Endodontic Practice - Spring 2016 Vol 9 No 1 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING

EXCELLENCE

Foraminal enlargement analysis Drs. Frederico Canato Martinho, Ricardo Machado, Professor Carlos Henrique Ferrari, and Leticia Aguiar

Converting from ProTaper Universal to ProTaper Gold Dr. John West

ENDODONTICS TotalFill putty in action Drs. Kazim Mahmood, Obyda Essam, Mike Dodd, and Fadi Jarad

Apexogenesis and apexification with mineral trioxide aggregate (MTA): a report of two cases Dr. Jorge Alberdi

Management of a tooth with a large internal resorption defect Dr. Robert Slosberg

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

Practice profile

Dr. Charles J. Goodis

We just have one question for you. See page 52.

Spring 2016 – Vol 9 No 1

We will never be “good enough.” average. adequate. Good enough. for too long, standard root canal treatment has left bacteria, biofilm and smear layer behind. and for too long, treatment failure has been considered unfortunate, but unavoidable. that’s why sonendo has developed breakthrough Multisonic Ultracleaning™ technology, giving you the power to deliver a level of cleaning that’s anything but “good enough.”

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1 sigurdsson a et al. (2016) J clin Exp Dent. © 2016 sonendo, inc. all rights reserved. sonEnDo, the sonEnDo logo, GEntlEWaVE, the GEntlEWaVE logo, MUltisonic UltraclEaninG, and soUnD sciEncE are trademarks of sonendo, inc. MM-0167 rev 01

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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 CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

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“Talkin’ ’bout regeneration”

he English rock band, The Who, helped shape rock ‘n’ roll with their song, “My Generation” and, as a result of the historical artistic and significant value, was inducted in the Grammy Hall of Fame. In similar fashion, I think that in the near future, we will see historical and significant value in delivering true pulpal regeneration. True pulpal regeneration is closer to reality than you may think, and not just for immature teeth with open apices. To achieve regeneration, there needs to be a biologic scaffold, numerous growth factors, and stem cells. Fortunately, these necessary elements are all contained within the blood, the cells of the apical papilla, and Dr. Randy W. Garland the dentinal tubules. If we can take advantage of the body’s natural mechanisms for healing, we can revitalize teeth. Research has shown that the blood contains mesenchymal stem cells (MSCs), many of the needed growth factors, and the physical structure (scaffold) required for reconstruction of the pulp. There are also stem cells in the periapical tissue called stem cells of the apical papilla (SCAPs) that, like the MSCs, can differentiate into pulpal tissue. Many growth factors are trapped within the dentinal tubules during tooth development. These growth factors are released when the dentin is damaged by decay and play a major role in pulp repair and regeneration. These are also released when the dentin is demineralized with EDTA. We have restorative materials such as MTA and bioceramic that promote regeneration and repair coronally. One stumbling block that researchers are running into is how to effectively clean the root canal system without damaging or destroying any of these cells or growth factors. If the cells entering through the apex encounter any bacteria or debris, they send signals that initiate an inflammatory response. This results in “repair” instead of “regeneration.” In the repair process, the body produces blood vessels, bone, and connective tissue. In regeneration, vital pulp tissue and odontoblasts are produced, restoring normal function. While repair is acceptable and preferred over gutta percha, restoring pulp tissue is ideal. An “ultraclean” environment is necessary in order to initiate the regeneration process; one that is free of biofilm, tissue remnants, or bacteria. That is the key to success in regenerative endodontics. Many different techniques have been tried with limited success. The current recommended protocol involves multiple appointments using triple-antibiotic pastes (TAP) as an intra-appointment medication. This technique can damage the stem cells, and it is nearly impossible to remove the TAP completely. The result is usually an inflammatory response and “repair,” as is evident in most of the research and case studies. A new and exciting technology called the GentleWave® System has been developed that shows great potential for the level of cleaning and disinfection needed for regeneration. Sound waves with multiple frequencies are initiated at the tip of the GentleWave™ Treatment Instrument. These sound waves reverberate throughout the entire root canal system, breaking apart tissue and even biofilm from all the canals, ramifications, isthmi, even well into the dentinal tubules. This, combined with fluid dynamics and continuous refreshment of treatment fluids, leaves the root canal system so ultraclean that the environment may be ideal for the regeneration process to occur. This appears to be the missing link in the regeneration chain and can often be done without even instrumenting the canals. I’m excited that our future may involve not only saving more teeth, but also revitalizing them. Then we can focus our specialized knowledge and skills on regrowing nerves instead of removing them. There’s a lot of new technology being revealed on the AAE floor this year. I hope to see you there.

