35(3):389-392. 3. Adorno CG, Yoshioka T, Suda H. The effect of working length and root canal preparation technique on crack development in the apical root canal wall. Int Endod J. 2010;43(4):321-327. 4. Ashwinkumar V, Krithikadatta J, Surendran S, Velmurugan N. Effect of reciprocating file motion on microcrack formation in root canals: an SEM study. Int Endod J. 2014;47(7):622-627. 5. Barreto MS, Moraes Rdo A, Rosa RA, Moreira CH, Só MV, Bier CA. Vertical root fractures and dentin defects: effects of root canal preparation, filling, and mechanical cycling. J Endod. 2012;38(8):1135-1139. 6. Bier CA, Shemesh H, Tanomaru-Filho M, Wesselink PR, Wu MK. The ability of different nickel-titanium rotary instruments to induce dentinal damage during canal preparation. J Endod. 2009;35(2):236-238. 7. Bürklein S, Tsotsis P, Schäfer E. Incidence of dentinal defects after root canal preparation: reciprocating versus rotary instrumentation. J Endod. 2013;39(4):501-504. 8. Capar ID, Arslan H, Akcay M, Uysal B. Effects of ProTaper Universal, ProTaper Next, and HyFlex instruments on crack formation in dentin. J Endod. 2014;40(9):1482-1484. 9. Çapar ID, Uysal B, Ok E, Arslan H. Effect of the size of the apical enlargement with rotary instruments, single-cone filling, post space preparation with drills, fiber post removal, and root canal filling removal on apical crack initiation and propagation. J Endod. 2015;41(2):253-256. 10. Haueisen H, Gärtner K, Kaiser L, Trohorsch D, Heidemann D (2013) Vertical root fracture: prevalence, etiology, and diagnosis. Quintessence Int. 2013;44(7):467-474. 11. Al-Zaka IM. The effects of canal preparation by different NiTi rotary instruments and reciprocating WaveOne file on the incidence of dentinal defects. M Dent J. 2012;9(2):137-142. 12. Kansal R, Rajput A, Talwar S, Roongta R, Verma M. Assessment of dentinal damage during canal preparation using reciprocating and rotary files. J Endod. 2014;40(9):1443-1446. 13. Karataş E, Gündüz HA, Kırıcı DÖ, Arslan H, Topçu MÇ, Yeter KY. Dentinal crack formation during root canal preparations by the Twisted File Adaptive, ProTaper Next, ProTaper Universal, and WaveOne instruments. J Endod. 2015;41(2):261-264. 14. Kim HC, Lee MH, Yum J, Versluis A, Lee CJ, Kim BM. Potential relationship between design of nickel-titanium rotary instruments and vertical root fracture. J Endod. 2010;36(7):1195-1199. 15. Krishna VN, Suneelkumar C, Madhusudhana K, Mathew VB, Reddy A, Babu L. Evaluation of dentinal damage after root canal preparation with ProTaper Universal, Twisted Files and Mtwo rotary systems – an in vitro study. Int J Med Appl Sci. 2014;3(4):146-151. 16. Kumaran P, Sivapriya E, Indhramohan J, Gopikrishna V, Savadamoorthi KS, Pradeepkumar AR. Dentinal defects before and after rotary root canal instrumentation with three different obturation techniques and two obturating materials. J Conserv Dent. 2013;16(6):522-526. 17. Liu R, Kaiwar A, Shemesh H, Wesselink PR, Hou B, Wu MK. Incidence of apical root cracks and apical dentinal detachments after canal preparation with hand and rotary files at different instrumentation lengths. J Endod. 2013;39(1):129-132. 18. Mahran AH, AboEl-Fotouh MM. Comparison of effects of ProTaper, HeroShaper, and Gates Glidden Burs on cervical dentin thickness and root canal volume by using multislice computed tomography. J Endod. 2008;34(10):1219-1222. 19. Pop I, Manoharan A, Zanini F, Tromba G, Patel S, Foschi F. Synchrotron light-based μCT to analyse the presence of dentinal microcracks post-rotary and reciprocating NiTi instrumentation. Clin Oral Investig. 2015;19(1):11-16. 20. Shemesh H, Bier CA, Wu MK, Tanomaru-Filho M, Wesselink PR. The effects of canal preparation and filling on the incidence of dentinal defects. Int Endod J. 2009;42(3):208-213. 21. Topçuoğlu HS, Düzgün S, Kesim B, Tuncay O. Incidence of apical crack initiation and propagation during the removal of root canal filling material with ProTaper and Mtwo rotary nickel-titanium retreatment instruments and hand files. J Endod. 2014;40(7):1009-1012. 22. Yoldas O, Yilmaz S, Atakan G, Kuden C, Kasan Z. Dentinal microcrack formation during root canal preparations by different NiTi rotary instruments and the self-adjusting file. Journal of Endodontics. 2012;38(2):232-235. 23. Zandbiglari T, Davids H, Schäfer E. Influence of instrument taper on the resistance to fracture of endodontically treated roots. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(1):126-131. 24. Zelic K, Milovanovic P, Rakocevic Z, Askrabic S, Potocnik J, Popovic M, Djuric M. Nano-structural and compositional basis of devitalized tooth fragility. Dent Mater. 2014;30(5):476-486.

Volume 8 Number 6

EVENT RECAP

CEREC® 30 An unforgettable extravaganza of unsurpassed hands-on learning and first-class entertainment

irona Dental, Inc., celebrated its momentous CEREC 30th Anniversary Celebration (C30) with a 3-day educational extravaganza geared toward all dental and laboratory professionals. An impressive ensemble of key opinion leaders journeyed from around the world to delve into a multitude of CEREC-specific topics. Excitement for this event The event was hosted at The Venetian and the Palazzo Las Vegas from September 17-19, 2015. Highlights included an extensive exhibit hall showcasing top dental companies, an outstanding educational curriculum, and amazing entertainment. Original attendance projections of 5,000 attendees were exceeded. MedMark’s Publisher Lisa Moler and National Sales Manager Adrienne Good were invited to attend Sirona’s premier continuing education forum. They had the opportunity to see an exhibit floor jampacked with the best and newest Tony Robbins speaking at C30 Train performing on stage with audience members technology, to attend educational This event will be difficult to top, but Lisa and Adrienne both noted that in their and uplifting main and breakout sessions, Sirona promises to host more extrava11 years of attending dental publishing events, to sample top-notch delicious food, and to ganza events. You do not want to miss that this one was one of the most valuable that enjoy unbeatable entertainment. the next one! they had ever experienced. Grammy awardLisa interviewed life success and business Visit the website: www.cereconline.com/ winning band, Train, rocked the night for all leadership coach Tony Robbins (see pages siroworld-information to stay apprised of attendees, and the Nasdaq closing bell was 4-5). His speech the previous evening was future events. EP live onsite! What a great experience! powerful and informative.

Exhibit floor Volume 8 Number 6

NASDAQ close Endodontic practice 21

CONTINUING EDUCATION

Cleaning the third dimension Drs. Gilberto Debelian and Martin Trope explain how a finishing file can contact areas that round files cannot while maintaining the original shape of the canal The challenge Apical periodontitis is caused by microbes in the root canal, so the practice of endodontics essentially means that microbes should be prevented from entering the root canal in non-infected (vital) teeth or removed when present (necrotic teeth) (Bergenholtz, 1974). The prevention or elimination of microbes from the root canal poses many challenges. While the vast majority of the microbes are in the main canal and in the planktonic (loose) form, there are complex anatomical irregularities such as accessory or lateral canals and canal isthmuses intercommunicating with the main canals. In addition, the dentinal walls of the root canal are often covered by biofilm that is particularly difficult to eliminate, as shown by Socransky and Haffajee (2002). While irrigation with disinfectants may be very effective against planktonic microbes, it is not effective enough when the microbes are in the biofilm form or in canal irregularities.

Educational aims and objectives

This clinical article aims to discuss the characteristics of files that facilitate cleaning and maintaining the shape of the canal.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 25 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some challenges of preventing or eliminating microbes. • See some characteristics for files that will produce acceptable solutions. • Recognize how different temperature conditions affect the shape of the XP-endo Finisher file. • Identify the different phases in the process with the XP-endo Finisher file.

In these cases the biofilm must be scraped first before the disinfectant will work. This is analogous to scaling and root planing in periodontal therapy. The challenge of scraping the biofilm internally in the canal is that almost all canals and roots contain a wider buccolingual dimension compared to the mesiodistal (Figure 1) (Wu, et al., 2000). Although there are a multitude of file systems with various metallurgical properties

Figure 1: Long oval canals were identified in 25% of teeth examined. In fact, all canals examined were longer in the buccolingual dimension than the mesiodistal dimension

and geometric designs available on the market, they all produce a final round shape on any given canal cross section (Figure 2). Thus, in root canal instrumentation, the practitioner is limited by the round shape that the file will produce while trying to scrape the walls of the non-round canal and root. Figure 3 illustrates the limited options for the practitioner because of the disparity of shape between the file and canal/root. The right-hand side represents the options

Figure 2: Most files make a round shape independent of the internal diameter and shape of the files

Gilberto Debelian, DMD, received his dental degree from the University of Săo Paulo, Brazil in 1987. He completed his specialization in endodontics at the University of Pennsylvania in 1991. He completed his PhD studies at the University of Oslo in 1997. He is an adjunct visiting professor in the postgraduate programs in endodontics at the University of North Carolina at Chapel Hill and the University of Pennsylvania. Dr. Debelian maintains a private specialist endodontics practice in Bekkestua, Norway. Martin Trope, BDS, was born in Johannesburg, South Africa, where he received his dental degree in 1976. He practiced general dentistry and endodontics from 1976 to 1980 and then moved to Philadelphia, Pennsylvania, to specialize in endodontics at the University of Pennsylvania. He became chair of endodontology at the School of Dentistry, Temple University in 1989. Dr Trope is now clinical professor at the Department of Endodontics, School of Dental Medicine, University of Pennsylvania. He is also in private practice in Philadelphia.

22 Endodontic practice

Figure 3: The practitioner is limited in root canal instrumentation by the round shape that the file will produce because of the disparity of shape between the file and the canal/root Volume 8 Number 6

CONTINUING EDUCATION

available to the practitioner using round files. The lower left diagram, “3D apical cleaning – ideal” represents the ideal situation, and the upper right, “minimal diameter” is the safest option. The round file fits the narrowest diameter and thus maintains the thickness of the mesiodistal diameter. This is safe but biologically unacceptable. In the “maximum diameter” diagram, the round file is used to the widest diameter. This will remove the biofilm but is, naturally, clinically unacceptable. In the “maximum safe apical size” diagram, the round file is instrumented to the maximum safe apical size, and so while it is not ideal biologically, it is the best we can achieve biologically and if performed correctly is safe for the root. Adjunct methods must then be used to attempt to remove toxins unreachable by the round files. The “3D apical cleaning – ideal” is the best option, which is to clean the root canal contents only in a three-dimensional fashion without removal of unnecessary dentin. Recently, the Self-Adjusting File (SAF) (ReDent Nova Ltd., Ra’anana, Israel) has been introduced on to the market (Metzger, et al., 2010) that has, for the first time, shown that it may be possible to clean the widest diameter of the canal without destroying the root structure of the narrow part of the canal. The SAF file requires additional equipment and time and at this point has not been universally adopted by the dental community.