$129 $319

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

Volume 9 Number 1

Dr. Randy W. Garland received his dental degree from University of Southern California (USC) in 1988 and completed his endodontic residency at Loma Linda University in 1997. He maintains a full-time private practice in Encinitas, California, and has lectured locally on the use of CBCT and the GentleWave System. Dr. Garland has published articles in Endodontic Practice US and Journal of Endodontics (JOE) and is a consultant for Sonendo®, Inc. He is an avid surfer and enjoys tennis, snowboarding, and singing in the rock band, “Novocaine.”

Endodontic practice 1

INTRODUCTION

Spring 2016 - Volume 9 Number 1

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TABLE OF CONTENTS

Financial focus Cash balance plans Tony Robbins and Tom Zgainer discuss an option to accelerate retirement savings and lower tax liability.........................................12

Practice profile Charles J. Goodis, DDS

An endodontic practice with “Edge”

Case study Management of a tooth with a large internal resorption defect Dr. Robert Slosberg’s patient returns to the office for her 18-month follow-up appointment.................................... 18

Educator profile William Leibow, DDS, MSD The fine art of endodontics.............. 24

Clinical 13 Apexogenesis and apexification with mineral trioxide aggregate (MTA): a report of two cases Dr. Jorge Alberdi discusses why MTA was his choice for treatments in these cases ON THE COVER Cover image courtesy of Advanced Endodontics, Santa Barbara, California. See article by Dr. John West on page 46.

4 Endodontic practice

Volume 9 Number 1

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TABLE OF CONTENTS

Continuing education Foraminal enlargement analysis Drs. Frederico Canato Martinho, Ricardo Machado, Professor Carlos Henrique Ferrari, and Leticia Aguiar analyze the benefits and risks of intentional foraminal enlargement, considering the impact both locally and systemically...............................34

Continuing education TotalFill® putty in action

Drs. Kazim Mahmood, Obyda Essam, Mike Dodd, and Fadi Jarad present case studies that demonstrate the use of a new bioceramic material

AAE preview................... 39 Focus on files Safe-ended hand files: What, when, how, why Dr. Rich Mounce discusses the benefits of safe-ended files..............44

Endodontic insight

Endospective

Converting from ProTaper Universal to ProTaper Gold: “Why, how, and is it for me?”

Written “must haves” for the modern endodontic practice

Dr. John West delves into an advance in NiTi technology............................ 46

Dr. Rich Mounce emphasizes the importance of operational documents ....................................................... 54

Small talk Materials & equipment......................... 51 Practice integrity, part II: selling the experience

Technology Is your practice good enough?

Dr. Joel Small discusses the value of viewing the practice through the eyes of the patient...................................56

Sonendo® discusses a system for disinfection and cleaning with minimal instrumentation................................ 52

6 Endodontic practice

Volume 9 Number 1

The Only Thing We Meddled With Is the Metal. Efficient. Flexible. Brilliant.

All the ProTaper® efficiency, now with advanced metallurgy for greater flexibility and resistance to cyclic fatigue. ProTaper Gold® – because performance is golden.

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PRACTICE PROFILE

Charles J. Goodis, DDS An endodontic practice with “Edge”

Dr. Charles Goodis, endodontist and founder of EdgeEndo

What can you tell us about your background? I was born and raised in Detroit, Michigan, and went to the University of Michigan for Mechanical Engineering and Dental School. I did the Indian Health Service for 2 years and GPR at the University of Minnesota. I completed my endodontic residency at the University of Connecticut. My endodontic practice is in Albuquerque, New Mexico. I started EdgeEndo to allow endodontists and dentists to use the best Endodontic NiTi rotary files at half the price to save them $10k, $20k, $30k, or more per year because I know how expensive NiTi rotary files can be. If this amount is invested over 20 years, it could be worth over $2 million — yes, $2 million or more!

When did you become a specialist, and why did you decide to focus on endodontics? It’s what I did best in Dental School. 8 Endodontic practice

Advanced Endodontics lobby Volume 9 Number 1

PRACTICE PROFILE

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

Do your patients come through referrals? Yes.

How long have you been practicing endodontics, and what systems do you use? I have been practicing for 20 years, and I use my EdgeEndo system.

Who has inspired you?

I have been inspired by Drs. John McSpadden, Ben Johnson, Stephen Buchanan, Cliff Ruddle, and George Goodis.

EdgeEndo customer service team

What is the most satisfying aspect of your practice?

It is very satisfying to treat patients with extreme patience, kindness, and understanding.

Professionally, what are you most proud of? Creating EdgeEndo for my profession.

What do you think is unique about your practice? Besides treating patients, I own EdgeEndo, an endodontic rotary file company and design the products that save endodontists $10,000 to $30,000 per year.

EdgeEndo operations team

Top 10 favorites 1. Wife 2. Kids 3. Dogs 4. Cats 5. Running 6. Lifting 7. Eating right 8. Eating wrong 9. Emotionally growing 10. Being more grateful for everything EdgeEndo pack and ship fulfillment team Volume 9 Number 1

Endodontic practice 9

PRACTICE PROFILE

Dental Assistant processing x-rays and prepping a patient

Friendly smiles add to a positive experience for patients

Advanced Endodontics office interior

Large glass doors in each operatory reveal views of outdoor waterfalls that make the procedures relaxing for patients

What has been your biggest challenge? Boy, this is going to sound like something off of an inspirational calendar, but it’s true! There are no challenges, only opportunities to grow. When things get to feel like a challenge, flip the script to it being an opportunity.

What would you have been if you had not become a dentist? I would have used my Mechanical Engineering background in the aerospace industry.

Advanced Endodontics operatory

What is the future of endodontics and dentistry?

What are your top tips for maintaining a successful specialty practice? Do you have advice for budding endodontists?

The future is amazing as long as we watch our expenses; hence, my inspiration for EdgeEndo.

Treat patients with extreme patience, kindness, and understanding. Also visit all the dentists’ offices in your area every 2

10 Endodontic practice

months, talk to the front office staff, and bring candy.

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

I hang out with the family and run the dogs in the mountains. EP Volume 9 Number 1

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FINANCIAL FOCUS

Cash balance plans Tony Robbins and Tom Zgainer discuss an option to accelerate retirement savings and lower tax liability

ach year around this time, we can all see the inevitable not too far in the distance. Our tax liability — and how we manage it — is generally not as festive as the recently past holiday season. However, your retirement planning and the type of plan you establish can offer a reduction of tax liability and accelerated contributions to help produce additional income when you’ll need it most — at retirement after active work. There are two general types of pension plans — defined-benefit plans and definedcontribution plans. In general, defined-benefit plans provide a specific benefit at retirement for each eligible employee, while definedcontribution plans specify the amount of contributions to be made by the employer toward an employee’s retirement account. In a defined-contribution plan, the actual amount of retirement benefits provided to employees depends on the amount of their contributions, along with employer contributions such as Safe Harbor or profit-sharing contributions, as well as the gains or losses of the account over time. Many of our dentist clients take advantage of this combination by “maxing” out the total allowable contributions, currently $53,000 if under age 50 or $59,000 if over age 50, while giving a needed ratio of contributions to eligible staff as well. However, we often are asked, “What else can I do aside from after tax investing? What other types of retirement plans are available?” Enter the cash balance plan, a type of defined-benefit plan that when paired with a 401k/profit-sharing plan provides an opportunity to essentially squeeze 20 years of saving into 10, while at the same time significantly reducing your tax liability along the way. As the chart accompanying this article shows, the benefits of the cash balance plan really start to accelerate as the business owner gets beyond age 45-50. While employer matching and profitsharing contributions are discretionary, cash

Peak performance strategist Tony Robbins and Tom Zgainer, founder and CEO of America’s Best 401k, offer advice on growing retirement savings.