Figure 4: The XP file dimensions

Figure 5: The XP file under different temperature conditions

Figure 6: The apical 10 mm of the file transforms into a bulb more coronally and a tip in the last few millimeters

The solution We feel that the XP-endo Finisher (FKG Dentaire, La Chaux‑de‑Fonds, Switzerland) is the solution after the use of any round file. The finisher has many properties that allow it to gain access and scrape the walls that are untouched when round files are used. In addition, the file causes turbulence of the irrigating solution that also enhances its antimicrobial properties. The file is a No. 25 (.25 tip diameter) with 00 taper (Figure 4). It is, therefore, extremely flexible and thus has tremendous resistance to cyclic fatigue. Its primary action within the root canal is to scrape the walls that it contacts rather than file a (new) shape into the wall of the canal. Figure 5 shows the shape of the file under different temperature conditions. When the file is cooled below 35ºC, it is in the martensite phase. In this phase, it is malleable and can be shaped according to the practitioner’s requirements (such as the martensite phase shown in Figure 5). It could also have been bent to any other shape when in this phase. When the file is Volume 8 Number 6

Figure 7: The apical 10 mm of the file transforms into a bulb shaped coronally, while retaining a tip in the last few millimeters

heated to body temperature (35ºC), it will change to the austenite phase. When the file is rotated in the austenite phase, it creates a very particular cleaning instrument (Figure 6). The apical 10 mm of the file transforms into a bulb shape coronally, while retaining a tip in the last few millimeters. Since the depth of the spoon is 1.5 mm, the total diameter

of the bulb and tip is 3 mm. However, if the bulb is “squeezed,” the tip will expand to a maximum of 6 mm; if the tip is “squeezed” the bulb will likewise expand. Therefore, if moved up and down in the canal, the bulb and tip will expand or contract according to the natural three-dimensional diameter of the canal (Figure 7). The maximum loss of Endodontic practice 23

CONTINUING EDUCATION length when transforming from straight to full austenite phase is 1 mm. However, it will change to full austenite phase shape in the canal very occasionally. Importantly, because of the small core diameter of the file, it maintains its flexibility, cyclic fatigue resistance and will scrape, but not shape, the walls. This, plus the turbulence that is created in the irrigant, results in a large surface area of the canal being touched by the file and removes biofilm that would not be removed by round files. Figure 7 shows the action of the XP-endo Finisher. In the “M-phase” the finisher is placed in the canal before it changes to full austenite phase. The middle illustration demonstrates full austenite phase at canal temperature; the file will expand to the extent that is determined by the canal anatomy. By moving the finisher up and down 7 mm8 mm, it expands and contracts according to the anatomy of the canal (shown in the right-hand illustration). Thus, the XP-endo finisher has the following advantages: 1. It can be an effective adjunct to any file that makes a round shape. 2. It is extremely flexible and resistant to cyclic fatigue. 3. It molds to the canal shape while not shaping the canal. 4. It loosens debris by scraping and agitating the irrigant.

The prevention or elimination of microbes from the root canal poses many challenges.

Figure 8: Plastic replica of distal canal of the lower molar (Truetooth)

Demonstration and case Figure 8 illustrates how the finisher will complete the cleaning that is impossible with round files and also maintain the original shape of the canal. Note that the root has two canals that are irregular in shape in the buccolingual dimension. These irregularities would not be seen in the mesiodistal dimension. The canals have also been instrumented to size 35/04, and in this buccolingual dimension, there is still a large part of the canals that were untouched. In most cases, however, size 35/04 in a root with two canals would look well cleaned. The XP-endo Finisher is working in the canal. By moving the file in and out of the canal for approximately 7 mm-8 mm, the file tip and bulb will expand and contract and contact all the irregularities in the buccolingual aspect of the canal. In addition, the irrigant is agitated so as to maximize its effectiveness on loosened microbes. Both canals are thoroughly cleaned and additionally, the original shape has been maintained. Figure 9 is an example of a case where the action of the finisher can be appreciated because the irregularity in the canal is also 24 Endodontic practice

Figure 9: Example case where the action of the finisher can be appreciated because the irregularity in the canal is also in the mesiodistal dimension due to internal resorption

in the mesiodistal dimension due to internal resorption. The finisher was able to assist in removing debris and tissue in the irregularity, and at the same time, the original shape of the canal was maintained and the root not weakened further. The preoperative periapical radiograph shows a mesiodistal resorptive defect. The CBCT images show that this is internal resorption and that it extends buccolingually as well. The postoperative radiograph shows that at the second visit, the canal is filled completely, which is an indication that the tissue and debris has been removed. Also,

and just as importantly, the original shape of the canal has been maintained so that the tooth has not been further weakened by the cleaning procedure. EP REFERENCES 1. Bergenholtz G. Micro-organisms from necrotic pulp of traumatized teeth. Odontol Revy. 1974;25(4):347–358. 2. Metzger Z, Teperovich E, Zary R, Cohen R, Hof R. The Self Adjusting File (SAF). Part 1: Respecting the root canal anatomy – a new concept of endodontic files and its implementation. J Endod. 2010;36(4):679–690. 3. Socransky SS, Haffajee AD. Dental biofilms: difficult therapeutic targets. Periodontol 2000. 2002;28:12–55. 4. Wu MK, R’oris A, Barkis D, Wesselink PR. Prevalence and extent of long oval canals in the apical third. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(6):739–743.

Volume 8 Number 6

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Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $129. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Endodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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Cleaning the third dimension DEBELIAN/TROPE

1. While the vast majority of the microbes are ____________, there are complex anatomical irregularities such as accessory or lateral canals and canal isthmuses intercommunicating with the main canals. a. in the main canal b. in the planktonic (loose) form c. not located in the main canal d. both a and b 2. While irrigation with disinfectants may be very effective against planktonic microbes, it is not effective enough when the microbes are _________. a. disparate in shape b. in the biofilm form c. in canal irregularities d. both b and c 3. Although there are a multitude of file systems with various metallurgical properties and geometric designs available on the market, they all produce __________ on any given canal cross section. a. a final round shape b. an ovoid shape c. a triangular shape d. a hexagonal shape

Volume 8 Number 6

4. When the file is cooled below 35ºC, it is in the ________ phase. a. austenite b. martensite c. eutectic d. pearlite 5. When the file is heated to body temperature (35ºC), it will change to the _______ phase. a. austenite b. martensite c. eutectic d. pearlite 6. Importantly, because of the small core diameter of the file, it _____________. a. maintains its flexibility b. maintains cyclic fatigue resistance c. will scrape, but not shape, the walls d. all of the above 7. This, plus the turbulence that is created in the irrigant, results in ____________ of the canal being touched by the file and removes biofilm that would not be removed by round files. a. a large surface area b. a small surface area

c. a negligible portion d. only the infected portion 8. By moving the finisher up and down __________, it expands and contracts according to the anatomy of the canal. a. 1 mm-2 mm b. 3 mm-4 mm c. 5 mm-6 mm d. 7 mm-8 mm 9. In addition (with the in-and-out movement of the file), the irrigant is agitated so as to maximize its effectiveness on __________. a. the root structure b. the most tightly integrated microbes c. loosened microbes d. the canal’s diameter 10. The finisher was able to assist in removing debris and tissue in the irregularity, and at the same time the original shape of the canal ___________ and the root not weakened further. a. was widened b. was narrowed c. was maintained d. was expanded

Endodontic practice 25

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Posterior composites and new bulk-fill materials Dr. Ron Jackson assesses the research behind posterior composites and new bulk-fill materials

n 1990, 94% of dentists in the United States chose amalgam as their primary intracoronal posterior restorative material (American Dental Association, 1997). By 2010, composite resin restorations had exceeded amalgam by a ratio of 2:1 — in fact, it is estimated that onethird of U.S. dentists no longer use amalgam, and those who do report a steady decline (Jackson, 2011). This is not an indictment of amalgam, a material that has served dentistry well for more than 100 years. There are many reasons for this relatively rapid and significant change in restorative dentistry. In this author’s opinion, the leading reasons are: • Individual patient desires for nonmetal, natural-looking restorations. • The less invasive nature of composite restorations (Lynch, et al., 2011). • The significant improvement in composite resin material physical properties, leading to increased durability and longevity, which, according to recent clinical studies, can rival amalgam (Opdam, et al., 2007; Opdam, et al., 2010). Nevertheless, many dentists still complain that placing posterior composites is exacting, tedious, time-consuming, and not always predictable.

Posterior composite predictability Predictability seems to center on two main issues. The first is postoperative sensitivity. Some dentists believe postoperative sensitivity to chewing is caused by the composite material. However, when properly placed, Ron Jackson, DDS, FACD, FAGD, FAACD, is a 1972 graduate of West Virginia University School of Dentistry. He has published many articles on esthetic, adhesive dentistry and lectures across the United States and abroad. Dr. Jackson is a fellow in the Academy of General Dentistry, a fellow in the American Academy of Cosmetic Dentistry, a Diplomate in the American Board of Aesthetic Dentistry, and is director of the Mastering Dynamic Adhesion program at the Las Vegas Institute for Advanced Dental Studies. Dr. Jackson practices in Middleburg, Virginia, emphasizing comprehensive restorative and cosmetic dentistry. He can be reached at 540-687-8075 or email at ron@ronjacksondds.com. Disclosure: Dr. Ron Jackson discloses that he acted as a consultant in the development of SonicFill™ and retains a financial interest.

26 Endodontic practice

Educational aims and objectives

This clinical article aims to discuss the research behind posterior composites and new bulk-fill materials.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 30 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize some statistics regarding dentists’ choice of amalgam and composite resin restorations. • Realize some characteristics of posterior composite predictability. • Recognize that some new composite resins and technologies are specifically designed for posterior use to allow dentists to place restorations faster and easier. • See some research regarding depth of cure of composite resins.

All of these newer bulk-fill composite resin materials are too new to have long-term clinical trial data; however, they are proving popular with dentists, and they continue to grow in the marketplace. this is very unlikely with today’s highly filled, low-shrink composite resins. If the patient states that the pain on chewing is sharp and occurs only when hitting a “certain” spot, the problem is almost always the result of an adhesive error (dentin not totally sealed), as opposed to a high restoration that hurts every time the patient chews on it. Thus, an intermittent type of postoperative sensitivity is, for the most part, iatrogenic (Perdiago, Geraldeli, and Hodges, 2003). It should be noted that this problem, once erroneously ascribed to the use of the etch-and-rinse adhesive technique, has declined significantly in recent years (Perdiago, Geraldeli, and Hodges, 2003). The majority of dentists now respect the precise nature of this particular category of adhesive and have learned how to execute the technique properly (i.e., don’t over-etch or underprime dentin, dry primers thoroughly after application, and light cure adequately). Additionally, there has been an increase in the use of the self-etch adhesives, with or without selective enamel etch. The author anticipates that the continued development of advanced universal adhesives will further reduce the incidence of this particular cause of postoperative sensitivity.

Sensitivity to cold following restoration placement is multifactorial and occurs with all kinds of operative procedures and materials. Because dentin is always sealed with an adhesive before placing composite resin, the incidence and duration of this problem should be less with posterior composite restorations as compared to unbonded amalgam restorations. The second major concern, regarding predictability, is the lack of achieving a proper contact. Again, this is not a fault of the composite material but entirely a matricing factor. Fortunately, newly designed sectional matrix systems, introduced in the past few years (such as Composi-Tight® 3D, Garrison Dental Solutions; Triodent™ V3 and V4 Systems, Ultradent) as well as newly introduced circumferential and specialty matrices, used with or without a contact former (PerForm™, Garrison Dental Solutions; Contact Pro 2, CEJ Dental, Inc.) have virtually eliminated this problem.

Faster placement Even with the predictability issue resolved, dentists still have to take the time and effort needed for the actual placement of the composite resin. Current composite Volume 8 Number 6

Examining the science The discussion surrounding bulk-fill materials and whether they meet their manufacturers’ claims rightly leads clinicians to examine the available research. The common understanding is that composite resin should be placed and cured in separate 2 mm increments to reduce polymerization shrinkage stress, and there is a preponderance of literature supporting this approach (Ferracane, 2011; Meira and Bragga, 2011; Park et al, 2008). However, in 1996, a paper published in the Journal of Dental Research by Versluis and colleagues first questioned whether the incremental filling technique actually reduced overall polymerization shrinkage stress (Versluis, et al., 1996). The authors concluded that this technique actually increased shrinkage stress. Since then, there have been many published papers concluding that placing composite resins in posterior restorations using incremental Volume 8 Number 6

layers does not appear to be clinically significant to the overall outcome of the restoration (Neiva, et al., 1998; Gallo, Bates, and Burgess, 2000; Choi, Condon, and Ferracane, 2000; Leevailoj, Cochran, and Matis, 2001; Idriss, et al., 2003). A more recent article examining cuspal deflection published in the Journal of the American Dental Association also confirmed this premise (Rees, et al., 2004). In addition, this paper further validated the transtooth illumination technique to improve depth of cure, which was espoused by Belvedere in 2001. However, 2 mm incremental layering is still recommended for non-bulk-fill composites due to depth of cure limitations. Regarding depth of cure of composite resins, there are two methods commonly used to measure depth of cure and extent of polymerization. One method, the International Organization for Standards (ISO) standard 4049:2009, cures a column of composite from the top surface. The soft, uncured composite is subsequently scraped away from the bottom surface until reaching hard-cured material. The depth of cure is then defined by dividing the remaining length of cured composite by two. In an investigation by Tiba and colleagues into the depth of cure of several bulk-fill materials presented at the International Association of Dental Research (IADR)

meeting in 2013, the authors concluded with the following statement: “This study shows some limitations of ISO 4049 for testing the depth of cure in relation to the more important hardness ratio for bulk-fill composites materials.” (Tiba, Hong, and Zeller, 2013.) In this author’s opinion, the ISO standard is limited to comparing relative “curability” of different composite resin materials. Since it does not measure how much composite resin has actually cured (carbon conversion) at any given depth, it is not specifically clinically relevant (Tiba, Hong, and Zeller, 2013). A second method used by many investigators, known as the Knoop hardness test, defines the depth of cure as the distance from the top of a cured column of composite to a point where the microhardness value is at least 80% of the top surface value. Hardness has been shown to correlate to polymerization (80% bottom-to-top hardness equals 90% carbon conversion). In the author’s opinion, this makes this method for determining depth of cure clinically relevant (Bouschlicher, Rueggeberg, and Wilson, 2004). The same authors of the IADR paper mentioned previously carried out an extensive investigation into the physical properties of several bulk-fill materials and compared the data to incrementally placed materials. This research was published by the

Table 1 Materials

Composite type

Depth of cure

Needs enamel replacement layer

Needs low viscosity liner

Surefill SDR Flow (Dentsply/Caulk)a

Flowable

4 mm

Yes

x-tra base (Voco)a

Flowable

4 mm

Yes

Venus Bulk Flow (Heraeus Kulzer)a

Flowable

4 mm

Yes

Filtek Flow Bulk Fill (3M ESPE)a

Flowable

4 mm

Yes

Tetric Evoceram Bulk Fill (Ivoclar Vivadent)

Highly filled composite

4 mm

Yes

x-tra fil (Voco)

Highly filled composite

4 mm

Yes

Sonicfill (Kerr)c

Highly filled composite

5 mm

(a) Dentin replacement (base) (b) Unless non-occlusal load bearing (c) Sonic delivery Endodontic practice 27

CONTINUING EDUCATION

resins now yield high physical properties of hardness, flexural strength, and fracture toughness, as well as low shrinkage and low wear. However, these highly filled, highly viscous materials can make it more difficult to achieve intimate adaptation to cavity walls, and because of low depth of cure, require multiple, separately adapted, and cured layers. Manufacturers have begun to address this concern by introducing new composite resins and technologies specifically designed for posterior use that allow dentists to place restorations faster and easier. In short, these new bulk-fill products reduce the need for multiple layers when placing posterior composite restorations. In addition, flowable base materials (such as SureFil® SDR® Flow, Dentsply; Filtek™ Bulk Fill Flowable, 3M ESPE), as well as a highly filled composite that is vibrated into the cavity (i.e., SonicFill™, Kerr), allow excellent adaptation to cavity walls. This, in turn, results in fewer voids and seams when compared to traditional lined and layered materials and techniques (Munoz and Campillo-Funollet, 2012; Ferracane, 2011). These advanced materials have required modifications in resin chemistry (and in the case of SonicFill, the addition of sonic energy technology) to address depth of cure and shrinkage stress. They have also necessitated a re-examination of the science of light curing, polymerization kinetics, and shrinkage stress, especially considering the higher output of today’s curing lights.

CONTINUING EDUCATION

Figures 1 and 2: Before photo and preoperative X-ray showing Class II amalgam needing replacement

Figures 3 and 4: 42-month postoperative view of SonicFill (Kerr) restoration. Note adaptation to cavity walls without the need for a low viscosity liner

American Dental Association (ADA) Laboratories (Belvedere, 2001). Using the hardness ratio method for depth of cure, all the products listed in Table 1 met their manufacturer’s claims (Belvedere, 2001). x-tra base, x-tra fill (Voco America), and SonicFill significantly exceeded their respective manufacturer’s claim. It should be pointed out that the values these authors obtained were different and lower when the ISO 4049 test method was used. Unfortunately, the opinion these same authors expressed in the IADR research regarding the “more important hardness ratio” did not appear. Although other investigators using the hardness ratio test have shown bulk-fill composites to meet or exceed manufacturer’s claims (Yapp, 28 Endodontic practice

Baumann, and Powers, 2014; Christensen, 2012), at least one paper published using a different protocol for hardness arrived at different results. So clinicians should pay close attention to various study methods (Flury, et al., 2012). Another concern regarding placing large increments of bulk-fill composite resin into a cavity is the potential for creating high-shrinkage stress. When the authors of the ADA study examined polymerization stress, the mean values for most of the bulk-fill products tested were not statistically different compared to the layered (non-bulkfill) controls. The shrinkage stress value for SonicFill was the lowest and was lower by a statistically significant amount compared

to the rest of the materials tested (Tiba, et al., 2013).

Case examples The main objective of these new posterior composite resin materials is to reduce the cured layers of composite the dentist has to place, thereby increasing efficiency. The materials rely on high depth of cure (at least 4 mm) along with low shrinkage and controlled stress to allow most preparations to be rapidly filled in fewer increments. In the experience of the author, the rapid insertion along with the non-slumping, nonsticky sculptability of SonicFill makes placement time and effort rapid, easy, and similar to amalgam. This is something dentists have Volume 8 Number 6

CONTINUING EDUCATION

asked for since composite resins were first used for posterior restorations. In the case shown in Figures 1-4, there is demonstrated adaptation to cavity walls without the need for a low-viscosity liner, which means this restoration was both clinically successful and more efficient to place. Figures 5 and 6 show a case in which bulk-fill materials demonstrate both clinical success and longevity.

Final thought All of these newer bulk-fill composite resin materials are too new to have long-term clinical trial data; however, they are proving popular with dentists, and they continue to grow in the marketplace. Given the number of posterior composites dentists place in practice, this growth would seem unlikely if these new posterior composite materials and technologies weren’t performing successfully. EP

Figure 5: Preoperative photo showing two Class II amalgams needing replacement

REFERENCES 1. American Dental Association. In your dental practice, is dental amalgam still the restorative material of choice? J Am Dent Assoc. 1997;128(11):1502. 2. Belvedere PC. Contemporary posterior direct composites using state-of-the-art techniques. Dent Clin North Am. 2001;45(1):49-70. 3. Bouschlicher MR, Rueggeberg FA, Wilson BM. Correlation of bottom-to-top surface microhardness and conversion ratios for a variety of resin composite compositions. Oper Dent. 2004;29(6):698-704. 4. Campodonico CE, Tantbirojn D, Olin PS, Versluis A. Cuspal deflection and depth of cure in resin-based composite restorations filled by using bulk, incremental and transtooth-illumination techniques. J Am Dent Assoc. 2011;142(10):1176 -1182. 5. Choi KK, Condon JR, Ferracane JL. The effects of adhesive thickness on polymerization contraction stress of composite. J Dent Res. 2000;79(3):812-817. 6. Christensen G. Advantages and challenges of bulk-fill resins. Clinician’s Report®. 2012;5(1):1-2. https://www. cliniciansreport.org/uploads/files/19/201201.pdf. Accessed October 15, 2015. 7. Ferracane JL. Resin composite – state of the art. Dental Mater. 2011;27(1):29-38. 8. Flury S, Hayoz S, Peutzfeldt A, Hüsler J, Lussi A. Depth of cure of resin composites: Is the ISO 4049 method suitable for bulk fill materials? Dent Mater. 2012;28(5):521-528.

Figure 6: 38-month postoperative view of SonicFill (Kerr) restorations

9. Gallo JR 3rd, Bates ML, Burgess JO. Microleakage and adaptation of Class II packable resin-based composites using incremental or bulk filling techniques. Am J Dent. 2000;13(4):205-208.

15. Munoz C, Campillo-Funollet M. Microleakage in Class II preparations restored with the Sonicfill System. Poster presented at: 41st Annual Meeting, American Association for Dental Research(AADR)/CADR Annual Meeting & Exhibition. March 22, 2012; Tampa Florida.

10. Idriss S, Habib C, Abduljabbar T, Omar R. Marginal adaptation of Class II resin composite restorations using incremental and bulk placement techniques: an ESEM study. J Oral Rehabil. 2003;30(10):1000-1007.

16. Neiva IF, deAndrada MA, Baratieri LN, Monteiro Júnior S, Ritter AV. An in vitro study of the effect of restorative technique on marginal leakage in posterior composites. Oper Dent. 1998;23(6):282-289.

11. Jackson RD. Placing posterior composites: increasing efficiency. Dent Today. 2011;30(4):126-131.

17. Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA. A restrospective clinical study on longevity of posterior composite and amalgam restorations. Dent Mater. 2007;23(1):2-8.

12. Leevailoj C, Cochran MA, Matis BA, Moore BK, Platt JA. Microleakage of posterior packable resin composites with and without flowable liners. Oper Dent. 2001;26(3):302-307. 13. Lynch CD, Frazier KB, McConnell RJ, Blum IR, Wilson NH. Minimally invasive management of dental caries: contemporary teaching of posterior resin-based composite placement in U.S. and Canadian dental schools. J Am Dent Assoc. 2011;142(6):612-620. 14. Meira JB, Bragga RR, Ballester RY, Tanaka CB, Versluis A. Understanding contradictory data in contraction stress tests. J Dent Res. 2011;90(3):365-370.

Volume 8 Number 6

18. Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC. 12 year survival of composite vs. amalgam restorations. J Dent Res. 2010;89(10):1063-1067. 19. Park J, Chang J, Ferracane J, Lee IB. How should composite be layered to reduce shrinkage stress: incremental or bulk filling? Dent Mater. 2008;24(11):1501-1505. 20. Perdigão J, Geraldeli S, Hodges JS. Total-etch versus selfetch adhesive: effect on postoperative sensitivity. J Am Dent Assoc. 2003;134(12):1621-1629.

21. Rees JS, Jagger DC, Williams DR, Brown G, Duguid W. A reappraisal of the incremental packing technique for light cured composite resins. J Oral Rehabil. 2004;31(1):81-84. 22. Tiba A, Hong A, Zeller G. Examining the depth of cure for bulk fill composite materials. Poster presented at: 91st General Session of the International Association for Dental Research (IADR). No. 2435. March 2013; Seattle Washington. 23. Tiba A, Zeller GG, Estrich CG, Hong A. A laboratory evaluation of bulk-fill versus traditional multi-increment-fill resin-based composites. J Am Dent Assoc. 2013;144(10):1182-1183. 24. Versluis A, Douglas WH, Cross M, Sakaguchi RL. Does an incremental filling technique reduce polymerization shrinkage stresses? J Dent Res. 1996;75(3):871-878. 25. Yapp R, Baumann A, Powers JM. Comparative curing and thermal properties of demi ultra LED curing light. The Dental Advisor: Research Report. 2014;Number 58. [online] http:// try-for-free.demiultra.eu/media/201537/The-Dental-Advisor_ Research-Report-58_February-2014_Comparative-Curingand-Thermal-Properties-of-Demi-Ultra-LED-Curing-LightEN.pdf. Accessed October 15, 2015.

Endodontic practice 29

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Posterior composites and new bulk-fill materials JACKSON

1. In 1990, _______ of dentists in the United States chose amalgam as their primary intracoronal posterior restorative material (American Dental Association, 1997). a. 35% b. 50% c. 75% d. 94% 2. By 2010, composite resin restorations had exceeded amalgam by a ratio of 2:1 â&#x20AC;&#x201D; in fact, it is estimated that _________ of U.S. dentists no longer use amalgam, and those who do report a steady decline. a. one-third b. one-quarter c. one-half d. three-quarters 3. This is not an indictment of amalgam, a material that has served dentistry well for more than ____. a. 25 years b. 50 years c. 75 years d. 100 years 4. The majority of dentists now respect the precise nature of this particular category of adhesive and have learned how to execute the technique properly (i.e.,_________).