12 Endodontic practice

2016 Contribution Limits 401(k) PROFIT-SHARING AND CASH BALANCE PLANS Age

401(k) with Profit Sharing*

Cash Balance

Total

Tax Savings**

$59,000

$237,000+

$296,000+

$133,200

$59,000

$237,000

$296,000

$133,200

$59,000

$243,000

$302,000

$135,900

$59,000

$248,000

$307,000

$138,150

$59,000

$254,000

$313,000

$140,850 $135,000

Above 65

$59,000

$241,000

$300,000

$59,000

$228,000

$287,000

$129,150

$59,000

$216,000

$275,000

$123,750

$59,000

$205,000

$264,000

$118,800

$59,000

$194,000

$253,000

$113,850

$59,000

$184,000

$243,000

$109,350

$59,000

$175,000

$234,000

$105,300

$59,000

$165,000

$224,000

$100,800

$59,000

$157,000

$216,000

$97,200

$59,000

$149,000

$208,000

$93,600

$59,000

$141,000

$200,000

$90,000

$59,000

$133,000

$192,000

$86,400

$53,000

$126,000

$179,000

$80,550

$53,000

$120,000

$173,000

$77,850

$53,000

$114,000

$167,000

$75,150

$53,000

$108,000

$161,000

$72,450

$53,000

$102,000

$155,000

$69,750

$53,000

$97,000

$150,000

$67,500

$53,000

$92,000

$145,000

$65,250

$53,000

$87,000

$140,000

$63,000

$53,000

$82,000

$135,000

$60,750

$53,000

$78,000

$131,000

$58,950

$53,000

$74,000

$127,000

$57,150

$53,000

$70,000

$123,000

$55,350

$53,000

$66,000

$119,000

$53,550

$53,000

$63,000

$116,000

$52,200

35 Under 35

$53,000

$59,000

$53,000

Up to $56,000

*401(k): $18,000; $6,000 catch-up; $35,000 profit sharing

balance plans require more of a commitment to fund the plan by the employer. Most plans are set up with a 3-5 year funding period, so they work well in environments where the business owner will have predictable income over that time frame. Different from a 401k plan where participants generally choose their investment options, the assets of a cash balance plan are managed by the employer or an investment manager. In a typical cash balance plan, a participant’s account is credited each year with a “pay credit” (such as 5% of

$112,000 Up to $109,000

$50,400 Up to $49,050

** Assuming 45% tax, varies by state. Taxes are deferred

AMERICA’S BEST 401k

compensation from the employer) and an “interest credit” (either a fixed rate or a variable rate that is linked to an index such as the 1-year Treasury Bill rate). To determine if a cash balance plan is right for you, enlist an actuary who is an expert in retirement plan design to analyze your practice demographics with a current census of full-time employees. If this plan design can meet your individual and corporate objectives, you have a far greater pool of income available when the time comes to hang up the white coat. EP Volume 9 Number 1

Dr. Jorge Alberdi discusses why MTA was his choice for treatments in these cases Abstract Multiple techniques and materials have been described for apexogenesis and apexification in immature permanent teeth. Two cases in which mineral trioxide aggregate (MTA) has been used as the material are described herein. In the first case, vital pulp capping was achieved in the left second mandibular premolar with vital pulp and a deep carious lesion. Dental pulp vitality was conserved, and apexogenesis treatment was successful. The second case had a right maxillary lateral incisor with necrotic pulp and an immature root. An MTA apical plug was the treatment choice. Treatment was successful in both cases, as evidenced on clinical and radiographic assessments and no observed complications during follow-up visits. Clinical aspects of apexogenesis and apexification and considerations about MTA have also been discussed.

Introduction Dental trauma and caries are the most frequent challenges of the developing tooth. Maintenance of pulp vitality in immature permanent teeth allows for complete physiological root development.1 Accurate diagnosis through clinical and radiographic evaluations will suggest proper treatment for the affected tooth. Radiographic evaluation is essential to determine the maturity of the developing root, and clinical evaluation is essential to determine the history of the pathology and pulp vitality.2 When pulp vitality is maintained, apexogenesis is the suggested treatment to promote natural root development.