30 Endodontic practice

a. b. c. d.

donâ&#x20AC;&#x2122;t over-etch or underprime dentin dry primers thoroughly after application light cure adequately all of the above

5. Sensitivity to _______ following restoration placement is multifactorial and occurs with all kinds of operative procedures and materials. a. heat b. cold c. tapping d. carbonated drinks 6. Current composite resins now yield high physical properties of hardness, flexural strength, and fracture toughness, as well as __________. a. low shrinkage b. low wear c. high shrinkage d. both a and b 7. The common understanding is that composite resin should be placed and cured in separate __________ increments to reduce polymerization shrinkage stress, and there is a preponderance of literature supporting this approach. a. 2 mm b. 4 mm c. 6 mm d. none of the above

8. A second method used by many investigators, known as the Knoop hardness test, defines the depth of cure as the distance from the top of a cured column of composite to a point where the microhardness value is at least _______ of the top surface value. a. 65% b. 75% c. 80% d. 95% 9. The main objective of these new posterior composite resin materials is to ________ the cured layers of composite the dentist has to place, thereby increasing efficiency. a. control b. increase c. reduce d. pre-shrink 10. In the experience of the author, the rapid insertion along with the non-slumping, nonsticky sculptability of SonicFill makes placement time and effort _________. a. rapid b. easy c. similar to amalgam d. all of the above

Volume 8 Number 6

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All the ProTaper® efficiency, now with advanced metallurgy for greater flexibility and resistance to cyclic fatigue. ProTaper Gold – because performance is golden. 1-800-662-1202 For the latest information consult www.TulsaDentalSpecialties.com © 2014 DENTSPLY International, Inc. ADPTG Rev. 2 5/14

TECHNOLOGY SPOTLIGHT

Resolve to save more teeth

he end of the year is invariably a time of reflection, and we often use this time to consider ways we can improve our lives and our relationships with others. But how often do you make resolutions that can have an immediate impact on the standard of care you provide for your patients? How often do you make resolutions that can help set your practice apart and grow your business? As endodontists, it is our responsibility to continuously question what constitutes an acceptable standard of care. For too long, that has meant root canal therapies that leave as much as 30%-40% of bacteria entombed in the canal.1,2 Left alone, that bacteria is only going to multiply. And for too long, we have allowed ourselves to accept reinfection and retreatment that results as an adequate outcome. During this time of annual contemplation, we have to ask ourselves, Can we do better? At Sonendo®, we believe the answer is yes. Sonendo has been challenging the current standard of endodontic care for nearly 9 years. By remaining committed to the principle of Sound Science®, we have developed visionary capabilities that will enable your practice to elevate your clinical efficacy. We call it Multisonic Ultracleaning™ technology, and it represents an exponential leap in the quality of care we are able to provide. Multisonic Ultracleaning™ technology works by delivering a broad spectrum of acoustic energy and creating a powerful vortex of treatment solutions that clean the entire root canal system from crown to apex. It is measurably superior to conventional therapies, relying far less on NiTi files and standard irrigation techniques and still removing more pulpal tissue and debris.3 In addition, Multisonic Ultracleaning™ technology can

dissolve organic tissue 8 times faster than conventional endodontic systems.4 In addition to detaching and dissolving debris and tissue, the advanced fluid dynamics and chemistry that are essential to Multisonic Ultracleaning™ give you the power to thoroughly disinfect even complex anatomies, including the microscopic tubules where bacteria can accumulate and spread. Smear layer is effectively removed, as well as the biofilm that can form in the root canal system within weeks of the initial conventional treatment — and which can lead to reinfection.5 Multisonic Ultracleaning™ is statistically more effective than conventional techniques, even in the apical third and areas of anatomical complexities within the root canal system.5 Multisonic Ultracleaning™ technology is only available with Sonendo’s GentleWave™ System, and since its introduction, endodontists everywhere have been impressed. And who better to speak to the transformative power of the GentleWave™ System than an endodontist who has personally experienced the procedure? Won-Jun Shon, DDS, MS, PhD — a professor at Seoul National University School of Dentistry (SNU) in Seoul, Korea,

and a visiting professor at UCLA — recently underwent a GentleWave™ root canal procedure and was very excited about what he referred to as a “breakthrough treatment by Sonendo®.” The endodontist who performed the treatment, Dr. Randy Garland, has been providing GentleWave™ therapies for a year, and his enthusiasm for the technology is rooted in the improved results he has seen in that time. According to Dr. Garland, “I am at a point where I wouldn’t feel comfortable performing a root canal procedure without my GentleWave™ System. Now that I have seen what root canal clean can look like, I personally feel I would be doing my patients a disservice leaving the amount of tissue, debris, biofilm, and bacteria behind that conventional endodontics allow. Making this improvement in my endodontic office has elevated our standard of care, the energy level of my staff, and our patients’ experience.” As for Dr. Shon’s experience with the GentleWave™ treatment, he described the treatment as very comfortable and virtually pain-free. “I did not feel any postoperative pain,” Dr. Shon said, “even though my tooth was a case of symptomatic irreversible pulpitis.” In addition, he praised the

Before GentleWave™ RCT

1 month after GentleWave™ RCT

7 months after GentleWave™ RCT

“Scheduling only 1-day root canal treatments and treating complex cases have always been a challenge. The GentleWave™ System will not only meet these challenges, but it will exceed them.” — Won-Jun Shon, DDS, MS, PhD

Clinical images from Dr. Won-Jun Shon’s GentleWave™ root canal therapy. Images courtesy of Randy Garland, DDS. 32 Endodontic practice

Volume 8 Number 6

TECHNOLOGY SPOTLIGHT

GentleWave™ System for its potential ability to provide increased revenues for practices. Because the GentleWave™ System enables endodontists to provide cleaning, disinfection, and obturation in one session rather than two, it enables practices to take on new billable patients, including the referrals that are becoming increasingly challenging in this industry. “As a current endodontist,” Dr. Shon said, “successfully scheduling only 1-day root canal treatments and treating complex cases have always been a challenge. The GentleWave™ System will not only meet these challenges, but it will exceed them. You will deliver unprecedented levels of cleaning with Sonendo’s Multisonic Ultracleaning™ technology. This is the efficacy we have been seeking in our field and the care you want to provide for your patients.” Challenging the status quo in our industry may seem like an overwhelming task. The standard of care for endodontics has only grown incrementally over the last several decades. But the arrival of the GentleWave™ System and its Multisonic

Ultracleaning™ technology means that there is an entirely new way of thinking about root canal therapies underway right now — an endodontic revolution that should be your 2016 resolution. Sonendo has grown from a concept in 2006 to its selective commercial release today. The device is FDA-cleared. For more information, visit www.sonendo.com or info@ sonendo.com. EP

REFERENCES 1. Siqueira JF Jr, Machado AG, Silveira RM, Lopes HP, de Uzeda M. Evaluation of the effectiveness of sodium hypochlorite used with three irrigation methods in the elimination of Enterococcus faecalis from the root canal, in vitro. Int Endod J. 1997; 30(4):279-282. 2. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J. 1997;30(5):297-306. 3. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement of human molars using the GentleWave System. J Endod. 2015;41(10):1701-1705. 4. Haapasalo M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour M. J Endod. 2014;40(8):1178-1181. 5. Vandrangi P, Basrani B. Multisonic ultracleaning in molars with the GentleWave System. Oral Health. May 2015;105(5):72-86.

The GentleWave™ System by Sonendo®

This information was provided by Sonendo®.

Endodontic practice 33

ABSTRACTS

The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research Predicting severe pain after root canal therapy in the National Dental PBRN Law AS, Nixdorf DR, Aguirre AM, Reams GJ, Tortomasi AJ, Manne BD, Harris DR, National Dental PBRN Collaborative Group. Journal of Dental Research. (0015) 94(3 Suppl):37S-43S Abstract Aim: Some patients experience severe pain following root canal therapy (RCT) despite advancements in care. The aim of this study was to identify factors that can be measured preoperatively, which predict this negative outcome so that future research may focus on pre-emptive steps to reduce postoperative pain intensity. Methodology: Sixty-two practitioners (46 general dentists and 16 endodontists) who are members of the National Dental Practice-Based Research Network (PBRN) enrolled patients receiving RCT for this prospective observational study. Baseline data collected from patients and dentists were obtained before treatment. Severe postoperative pain was defined based on a rating of greater than seven on a scale from zero (no pain) to 10 (pain as bad as can be) for the worst pain intensity experienced during the preceding week, and this was collected 1 week after treatment. Multiple logistic regression analyses were used to develop and validate the model. Results: A total of 708 patients were enrolled during a 6-month period. Pain intensity data were collected 1 week postoperatively from 652 patients (92.1%), with 19.5% (n = 127) reporting severe pain. In multivariable modeling, baseline factors predicting severe postoperative pain included current pain intensity (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07 to 1.25; P = 0.0003), number of days in the past week Kishor Gulabivala, BDS, MSc, FDSRCS, PhD, FHEA, is professor and chairman of endodontology, and head of department of restorative dentistry at Eastman Dental Institute, University College London. He is also training program director for endodontics in London.

34 Endodontic practice

that the subject was kept from their usual activities due to pain (OR, 1.32; 95% CI, 1.13 to 1.55; P = 0.0005), pain made worse by stress (OR, 2.55; 95% CI, 1.22 to 5.35; P = 0.0130), and a diagnosis of symptomatic apical periodontitis (OR, 1.63; 95% CI, 1.01 to 2.64; P = 0.0452). Among the factors that did not contribute to predicting severe postoperative pain were the dentistâ&#x20AC;&#x2122;s specialty training, the patientâ&#x20AC;&#x2122;s age and sex, the type of tooth, the presence of swelling, or other pulpal and apical endodontic diagnoses. Conclusions: Factors measured preoperatively were found to predict severe postoperative pain following RCT. Practitioners could use this information to better inform patients about RCT outcomes and possibly use different treatment strategies to manage their patients.

Effect of education intervention on the quality and long-term outcomes of root canal treatment in general practice Koch M, Wolf E, Tegelberg A, Petersson K. International Endodontic Journal. (2015) 48(7):680-9 Abstract Aim: To compare the technical quality and long-term outcomes of root canal treatment by general practitioners of a Swedish Public Dental Service, before and after an endodontic education, including Ni-Ti rotary technique (NiTiR). Methodology: A random sample was compiled, comprising one root-filled tooth from each of 830 patients, treated by 69 general practitioners participating in the education: 414 teeth root-filled in 2002, pre-education, using primarily stainless steel instrumentation and filling by lateral compaction, and 416 teeth root filled post-education (2005), using mainly NiTiR and single-cone obturation. Follow-up radiographs taken in 2009 were evaluated alongside immediate post-filling radiographs from 2002 to 2005. The density and length of the root fillings were registered; periapical status was assessed by the Periapical Index (PAI), using two definitions of disease: apical periodontitis

(AP) (PAI 3 + 4 + 5) and definite AP (PAI 4 + 5). Tooth survival was registered. Root fillings pre- and post-education were compared using chi-square and Fisherâ&#x20AC;&#x2122;s exact tests. Crude extraction rates per 100 years were calculated for comparison of tooth survival. Explanatory variables (type of tooth, rootfilling quality, periapical status, marginal bone loss, type and quality of coronal restoration) in relation to the dependent variable (AP at follow-up) were analyzed by multivariable logistic regression. Results: Follow-up data were available for 229 (55%) of teeth treated pre-education and 288 (69%) treated post-education: Both tooth survival (P < 0.001) and root-filling quality were significantly higher (P < 0.001) in the latter. However, there was no corresponding improvement in periapical status. Both pre- and post-education root fillings with definite AP on completion of treatment had significantly higher odds of AP or definite AP at follow-up. For teeth treated posteducation, inadequate root-filling quality was significantly associated with AP at follow-up. Conclusions: Despite a higher tooth survival rate and a significant improvement in technical quality of root fillings after the education, there was no corresponding improvement in periapical status.

Mesenchymal dental pulp cells attenuate dentin resorption in homeostasis Zheng Y, Chen M, He L, Marao HF, Sun DM, Zhou J, Kim SG, Song S, Wang SL, Mao JJ. Journal of Dental Research. (2015) 94(6):821-7 Abstract Aim: Dentin in permanent teeth rarely undergoes resorption in development, homeostasis, or aging, in contrast to bone that undergoes periodic resorption/remodeling. The authors hypothesized that cells Volume 8 Number 6

A prospective study of the incidence of asymptomatic pulp necrosis following crown preparation

preparation as well as the positive predictive value of the electric pulp testing. Methodology: A total of 120 teeth with healthy pulps scheduled to receive fixed crowns (experimental teeth) were included. Teeth were divided into two groups according to the preoperative crown condition (intact teeth and teeth with preoperative caries, restorations or crowns) and into four groups according to tooth type (maxillary anterior teeth, maxillary posterior teeth, mandibular anterior teeth, and mandibular posterior teeth). Experimental and control teeth were submitted to electric pulp testing on three different occasions before treatment commencement (stage zero), at the impression-making session (stage one) and just before the final cementation of the crown (stage two). Teeth that were considered to contain necrotic pulps were submitted to root canal treatment. Upon access, absence of bleeding was considered as a confirmation of pulp necrosis. Data were analyzed

using bivariate (chi-square) and multivariate analysis (logistic regression). All reported probability values (P-values) were based on two-sided tests and compared to a significance level of 5%. Results: The overall incidence of pulp necrosis was 9%. Intact teeth had a significantly lower incidence of pulp necrosis (5%) compared with preoperatively structurally compromised teeth (13%) [(OR: 9.113, P = 0.035)]. No significant differences were found among the four groups with regard to tooth type (P = 0.923). The positive predictive value of the electric pulp testing was 1.00. Conclusions: The incidence of asymptomatic pulp necrosis of teeth following crown preparation is noteworthy. The presence of preoperative caries, restorations or crowns of experimental teeth correlated with a significantly higher incidence of pulp necrosis. Electric pulp testing remains a useful diagnostic instrument for determining the pulp condition.

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Endodontic practice 35

ABSTRACTS

in the mesenchymal compartment of dental pulp attenuate osteoclastogenesis. Methodology: Mononucleated and adherent cells from donor-matched rat dental pulp (dental pulp cells [DPCs]) and alveolar bone (alveolar bone cells [ABCs]) were isolated and separately co-cultured with primary rat splenocytes. In vivo, rat maxillary incisors were atraumatically extracted (without any tooth fractures), followed by retrograde pulpectomy to remove DPCs and immediate replantation into the extraction sockets to allow repopulation of the surgically treated root canal with periodontal and alveolar bone-derived cells. Results: Primary splenocytes readily aggregated and formed osteoclast-like cells in chemically defined osteoclastogenesis medium with 20 ng/mL of macrophage colony-stimulating factor (M-CSF) and 50 ng/mL of receptor activator of nuclear factor kappa-b ligand (RANKL). Strikingly, DPCs attenuated osteoclastogenesis when cocultured with primary splenocytes, whereas ABCs slightly but significantly promoted osteoclastogenesis. DPCs yielded ~20-fold lower RANKL expression but >2-fold higher osteoprotegerin (OPG) expression than donor-matched ABCs, yielding a RANKL/ OPG ratio of 41:1 (ABCs:DPCs). Vitamin D3 significantly promoted RANKL expression in ABCs and OPG in DPCs. In the vivo experiment, after 8 weeks, multiple dentin/ root resorption lacunae were present in root dentin with robust RANKL and OPG expression. There were areas of dentin resorption alternating with areas of osteodentin formation in root dentin surface in the observed 8 weeks. Conclusions: These findings suggest that DPCs of the mesenchymal compartment have an innate ability to attenuate osteoclastogenesis, and that this innate ability may be responsible for the absence of dentin resorption in homeostasis. Mesenchymal attenuation of dentin resorption may have implications in internal resorption in the root canal, pulp/dentin regeneration, and root resorption in orthodontic tooth movement.

ABSTRACTS Three-year outcomes of root canal treatment: Mining an insurance database Raedel M, Hartmann A, Bohm S, Walter MH. Journal of Dentistry. (2015) 43(4):412-7 Abstract Aim: There is doubt whether success rates of root canal treatments reported from clinical trials are achievable outside of standardized study populations. The aim of this study was to analyze the outcome of a large number of root canal treatments conducted in general practice. Methodology: The data were collected from the digital database of a major German national health insurance company. All teeth with complete treatment data were included. Only patients who had been insurance members for the whole 3-year period from 2010 to 2012 were eligible. Kaplan-Meier survival analyses were conducted based on completed root canal treatments. Target events were re-interventions such as (1) retreatment of the root canal treatment, (2) apical root resection (apicoectomy), and (3) extraction. The influences of vitality status and root numbers on survival were tested with the log-rank test. Results: A total of 556,067 root canal treatments were included. The cumulative overall survival rate for all target events combined was 84.3% for 3 years. The survival rate for nonvital teeth (82.6%) was significantly lower than for vital teeth (85.6%; p < 0.001). The survival rate for single-rooted teeth (83.4%) was significantly lower than for multi-rooted teeth (85.5%; p < 0.001). The most frequent target event was extraction followed by apical root resection and retreatment. Conclusions: Based on these 3-year outcomes, root canal treatment is considered a reliable treatment in practice routine under the conditions of the German national health insurance system. Root canal treatment can be considered as a reliable treatment option suitable to salvage most of the affected teeth. This statement applies to treatments that in the vast majority of cases were delivered by general practitioners under the terms and conditions of a nationwide health insurance system.

Outcome of nonsurgical retreatment and endodontic microsurgery: a meta-analysis Kang M, In Jung H, Song M, Kim SY, Kim HC, Kim E. Clinical Oral Investigations. (2015) 19(3):569-82 36 Endodontic practice

Abstract Aim: The purpose of this study was to evaluate and compare the clinical and radiographic outcomes of nonsurgical endodontic retreatment and endodontic microsurgery by a meta-analysis. Methodology: Electronic databases, including Pubmed, Embase, Medline, and the Cochrane Library, were searched, and the references of related articles were manually searched to identify all the clinical studies that evaluated the clinical and radiographic outcomes after retreatment or microsurgery. The first- and second-screening processes were conducted by three reviewers independently. The final studies were selected after strict application of the inclusion and exclusion criteria. The random effects meta-analysis model with the DerSimonianLaird pooling method was performed. The weighted pooled success rates, and 95% confidence interval estimates of the outcome were calculated. Additionally, the effects of the follow-up period and study quality were investigated by a subgroup analysis. Results: Endodontic microsurgery and nonsurgical retreatment have stable outcomes presenting 92% and 80% of overall pooled success rates, respectively. The microsurgery group had a significantly higher success rate than the retreatment group. When the data were organized and analyzed according to their follow-up periods, a significantly higher success rate was found for the microsurgery group in the short-term follow-up (less than 4 years), whereas no significant difference was observed in the long-term follow-up (more than 4 years). Conclusions: Endodontic microsurgery was confirmed as a reliable treatment option with favorable initial healing and a predictable outcome. Clinicians may consider the microsurgery as an effective way of retreatment as well as nonsurgical retreatment depending on the clinical situations.

Analysis of the possible causes of endodontic treatment failure by inspection during apical microsurgery treatment Qian WH, Hong J, Xu PC. Shanghai Kou Qiang Yi Xue/Shanghai Journal of Stomatology. (2015) 24(2):206-9 Abstract Aim: To analyze the possible causes of previous endodontic treatment failure by microscopic inspection during apical microsurgery. Methodology: Two hundred and

eighty-nine teeth of previous endodontic treatment failure were collected from patients in Shanghai Xuhui District Dental Center between January 2006 and January 2014. All surgical procedures were performed by using an operating microscope, and 238 roots were included in the study. The surface of the apical root to be resected or the resected root surface after methylene blue staining was examined during the surgical procedure and inspected with 26 magnification to determine the state of the previous endodontic treatment by using an operating microscope. Fisherâ&#x20AC;&#x2122;s exact test was used to analyze the data with SPSS 19.0 software package. Results: Among the 238 roots with periapical surgery, analysis of the reasons for previous endodontic treatment failure included leaky canal (29.41%), missing canal (15.55%), underfilling (15.55%), anatomical complexity (7.98%), overfilling (4.20%), apical fenestration (4.20%), iatrogenic problem (3.36%), apical calculus (2.52%), apical cracks (1.68%), and unknown reasons (15.55%). The frequency of possible failure causes and tooth position was closely correlated (p < 0.001). Conclusions: Apical microsurgery can better inspect possible causes of previous endodontic treatment failure in order to improve the success rate of endodontic treatment.

Evaluating the effects of different dental devices on implantable cardioverter defibrillators Maheshwari KR; Nikdel K; Guillaume G; Letra AM; Silva RM; Dorn SO. Journal of Endodontics. (2015) 41(5):692-5 Abstract Aim: The implantable cardioverter defibrillator (ICD) is an electronic device that emits electrical signals to the heart via lead wires and electrodes. It is used for cardiac rhythm monitoring and treatment. Because electronic dental devices have been shown to produce electromagnetic fields, we hypothesize that they may interfere with ICD function. Methodology: Nine dental devices (heat carrier, electronic apex locator, electric pulp tester, unipolar electrosurgery unit, electric motor, curing light, and three gutta-percha guns) were tested in this study for their ability to interfere with the function of four ICDs (two single-chambered and two dual-chambered ICDs). ICD activity was monitored for 30 seconds using an ICD programmer (Medtronic 2090; Minneapolis, Minnesota) Volume 8 Number 6

Dental pulp: correspondences and contradictions between clinical and histological diagnosis

Conclusions: On the basis of the predominant pathological aspects — namely, acute and chronic pulpitis — we consider that the classification schemes can be simplified by adequately reducing the number of clinical entities.

Pathways of fear and anxiety in endodontic patients Carter AE, Carter G, George R. International Endodontic Journal. (2015) 48(6): 528-32 Abstract Aim: To evaluate the most common pathways of fear and anxiety in patients who have had root canal treatment or are planned to have one. Methodology: Six hundred and twentyseven patients were approached to participate of which 594 patients (20-90 years) accepted. All consenting patients had a root filling or were treatment planned to

have one. The survey by Ost and Hugdahl on anxiety response patterns was modified and used. Data were presented using descriptive statistics, tested for normality using the Kolmogorov-Smirnov test and analyzed with nonparametric anova (Kruskal-Wallis) and post hoc test. Results: Cognitive conditioning and parental pathways seem to be the primary cause (p < 0.05) of fear and anxiety with root canal treatment. Females were significantly more likely to be influenced by indirect conditioned experiences such as informative, parental, verbal threat, and vicarious pathways. Conclusion: The origin of patients’ fears requires more attention in terms of treating endodontic-related fear and anxiety. More detailed research into the effects of demographics, causative factors, and ethnicity on pathways of fear in dentistry is required to help dentists better manage patients in a multicultural society. EP

Giuroiu CL, Caruntu ID, Lozneanu L, Melian A, Vataman M, Andrian S. Biomed Research International. (2015) 2015:960321 Abstract Aim: Dental pulp represents a specialized connective tissue enclosed by dentin and enamel — the most highly mineralized tissues of the body. Consequently, the direct examination as well as pathological evaluation of dental pulp is difficult. Within this anatomical context, our study aimed to evaluate the correlation between dental pulp lesions and clinical diagnosis. Methodology: Pulpectomies were performed for 54 patients with acute and chronic irreversible pulpitides and for five patients (control group) with orthodontic extractions. The morphological features were semi-quantitatively assessed by specific score values. The clinical and morphological correspondence was noted for 35 cases (68.62%), whereas inconsistency was recorded for 16 cases (31.38%). Results: The results of the statistical analysis revealed the correlations between clinically and pathologically diagnosed acute/ chronic pulpitides. No significant differences were established between the score values for inflammatory infiltrate intensity, collagen depositions, calcifications and necrosis, and acute, respectively, chronic pulpitides. We also obtained significant differences between acute pulpitides and inflammatory infiltrate and calcifications and between chronic pulpitides and inflammatory infiltrate, collagen deposition, and calcifications. Volume 8 Number 6

Endodontic practice 37

ABSTRACTS

and evaluated through an electrogram test strip printout. Results: Electromagnetic interference was detected with the electric motor, curing light, electric pulp tester, and electrosurgery unit, although no electromagnetic disturbances were detected with these devices. No electromagnetic interferences were observed for the gutta-percha guns, heat carrier, and apex locator. However, the electrosurgery unit affected the dual-chambered ICD (Consulta CRT-D, Medtronic) and delivered therapies for fibrillation when no ventricular fibrillation was present. Conclusions: Our results suggest that the electrosurgery unit produces electromagnetic disturbances with unwanted therapy delivery shock and potentially clinically significant outcomes.