Depending on the extent of inflammation, pulp capping, shallow pulpotomy, or conventional pulpotomy may be suggested.1,2 Pulp capping was the treatment method in case 1 presented in this report. There are longterm prognostic advantages of this treatment outcome over the apexification procedure. MTA has become the new material of choice for pulp capping.4 These advantages include the fact that tooth structure formed has a greater structural integrity, as the tooth is more resistant to vertical fracture.3,5 If pulpal necrosis occurs in immature teeth, an alternative approach must be used because of the presence of an open apex. Young, pulpless teeth often have thin and fragile walls, which make adequate cleaning and apical sealing difficult and increases the potential for root fracture.2-3,5 Apexification is defined as “a method of inducing a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in teeth with necrotic pulp.”2 In these cases, the apical filling material used may induce the formation of a hard tissue barrier, but root length is not improved.6,7 However, this paradigm has been challenged by recent reports showing that immature teeth clinically diagnosed with necrotic pulp can undergo apexogenesis. That means the continuation of root development, which leads to normal root length, apical closure, and a greater structural

integrity. In these cases of necrotic pulp, the procedure is described as regenerative endodontic treatment or revascularization.8,9 In 1999, Torabinejad and Chivian described multiple clinical applications of MTA, including capping of pulps in reversible pulpitis and apexification by means of an apical plug in immature roots with a necrotic pulp.10 MTA is a powder that consists of fine hydrophilic particles that harden in the presence of moisture. Hydration of the powder results in a colloidal gel with a pH of 12.5 that solidifies into a hard structure. The setting time for the cement is around 4 hours. MTA has been recognized as a bioactive material that induces and supports tissue mineralization, is a good sealant, and is biocompatible. In addition, MTA is insoluble in tissue fluids, dimensionally stable, and has an adequate radiopacity.10-15 It has been suggested that biocompatibility and sealing ability of MTA originate from the physicochemical reactions between MTA and dentin.11 The study of the physicochemical interaction between MTA and root canal walls revealed that MTA appeared to bond chemically to dentin via a diffusion-controlled reaction between its apatitic surface and dentin, when it is placed against dentin walls.16 Investigation of the bond strength between MTA and dentin will reveal the value of adhesion between them.17

Jorge Alberdi, DDS, is a specialist in endodontics with a private practice at Las Rosas, Santa Fe, Argentina. He is a visiting professor at Universidad del Salvador/Asociación Odontológica Argentina (U.S.A.L./A.O.A.), Buenos Aires, Argentina, and co-director at Postgraduate Endodontic Course at Círculo Odontológico de Rosario (COR), Rosario, Santa Fe, Argentina. Dr. Alberdi is a member of the Institute Troiano Odontología, dedicated to Endodontics and Restorative Post-endodontics, Rosario, Santa Fe, Argentina. Disclaimer: The author denies any conflicts of interest.

Volume 9 Number 1

Figures 1A-1B: 1A. Preoperative radiograph showing carious lesion and the immature root. 1B. Postoperative radiograph after pulp capping with MTA Endodontic practice 13

CLINICAL

Apexogenesis and apexification with mineral trioxide aggregate (MTA): a report of two cases

CLINICAL

Figures 2A-2C: Follow-up radiographs. 2A. 5 months. 2B. 1 year 3 months. 2C. 1 year 9 months after the procedure

Previously described features make MTA the optimal material for both apexogenesis and apexification. Historically, calcium hydroxide (CaOH) has been the preferred material for apexogenesis and apexification.14 Both therapies require longterm follow-up with clinical and radiographic evaluations to confirm treatment success.

Case report 1: apexogenesis The patient is a 10-year-old boy with a 6-month history of caries and pain in the left second mandibular premolar (tooth No. 20). The patient complained of sensitivity to cold beverages and pain during mastication; he did not report spontaneous pain. Clinical examination showed deep crown caries and minimal pulpal exposure. The tooth was not sensitive on the percussion test. Radiographic examination showed a carious lesion in contact with pulp chamber cavity and a short immature root (Figure 1A). The patient’s medical history was contributory. Under local anesthesia with 2% lidocaine/1:50,000 epinephrine (Indican, Sidus, Argentina) and rubber dam isolation, caries was removed using a round No. 7 carbide bur (SS White®), with rapid and copious water sprays to prevent heat damage to the subjacent pulp. The cleaned dentin area was irrigated with 2.5% sodium hypochlorite, with saline solution used on last irrigation. Hemostasis was achieved by gentle placement of a sterile cotton pellet moistened with saline solution over the pulp exposure. Following the manufacturer’s instructions, ProRoot® MTA (Dentsply Maillefer, Ballaigues, Switzerland) powder and liquid were mixed to achieve adequate consistency. An approximately 1-mm thick layer of MTA was placed over the exposed pulp exposure using a small resin spatula and was gently compressed with a dry cotton pellet. Then the tooth was permanently filled with Vitremer™ (3M ESPE) (Figure 1B), a glass ionomer. At 1-week follow-up, the tooth was functional and nonsymptomatic, with no 14 Endodontic practice