PRACTICE MANAGEMENT

Transitioning employees after a practice purchase Paul Edwards offers five effective postpurchase policies

henever I hear that a dental professional is thinking about buying a practice or has just gone through with a purchase, the first question that springs to my mind is, Do you have a plan for transitioning the employees? Practice transitions are fascinating because they touch upon nearly every HR issue possible — from your underlying policies and onboarding employees, to managing complex ongoing HR issues, to (in many cases) letting one or more employees go by the time the transition is complete. After watching the post-purchase HR scenario play out time and time again and providing guidance and problem-solving for scores of dentists during the rough patches, I’d like to share the treasure trove

Paul Edwards is the CEO and Co-Founder of CEDR HR Solutions (www.cedrsolutions.com), which provides individually customized employee handbooks and HR solutions to dental offices of all sizes across the United States. He has over 25 years’ experience as a manager and owner and specializes in helping dental offices solve employee issues. Paul is a featured writer for The Profitable Dentist, Dental Economics, and other publications, and speaks at employment education seminars, conferences, and CE courses across the country. He can be reached at pauledwards@ cedrsolutions.com, or by calling 866- 414-6056.

38 Endodontic practice

of recommendations I’ve stockpiled. Some are directly aimed at lowering your risks as an employer, and others will smooth out your management transition with your new team (which, by the way, also lowers your risks). This guidance applies whether you’ve just bought your first practice or have purchased a second or third. I’m also assuming that you’re trying to keep at least some of the practice’s existing staff, although I’m by no means suggesting that you keep them all. First, though, I want to point out that transitions in practice ownership are scary for employees; and fear, intimidation, and insecurity are not the way to begin, maintain, or grow your management relationship — especially when what you want in return is loyalty, positivity, and commitment to your goals. Employees are your lifeline to your patients. Keep that in mind throughout your transition, along with these tips.

1. Start with honesty. It’s critical to be honest with all employees involved in the transition because you need their honesty and good faith efforts in return. During this time of uncertainty, you’ll establish

control more easily if you don’t exacerbate their negative feelings. Employees will be worried — and rightly so — about whether they can expect to keep their jobs, whether their pay or benefits will change, and whether there are going to be unpleasant upheavals. They want to know what to expect from you, and what you expect from them. Address all of those issues. If some things have not been decided yet, such as whether PTO or benefits will be changing, let the employees know when they can expect a decision. Meet with each employee as soon as you can (if possible, before the deal is even done) to discuss the transition. Ask them what they do, if they are happy, and how they see the practice evolving. This is an opportunity to show you are a worthy leader, capable of compassion, and rewarding of those who commit to the practice’s success. A good approach is: “I want to be very clear about my expectations for each employee and will be evaluating each individual. I want employees who support our patients and my vision for our success. But it is not my intention to keep anyone in a position you don’t want to be in. I encourage you Volume 8 Number 6

2. Know what you don’t know, and get help. You might be hoping not to upset the apple cart too far during your transition, especially if you’re buying a practice that’s apparently been running smoothly for years. But you’ll still want to put your own employee policies in place, not retain the potentially mine-filled preexisting employee manual. To do this, you’ll need expert help because chances are you didn’t spend dental school studying employment law or getting an advanced HR degree in your spare time. But why can’t you keep those preexisting policies, since they seemed to work fine? It’s just not safe, no matter how fervently the selling doctor may believe in them. Countless ever-shifting laws govern employers’ every action, and you’ll have no idea which policies have been recently updated and which ones are risky or outright dangerous now. Most employee handbooks are full of policy errors, missing protections, and illegal or unenforceable “red flag” areas that invite legal claims. Often, everything looks fine on the surface. You won’t find out there’s a problem until the day you get a very unpleasant letter … from an employee’s attorney. Instead, you want a policy manual that is professionally written and up-to-date, and you need expert guidance you can trust to safely resolve or minimize the risks in any issues you encounter. Have your new employee handbook ready early in the game! The most common mistake I see in practice transitions is not getting reliable expert support on employment issues.

Practice transitions are fascinating because they touch upon nearly every HR issue possible — from your underlying policies and onboarding employees, to managing complex ongoing HR issues, to (in many cases) letting one or more employees go by the time the transition is complete. to read it thoroughly. Let everyone know that you need his/her signed acknowledgment by the next day. Note that employees are signing an acknowledgement. They do not need to agree with each policy, but they do need to understand that you will hold them accountable if they choose to break the rules you’ve laid down. If your handbook is good enough, your employees are also acknowledging their responsibility to let you know when they experience a problem while working at your practice. Make sure the expectations you set are clear and aboveboard. This is the first day of the rest of your employment relationship.

4. Make affirmative decisions to hire or fire. Don’t passively inherit the entire team of the practice you’re purchasing — this is your chance to eliminate any obvious “bad apple” employees before they spoil the whole barrel (your new team and practice). Instead, make affirmative decisions to hire or fire. Keep in mind that you still need to be careful your actions won’t seem discriminatory. For the employees you’re hiring, let them know they are in their 90-day “gettingacquainted period,” during which you can both decide if the new employment situation is a good fit.

3. There’s a new sheriff in town.

5. Fixing small problems early prevents huge problems later.

Establishing a comprehensive set of policies isn’t enough — your real goal is to establish yourself as the “new sheriff in town,” and make sure the team has read and understood the law of the land. Meet with them, distribute your employee handbook, and allocate some time on the clock for them

Once your purchase goes through, the obligations of being an employer immediately fall upon you. Hopefully, you already developed some pre-sale impressions of the biggest challenges ahead. But post-sale, it’s up to you to identify, evaluate, and solve small transition problems rapidly so they

Volume 8 Number 6

don’t grow into big employer nightmares. Check each employee’s files. Do they contain old paperwork or write-ups, or are they empty? If they are, just remember an empty file does not mean there’s never been a problem. It just means you’ve got no documentation from the previous owner about what type of employee this person has been up to now. Make everything official with all-new hiring paperwork, and don’t put this off. Use a hiring checklist to ensure you hit everything that is required (e.g., new I-9s, W4s, other state and federal requirements, noncontractual offer letters, job descriptions, and background or reference checks, to name only a few). Email me if you’d like a free hiring checklist that’s attorney-reviewed. As you move forward, and issues arise with your new staff — and they probably will, as you get used to each other — be proactive and diligent about letting employees know what changes you need to see. Document your requests, any corrective actions, and what did or did not occur, especially if you took over an empty file cabinet! If you have an employee or two whose pushback is excessive, or who is simply not adjusting in the way you need, evaluate your risk factors and then let them go as soon as you can safely do so. Every transition situation is unique, and I could fill books with the sum total of what you should do before, during, and afterward to streamline your experience and improve your experience with your new team. You’ll definitely want to consult with your favorite attorney or HR expert before you make final decisions about policies, grandfathered benefits, terminations, and situations unique to your sale. But if you begin with these five tips, you’ll have made a very good start. EP Endodontic practice 39

PRACTICE MANAGEMENT

to talk to me, and tell me your concerns, and you can expect the same from me.” Even if you are the World’s Best Boss and have the coffee cup to prove it, you will probably encounter resistance to your changes because human nature is great at resisting change. Sometimes we even resist positive change, just because it’s different! So while you want to show understanding, this is also the time to let employees know that you won’t be managing from a place of fear.

PRODUCT PROFILE

EndoSequence® BC Sealer™ and Root Repair Material (BC-RRM™)

ndoSequence® BC Sealer™ and Root Repair Material are redefining the way many specialists approach endodontic obturation and root repair procedures. For years, scientists and practitioners alike have been in search of the ideal root canal sealing and repair material. Unlike other facets of dentistry, endodontic sealing and repair applications demand the use of a material that is capable of setting in the presence of moisture and that it is antibacterial while also being highly biocompatible. EndoSequence BC Sealer and Root Repair Material meet these basic needs and so much more. These materials are available in three different viscosities: BC Sealer is the most flowable; BC RRM Paste has a thicker flowable viscosity; and BC RRM Putty has a moldable, condensable viscosity. These three premixed formulations provide the modern endodontist with the ideal biocompatible material for all endodontic sealing, filling, repair, and regenerative procedures.

EndoSequence® BC Sealer™ EndoSequence BC Sealer is a patented, revolutionary premixed root canal sealer which utilizes new bioceramic nanotechnology.

Unlike conventional base/catalyst sealers, BC Sealer utilizes the moisture naturally present in the dentinal tubules to initiate its setting reaction. The canal should be dried just as you normally would, but unlike other sealers, the set will not be inhibited by moisture. This highly radiopaque and hydrophilic sealer forms hydroxyapatite upon setting and chemically bonds to both dentin and to our bioceramic points (EndoSequence BC Points™). BC Sealer is antibacterial during setting due to its highly alkaline pH (+12), and unlike traditional sealers, BC Sealer exhibits absolutely zero shrinkage and is extremely biocompatible. BC Sealer can either be syringed directly into the coronal third of the canal or delivered via a hand file or point. BC Sealer can be used with cold or heated methods (use BC Points 150 Series™ for WVC at 150C). However, many specialists have come to the conclusion that heat (and aggressive condensation) is not necessary with BC Sealer because of its slight expansion (.03%) and its ability to bond to dentin and BC Points. This truly revolutionary sealer has remarkable healing properties and is designed specifically to be non-resorbable. In the event of a slight overfill (puff), an antiinflammatory reaction will not occur because the sealer is essentially a root repair material with a flowable viscosity. BC Sealer (and BC Points) can be retreated utilizing conventional retreatment methods. The manufacturer welcomes all endodontists to test this claim by obturating an extracted tooth with BC Sealer and retreating it with their standard protocol. The gutta-percha point simply provides a path for retreatment and helps deliver the sealer through hydraulics.

EndoSequence® Root Repair Material (RRM™) BC Sealer syringe

BC Points with hydroxyapatite 40 Endodontic practice

EndoSequence® Root Repair Material (RRM™) is available in two specifically formulated consistencies (syringable paste or condensable putty) and contains many of the same characteristics as BC Sealer. Like BC Sealer, the setting reaction of RRM is driven by the moisture naturally present within the dentinal tubules, so there is no mixing required. The favorable handling properties, increased strength, and shortened set time

BC RRM syringe

BC RRM Putty

make BC-RRM highly resistant to washout and ideal for all root repair and pulp-capping procedures. BC-RRM is antibacterial (12+ pH) and is extremely biocompatible and osteogenic. Unlike MTA and other conventional root repair materials containing metals, BC Sealer and BC-RRM are metal-free and do not stain. The putty consistency is ideal for retrofills, one-step apexifications (apical barrier technique), external resorptions, and pulp capping. The syringable version is recommended for retrofills, perfs, internal resorptions, and pulp capping. Many specialists employ a retrofill technique, which involves syringing the flowable RRM into the apico prep and following it up with preformed cones of the RRM Putty. The consistency of RRM Putty is similar to that of Cavit™, and it is extremely resistant to washout making it ideal in difficult fields. The versatility of these premixed materials allow the practitioner to select the consistency that is ideal for the clinical application. For more information or to place an order, contact Brasseler USA® call 800-841-4522, or visit www.brasselerusa.com. EP Cavit™ is not a trademark of Brasseler USA or Endodontic Practice US. This information was provided by Brasseler USA.

Volume 8 Number 6

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PRODUCT PROFILE

Don’t choose between the safety of reciprocation or the efficiency of rotation: Get both with the Endo-Eze® Genius™ files and EVOS™ motor Dr. Carlos Spironelli Ramos discusses newly debuted products by Ultradent

ndodontic NiTi instruments feature the shape memory effect and super elasticity of NiTi alloy that make them ideal for the enlargement of curved root canals; and NiTi rotary instruments with varying cross-sectional designs and tapers have been developed and marketed over the past 2 decades. However, despite their clear advantages, NiTi instruments in rotational movement may undergo premature failure from cyclic fatigue, which is the life-limiting factor for these instruments’ clinical use.1 A reciprocating motion decreases the impact of cyclic fatigue on NiTi instrument life compared with rotational motion. In reciprocation, the instrument is subjected to lower tensile and compressive stress, operating for a longer period of time before separation.2 But there is a downside to employing only reciprocation movement — debris removal appears to be less efficient when compared to rotary movement. Furthermore, the internal dentin wall surface looks better under the effect of rotary instruments than when instrumented only with reciprocating movement. It seems reasonable to begin with the safety of reciprocating movement to open the space securely until the apical limit and then to finish with rotation to carry out the debris. Unfortunately, if the clinician chooses to use the two movements for safety and efficiency, it must be performed with two different file systems — starting with reciprocation, changing the file for another

Figure 1: The EVOS Motor, designed to be used with the Genius Files

system, and then trying to match to the proper rotary file in sequence.

The Genius™ files and EVOS™ motor Genius files are designed with an S-cross section and constant .04 taper to shape and clean the root canal system while preserving more tooth structure. They are compatible with both reciprocation and rotary movement, and operate ideally in the 90° clockwise and 30° counterclockwise movement provided by the EVOS endodontic motor. This reciprocation movement not

Carlos A. S. Ramos, DDS, MS, PhD, graduated in dentistry in 1987 from State University of Londrina, Brazil. In 1990, he received the title of endodontics specialist from the University of São Paulo, Bauru School of Dentistry. From 1991 to 1993, he attended the Master’s program in endodontics at the same university, receiving a Master’s of Science degree. From there, he began the PhD program in endodontics, completing it in 1997 and culminating in his presentation of an in vivo thesis on apex locators. In the same year, he published his first book, Endodontics, Biological and Clinical Foundations. From 1995 to 2012, as professor of endodontics at State University of Londrina, he coordinated the endodontics sector, predoctoral endodontic dental course, and graduate program. Now Dr. Ramos is an adjunct professor in the Endodontics Department at Roseman University, College of Health Sciences, Salt Lake City, Utah. Disclosure: Dr. Carlos Ramos is a paid consultant for Ultradent.

42 Endodontic practice

only reduces the risk of file fracture due to torsional and cyclic fatigue, but also creates a smooth path to the apical limit. After safely reaching the apical limit, Genius files can then be used in 360° rotation to better remove debris from the canal. The EVOS endodontic motor also features auto-stop settings that interrupt movement when a set torque limit is reached. The EVOS endodontic motor and Genius files: designed to put rotary and reciprocation together Studies show that reciprocating motion reduces cyclic and torsional fatigue, while rotary movement removes debris more efficiently. Utilizing an endodontic system, which allows both reciprocation and rotary movements, minimizes the risk of complications. The new EVOS endodontic motor with the pre-programmed Genius settings and the new Genius endodontic file system can help minimize the risk of file separation while shaping and removing debris. Volume 8 Number 6

PRODUCT PROFILE Figure 2: Genius sequence: After pre-flaring, use the Genius 25 .04 in reciprocation until the working length. Choose one of the final enlargement options based on the anatomy of the canal. The final file will be used in reciprocation until the working length, and after that, rotation movement will be used to remove debris

Is ending a preparation with a 25 diameter tip effective? The clinical philosophy that apical preparation sizes should be kept as small as possible, rather than as large as required, disregards existing endodontic scientific literature.3 Larger preparations, as large as apical anatomy permits, play an important role in maximizing the effect of chemomechanical preparation.4 The Genius system always starts in reciprocation with a 25 .04 file to open space until the working length, and then the clinician, based on anatomy, will decide what the best file is for final enlargement. The Genius system offers 30, 35, 40, and 50 diameter options, reaching the most common apical finishing enlargements possible. After reaching the working length in reciprocation mode, the final file will be used in rotation movement to remove debris properly. Why clockwise and not counterclockwise? Since the beginning, endodontic files have been designed to work in a rightdirectional cutting action. Even though the first engine-driven asymmetric reciprocation systems gave a left-cutting, counterVolume 8 Number 6

clockwise action, there is no evidence5 that left-cutting is the most efficient. Genius files are right-cutting instruments to allow the file to be used in reciprocation and rotation. Since Genius files are both reciprocation and rotary files, is it a single file technique? Reciprocation is not synonymous with “single file technique,” though the first reciprocation system claimed only one file to perform all instrumentation. And though using one file allows a tapered preparation to be achieved quickly, in the context of root canal

debridement and disinfection, faster is not necessarily better.6 In using more than one instrument during instrumentation, the clinician has the ability to irrigate more frequently, and debris may have less opportunity to accumulate in a tooth that is more frequently irrigated.7 The Genius system allows the clinician to begin with one file in reciprocation movement and finish with a larger file in reciprocation and rotation. Plus, it is recommended to use a crown-down approach, using a large amount of irrigation during the procedure. EP

REFERENCES 1. De-Deus G, Moreira EJ, Lopes HP, Elias CN. Extended cyclic fatigue life of F2 ProTaper instruments used in reciprocating movement. Int Endod J. 2010;43(12):1063–1068. 2. Castelló-Escrivá R, Alegre-Domingo T, Faus-Matoses V, Román-Richon S, Faus-Llácer VJ. In vitro comparison of cyclic fatigue resistance of ProTaper, WaveOne, and Twisted Files. J Endod. 2012; 38(11):1521-1524. 3. Baugh D, Wallace J. The role of apical instrumentation in root canal treatment: a review of the literature. J Endod. 2005;31(5):333-340. 4. Siqueira JF Jr, Rôças IN, Santos SR, Lima KC, Magalhães FA, de Uzeda M. Efficacy of instrumentation techniques and irrigation regimens in reducing the bacterial population within root canals. J Endod. 2002;28(3):181-184. 5. Saber Sel D, Abu El Sadat SM. The effect of altering the reciprocation range on the fatigue life and shaping ability of Wave-One nickel-titanium instruments. J Endod. 2013;39(5):685-688. 6. Paqué F, Zehnder M, De-Deus G. Microtomography-based comparison of reciprocating single-file F2 ProTaper technique versus rotary full sequence. J Endod. 2011;37(10):1394-1397. 7. Robinson JP, Lumley PJ, Cooper PR, Grover LM, Walmsley AD. Reciprocating root canal technique induces greater debris accumulation than a continuous rotary technique as assessed by 3-dimension micro-computed tomography. J Endod. 2013;39(8):1067-1070.

Endodontic practice 43

PRODUCT SPOTLIGHT

Mani Gutta Percha Removal (GPR) instruments: opening the path Dr. Rich Mounce reviews a technique for removal of GP during endodontic retreatment

emoval of gutta percha (GP) is a critical step in endodontic retreatment. Removal of GP is generally accomplished by the use of heat, Hedstrom files, GP solvents, and rotary GP removal instruments. This column was written to describe the steps commonly used for GP removal in endodontic retreatment with a focus on the Mani GP Removal (GPR) instruments (Figure 1). Conceptually, assuming the tooth is restorable and retreatment is indicated, the key procedural objectives in retreatment are to atraumatically remove existing GP while simultaneously avoiding canal transportation and/or excessive removal of dentin and achieve patency, followed by completion of the root canal. Prior to engaging in retreatment, preoperative radiographs and possibly cone beam images should be carefully evaluated. Radiographic images may or may not reflect the clinical reality. For example, some paste root canals may appear to be GP, and once encountered, such paste root canals may require a completely different set of procedures for predictable removal. Initially, all defective restorations and caries are removed, straight-line access is obtained, and the coronal GP is uncovered. Generally, as a first step in GP removal, either a heat source such as the Meta Biomed E&Q Master™ heat source is used in a downpacking motion to create a small space for the subsequent use of GPR, or alternatively, a GP removal instrument is used without the aforementioned “heating step.” If the heat source is inserted first for bulk removal, most commonly, the FM tip (.08

Dr. Mounce is an endodontist who has lectured and written globally in the specialty of endodontics. Dr. Mounce owns MounceEndo. com, an endodontic supply company based in Rapid City, South Dakota. 605-791-7000. He can be reached at RichardMounce@MounceEndo. com, MounceEndo.com. Disclosure: Dr. Mounce is a consultant for Mani Dental and receives an honorarium for his work.

44 Endodontic practice

Figure 1: Mani GPR files, the Assorted Pack 1S, 2S, 3N, 4N

tapered) is used at approximately 200ºC in a 3-second vertical downpack motion. The insertion of the heat tip is passive, never forced, and solvents are not used at this stage in the process. Whether utilizing heat first or not, the Mani GPR file chosen for bulk GP removal is dependent on the size of the canal being evacuated. Large and relatively straight canals are best evacuated through the use of the 1S and 2S instruments. Alternatively, more narrow and curved canals may require the 3N and 4N instruments. If the GPR instrument is inserted directly into the GP without the initial use of heat, advancement of the instrument should be slow, deliberate, and if undue resistance is encountered, the apical advancement should be stopped immediately. The foot pedal of the motor is engaged fully so that the maximum rpm is utilized while driving the GPR into the GP. GPR instruments, used appropriately, should move through the GP “like a hot knife through butter” as the rotation of the file both heats the GP and drives the debris coronally. Most commonly, only one GPR insertion is required to remove the bulk of the GP, often leaving only a small amount at the apex which will be removed with solvents and hand files. If the GPR instrument does not move easily through the GP, the clinician should chose the next smaller GPR instrument, apply heat, and/or perhaps try a slightly higher rpm. It is not advised to take the GPR file to the minor constriction. The Mani GPR system is a 4-file system that is configured into an assorted pack of 4 instruments (1S, 2S, 3N, 4N) and 4 individual sizes, again, 1S, 2S, 3N, and 4N sizes. The 1 and 2 “S” instruments are stainless steel,

Figure 2: Mani Sec O K files

and the 3 and 4 “N” instruments are nickel titanium. In order of decreasing tip sizes — the 1S (16 mm, green, .70 mm tip size); 2S (18 mm, yellow, .50 mm tip size); 3N (21 mm, black, .40 mm tip size); and the 4N (21mm, blue, .03 mm tip size) — the files can be used in any sequence desired. Not all GPR files are required for any given canal, and often only one file is needed. All files are teardrop shaped in cross section and .04 tapered. Usually, 1500 rpm is adequate to power the GPR files. In my hands, the most common GPR instrument utilized is the blue 4N No. 30 tip size nickel-titanium instrument. Once the bulk of the GP has been removed and prior to using solvents to remove GP, it is often advantageous to use H files to remove any significantly sized fragments of remaining GP. Mani H files are available in many varieties for this purpose and include standard stainless steel H files, safe-ended stainless steel H files (SEC O H files), nickel-titanium H files, and/or medium sizes of stainless steel H files (12, 17, 22, 27, etc.). Which of these H files is indicated for treatment is generally a matter of personal preference. Once the bulk of the GP is removed as previously described, if apical gutta percha Volume 8 Number 6

PRODUCT SPOTLIGHT

remains, pre-curved hand files (Mani SEC O K files safe-ended K files, Mani D Finders, K files, etc.) are used to obtain patency in the presence of a drop of GP solvent (Figures 2-3C). This article has reviewed the common techniques for removal of GP during

endodontic retreatment with a focus on atraumatic removal of GP using heat, Mani GPR files, H files, and solvents with hand files. Emphasis has been placed on removing GP without transporting canals and the vital importance of achieving and maintaining apical patency. I welcome your feedback. EP

Figures 3A-3C: A clinical case pre- and post-op, treated utilizing the techniques described. Courtesy of Dr. David McCarty, Colorado Springs, Colorado

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Endodontic practice 45

SMALL TALK

Practice integrity, part 1: fulfilling the promise Dr. Joel Small discusses a strategy to create and maintain long-term success

ave you ever stopped to consider the enormous amount of time and effort spent in the healthcare profession trying to identify the secret to long-term success for our clinical practices? Today there is a continually growing abundance of courses, journals, and consultants dedicated to teaching us any number of techniques or tricks of the trade to guarantee our successful longevity. Perhaps this is an indication that today’s healthcare providers are coming to the realization that technical skill, although a key factor, is not the only determining factor of our overall success. With all of this diverse information coming at us from all directions, wouldn’t it be helpful if there was one overarching theme that consolidated this information into a single concept that allowed us to better focus and gain clarity with regard to a long-term “success” strategy?... a theme that provided for us a clear line of sight between where we are now and where we need to be to ensure years of prosperity and fulfillment? One school of thought maintains that BRANDING is this overarching theme, and yes. Branding is important. Unfortunately, the idea that a brand is created through marketing is a common misconception that actually hurts rather than helps our strategic plan for success. Marketing, for all of its hype, is simply a means of presenting our message to prospective patients and referrers. All marketing messages contain both stated and implied promises that we make to patients and referral sources. What we often fail to realize is that it is our ability to deliver

Dr. Joel C. Small is a practicing endodontist and the author of Face to Face: A Leadership Guide for Healthcare Professionals and Entrepreneurs. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity. Dr. Small can be reached at joel@joelsmall.com. Readers can sign up for his blog at www.leadfaceface.com.