Figure 3: Recall 2 years 5 months — the root was completely developed, and vital pulp was maintained

evident clinical signs. Natural development of root was observed, and formation of a calcified bridge beneath MTA cement was observed on radiographs obtained at followup sessions in 5 months (Figure 2A), 1 year 3 months (Figure 2B), and 1 year 9 months after the procedure (Figure 2C). At a followup visit after 2 years 5 months, the root was completely developed, and vital pulp was maintained (Figure 3).

Case report 2: apexification The patient was a 9-year-old girl with a noncontributory medical history. Two months prior, she had swelling and pain in the right maxillary lateral incisor (tooth No. 7). She was on amoxicillin 500 mg, recently prescribed by her referring dentist. There was no current evidence of swelling or tooth mobility upon presentation. However, a draining sinus tract was seen in the mucolabial fold near the apex. Thermal and electric pulp tests

confirmed that tooth No. 7 was nonvital, whereas all adjacent teeth contained vital pulps. The radiograph revealed that tooth No. 7 had an incompletely formed root with an immature apex, surrounded by a periradicular rarefaction (Figure 4A). With her mother’s concurrence, apexification root canal therapy with CaOH was performed. The access cavity was prepared, and the canal was lightly shaped with manual K-files (Dentsply Maillefer, Ballaigues, Switzerland) because of the thickness of the walls. Before shaping, a tentative root canal length was determined using an electronic apical locator and radiographs. It was difficult to determine the precise root canal length because of the opening of the apex. Irrigation was performed using 2.5% sodium hypochlorite (NaOCl) and sterile saline solution. Once chemomechanical preparation was finished, the root canal was dried with sterile paper points and dressed with CaOH paste (Farmadental, Volume 9 Number 1

Volume 9 Number 1

CLINICAL

Argentina). A sterile, dried-cotton pellet was placed into the access cavity and filled using glass ionomer Vitremer (3M ESPE). The sinus tract was resolved 4 days after the start of treatment, and the patient was instructed to discontinue amoxicillin. Attempts to schedule treatments at 2-month intervals were unsuccessful because of the patient’s parent’s noncooperation. On the 7th month reexamination after the first visit, her mother expressed the inability to continue further treatment because the family had moved to another city, and it was impossible for them to transport the patient to the dental office to continue the treatment. Hence, canal filling with an apical MTA plug and subsequent clinical and radiographic follow-ups were recommended, to which the patient’s mother agreed. After removal of the restorations, a tentative root canal length was determined again using an electronic apical locator and radiographs. The root canal was shaped and cleaned using hand files and 2.5% sodium hypochlorite, and dried with sterile paper points. Then a thick mixture of ProRoot MTA (Dentsply Maillefer, Ballaigues, Switzerland) was prepared and applied to the apical portion of the canal using a Messing syringe, calibrated to 2 mm less than the working length, to introduce the MTA in the apical portion. The MTA was condensed vertically with Machtou pluggers (Dentsply Maillefer, Ballaigues, Switzerland) No. 2 and No. 3 and the rear end of sterilized paper points. During this procedure, radiographs were obtained to evaluate the conformation of the MTA plug and its placement in relation to the apical extent of the root structure (Figures 5A-5B). The thickness of the MTA was approximately 3 mm to 4 mm at the apical portion of the root. A moist cotton pellet was placed in the canal, and the access cavity was closed with a temporary restoration material, Cavit™ G (3M ESPE) for 4 hours. The patient returned to the dental office 4 hours later, and Cavit G and the moist cotton pellet were removed. The rest of the canal was filled with flow gutta percha dispensed by Calamus® Dual (Dentsply Maillefer, Ballaigues, Switzerland). The access cavity was sealed with Vitremer (3M ESPE) for final restoration (Figure 6). The tooth has been asymptomatic since the final obturation of the root canal. Radiographs obtained at follow-up visits both after 5 years (Figure 7A) and 7 years 5 months (Figure 7B) demonstrated the regeneration of periradicular tissue and revealed a hard tissue apical barrier around the MTA plug.