46 Endodontic practice

on these promises that creates our brand and the environment for long-term success in the service industry. It is my opinion that marketing campaigns consistently fail, not because the message was not ideally crafted, but rather the underlying promise is not kept. I would like to submit that the overarching theme that drives our success is not simply branding but what I call Practice Integrity. So, what is practice integrity and why is it so vital to our success? Before answering this question, let me begin by asking you to consider what qualities you personally admire most in those people who have positively influenced your life. I’ve asked this question to literally hundreds of our colleagues, and invariably many if not most of us say that it is these influencer’s ability to exhibited impeccable honesty and a consistent willingness and ability to fulfill their commitments that we admire most. Interestingly, this same concept of honesty and fulfillment of commitment is the found in the definition of integrity, and whether it is applied to a personal or professional relationship, it still holds true. Practice Integrity knows no boundary. Whether we have a small solo practice or a large multi-doctor, multi-office practice, it is our practice integrity that both creates and maintains our longterm success. So here’s an exercise that I would like to suggest … one that I believe you will find to be very beneficial in helping you and your team find clarity and direction when designing your strategic plans and creating your brand. First, ask your referral sources what they expect from you with regard to your patient care and interaction with their office. Meet with their staff if necessary to gain a clear understanding of their expectations and needs. Next, survey or ask your patients what their expectations might be. Dig deep to go beyond the superficial expectations. Once you have accumulated this

information, gather your team together, both doctors and staff, to have a frank discussion regarding your Practice Integrity. Create a list of both the implied and stated promises you make to your referral sources and patients. Does your promise match their expectations, and more importantly, are you able to fulfill your promise. Again, it is important to dig deep … to go beyond the superficial obligatory responses to the deeper more meaningful answers. Identify the universal expectations expressed by the vast majority of your patients and referrers. Determine if and how you are meeting those expectations. Next look for those unique expectations expressed by specific referral sources. Ask yourself and your team if collectively you are willing to extend the promise of consistently meeting these expectations, and if so, how will this best be accomplished? Finally, let your referral sources know that you will periodically check in with them to ensure that you are fulfilling your promise to them and their patients. Once we clarify these expectations and develop a reputation for consistently delivering on our promise, the word will spread from our satisfied referral sources, and we will find that our reputation becomes a magnet for attracting other referral sources. Furthermore, as these word-of-mouth referrals increase to critical mass, our practices will eventually reach a tipping point from which we will experience exponential growth through lasting professional relationships that ensure our long-term success even in the most competitive environments. EP Volume 8 Number 6

Dr. Rich Mounce offers some tips for professional growth

he traditional model of endodontic private practice referral has changed since I graduated in 1991. Challenged by implants, corporate dentistry, and a glut of endodontists in major metropolitan areas, referral-based practices are more difficult than ever. In 1991, hanging out a shingle was almost a guarantee of success. At the present time, practices are often location dependent, and competition for referrals can be fierce. Given these headwinds, this article was written to give endodontists (and GPs) actionable ideas to help elevate their practices to a new level. I believe the first and most essential ingredient for professional satisfaction in a referral-based practice (and any practice for that matter) lies in a positive outlook and a willingness to change some of our deepestheld biases and beliefs as we experience that which challenges our dogma. There will always be setbacks (staff problems, clinical misadventures, difficult patients, etc.) but ultimately, our ascension into a higher level of practice depends on what we learn, and how we change from these setbacks. It certainly did mine. We can become bitter and negative, or we learn and ultimately fine-tune our actions, behavior, and policies to become stronger, wiser, and to perform better the next time the issue arises. For example, one small course correction I made over time related to scheduling. We evolved from one-size-fits-all scheduling to one more tailored to the patient’s needs. Specifically, if the patient was a senior citizen, or his/her medical history complex, we moved to a method of consultation appointment first, then a treatment appointment. Over a career, literally thousands of such small adjustments and improvements can and should be made on a daily basis.

Rich Mounce, DDS, a practicing endodontist, has lectured and written globally in the specialty. He owns MounceEndo, an endodontic supply company also based in Rapid City, South Dakota. Dr. Mounce can be reached by calling 605-7917000, emailing RichardMounce@MounceEndo. com, or visiting MounceEndo.com.

Volume 8 Number 6

Coincident to such evolution, as endodontists, the strength of our personal relationships with our referring doctors cannot be overstated in value. The same is true in reverse. A solid referral relationship with one’s specialists always benefits all parties. Whether in a phone call, handwritten note, or short unannounced office visit, every personal touch is designed to develop a connection and lets your referring doctors (and specialists) know you care. People like to work with people they like. Growing personal relationships grows your practice. Similarly, a personal connection between your staff and that of your referring doctors (and vice versa) reinforces this connection. Alternatively, referrals from “strangers” are almost always problematic. A real-world scenario is the iatrogenic event referred with no clinical information provided by the referring doctor prior the patient’s arrival and in the absence of a personal relationship between the doctors. This scenario is not predictive of a good outcome for any of the parties involved. Some form of relationship and communication prior to referral certainly minimizes the potential negative impact of the challenge. Lower fees to attract business, flashy brochures, chair massagers, providing CE (at any level), sending newsletters, muffins,

chocolates, flowers, etc., while nice, for me almost never were the “fire starter” of referral relationships. If anything, the reverse was true. It made me seem desperate for referrals, which was never the case. In fact, the time invested in personal contact and relationship with doctors is ultimately far more economical than using resources to provide the preceding premiums. While much could be written about staff and their impact on the success of our practices, I have come to appreciate that recruiting, maintaining, and improving staff are every bit as important as any other foundational pillar of practice success. A capable staff reinforces the relationships we develop with our referring doctors by delivering on the promise that the patient will be well taken care of. The reverse is true. And finally, there are exceptions to every rule. Counterintuitive and uncommon, I have had good referring relationships where little or no relationship exists with the referring doctor due to distance, and/or clearly the referring doctor did not want a personal relationship. As in all practice challenges, we cannot control the outer environment we work in, but in order to improve, we can and must adapt to what it brings. Such evolution is a harbinger of our personal and professional growth. I welcome your feedback. EP Endodontic practice 47

ENDOSPECTIVE

Reflections on a referral-based endodontic practice

INDUSTRY NEWS No evidence linking dental treatment to Alzheimer’s disease

DENTSPLY and Sirona enter into definitive merger agreement

Despite provocative reporting and sensational headlines, the American Association of Endodontists (AAE) has issued a statement that there is no evidence that Alzheimer’s disease can be spread from person to person by direct contact or through any dental procedures or dental instruments. “There is no evidence that root canal treatment poses a risk of developing Alzheimer’s disease,” said AAE President Dr. Terryl A. Propper, a private practicing endodontist in Nashville, Tennessee. “There are procedures in place to minimize infection risk from endodontic instruments such as files and reamers. Many endodontists employ single-use instruments and, if not, instruments are thoroughly sterilized prior to each use.” The study published in the journal Nature makes no mention of dental procedures as a risk factor, and the study author, Professor John Collinge, said, “Our current data has no bearing on dental surgery and certainly does not argue that dentistry poses a risk of Alzheimer’s disease.” “There is nothing definitive in this study,” said Dr. Propper. “Questions remain and the study authors acknowledge that more research is needed.” For more information, visit the AAE’s Root Canal Safety web page which has additional resources designed to help dental professionals advocate for good dental health and root canal safety.

DENTSPLY International Inc. and Sirona Dental Systems, Inc., announced that Boards of Directors of both companies have unanimously approved a definitive merger agreement, which will result in the world’s leading manufacturer of professional dental products and technologies. The combination will create a combined company with the largest sales and service infrastructure in dental with 15,000 employees globally. The combined company, supported by its leading platforms in consumables, equipment, and technology, will offer a powerful set of complementary offerings and end-to-end solutions to enhance patient care. Dental professionals across the globe will be supported by the largest sales and service infrastructure in the industry, supported by leading distributors, to deliver an optimized product range that will meet the increasing global demand for digital dentistry and integrated solutions. For more information, visit www.DENTSPLY.com or www.sirona.com.

Sonendo® appoints new officers Sonendo®, Inc., has appointed Christopher Rabbitt as Chief Commercial Officer. Mr. Rabbitt will be responsible for driving the commercialization strategy for Sonendo’s GentleWave™ System and future technologies. Mr. Rabbitt joins Sonendo from Intuitive Surgical, Inc., a rapidly growing company in robotic surgery, where he held a variety of senior level sales and marketing roles, most recently serving as Director of Global Sales and Marketing for the company’s Cardiothoracic Surgery division. He also has served in product manager and sales roles at CardioVations, a division of Ethicon, Inc. He holds a B.A. in Political Economy of Industrial Societies from The University of California, Berkeley. The company also has appointed Bob Anthony as Vice President of Operations. Mr. Anthony will be responsible for Sonendo’s supply chain, including purchasing, manufacturing, manufacturing engineering, field support and facilities. Most recently Mr. Anthony served as Vice President, Supply Chain, for Masimo Corporation. Previously, he served as Vice President of Engineering and Manufacturing at PhotoThera, Inc., a start-up medical device company focused on noninvasive transcranial laser therapy. For more information, visit www.sonendo.com.

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Ultradent Products, Inc., introduces Endo-Eze® EVOS™ endodontic motor, Endo-Eze® EVOS™ contra-angle, and Endo-Eze® Genius™ files Clinicians no longer have to choose between the safety of reciprocation and the efficiency of rotary, thanks to the Endo-Eze® EVOS™ (Endodontic Variable Operating System) motor, which allows for easy movement between the two modes. The EVOS motor is an electric, motor-driven handpiece intended for root canal preparation procedures in the endodontic field. Pre-programmed for the Genius™ files, the EVOS motor helps minimize the risk of file separation (in reciprocation mode) while shaping and removing debris efficiently (in rotation mode) — seamlessly meeting the need for safety and efficiency. The Endo-Eze EVOS contra-angle is an 8:1 reduction, stainless steel contra-angle intended for use during endodontic treatment. The EVOS contra-angle can rotate in both rotary and reciprocation mode, depending on the motor settings. Last, the Endo-Eze Genius files are designed for use in endodontic treatment for shaping and cleaning the root canal system. The working part of each Genius file consists of nickel-titanium alloy, heat-treated to increase flexibility while retaining strength in order to provide superior instrumentation. The Endo-Eze Genius files were designed specifically for use with the EVOS motor and can be used in both reciprocation and rotary mode. For information, call 800-552-5512, or visit ultradent.com.

Volume 8 Number 6

Thinking ahead. Focused on life.

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

RVG 6200 SENSOR • Provides high-resolution, film-quality digital images. • CS Adapt module has 12 customizable endodontic filters for more accurate diagnoses. • Always-active sensor provides a simplified workflow: Position. Expose. View.