Figures 4A-4B: 4A. Preoperative radiograph; 4B. During CaOH treatment

Figures 5A-5B: Radiograph series during the conformation of the MTA plug

Discussion In case 1, apexogenesis with MTA was confirmed at the follow-up visit after 2 years 5 months. No evidence of periapical pathology was noted during the follow-up period. The main difficulty in treating permanent immature teeth is the ability to predictably diagnose the state of dental pulpal health and, consequently, the ability to predict its healing. The contemporary tests available to the clinician make it difficult to accurately predict the degree of pulpal degeneration before starting treatment. However, the clinician’s skill in assessing pulpal tissue health is of importance. Currently, to control pulpal hemorrhage, NaOCl between 2.5% and 5.5% is the best choice. 1,2-4 Vital pulp capping with MTA in apexogenesis has superior long-term sealing ability and stimulates formation of a higher quality and greater amount of reparative dentin.2,4,10

Figure 6: Postoperative radiograph showing the MTA plug, full canal filled, and access cavity restoration Endodontic practice 15

CLINICAL Acknowledgments The author thanks Prof. Dr. Fernando Goldberg, Buenos Aires, Argentina, and Dra. Arminia Baroffi, Rosario, Argentina, for providing valuable advice during his endodontic career.

REFERENCES 1. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives – permanent teeth. J Endod. 2008;34(7 Suppl): S25-S28. 2. Shabahang S. Treatment options: apexogenesis and apexification. J Endod. 2013;39(3 Suppl):S26-S29. 3. Karapinar-Kazandag M, Basrani B, Tom-Kun Yamagishi V, Azarpazhooh A, Friedman S2. Fracture resistance of simulated immature tooth roots reinforced with MTA or restorative materials. Dent Traumatol. 2015;doi: 10.1111/ edt.12230. [Epub ahead of print]. 4. Boksman L, and Friedman M. MTA: the new material of choice for pulp capping. Endodontic Practice US. 2014;7(2):20-25. 5. Nosrat A, Asgary S. Apexogenesis treatment with a new endodontic cement: a case report. J Endod. 2010;36(5):912-914.

Figures 7A-7B: Radiographs obtained at follow-up visits after 5 years (Figure 7A) and 7 years 5 months (Figure 7B) revealing treatment success

The calcified bridge formed by MTA is continuous and has no evidence of tunnel defects, similar to that formed by CaOH. The presence of tunnel defects or the formation of a permeable dentin bridge does not allow a hermetic seal to the underlying pulp. These defects can serve as pathways for bacterial leakage, which deteriorates dental pulp health and can lead to further endodontic treatment necessary due to possible infection or inflammation of the pulpal tissue due to incomplete sealing.5,18 In addition, pulpal inflammation occurs more frequently in dental pulps capped with CaOH compared to those capped with MTA.4,10-12,18 MTA has demonstrated the ability to induce hard tissue formation in pulpal tissues when used as either a direct pulp capping or a pulpotomy material.4,10,19 Histologic evaluation in animal and human studies has revealed that MTA stimulates reparative dentin development, with thick dentinal bridging, negligible inflammation, and minimal hyperemia. MTA also appears to induce the formation of a dentin bridge at a faster rate than CaOH.1,13,21 In case 2, apexogenesis with MTA was confirmed at 5 years after the placement of the MTA apical plug, as the patient declined preceding follow-up visits. Nonclinical and clinical studies have reported good results with a variety of techniques. The most significant reason for long-term CaOH therapy failure is inadequate time for completion and patient disregard toward follow-up visits. This relates to the time needed for CaOH to work to close the immature apical of the tooth requiring multiple visits over a sometimes long period of time. The average length of time for apical barrier formation with CaOH is approximately 16 Endodontic practice

between 3 and 24 months.2-14-22-23 Another major disadvantage of the apexification with CaOH is the effect of long-term application of CaOH on the structural integrity of the root dentin. Several studies have demonstrated that with longer exposures of dentin to CaOH, its ability to resist fracture is significantly decreased. In addition to this tissue structure alteration, thin dentin at the cervical region is another causative factor of root fracture at the cervical third of the root. 5,7,11 Particularly regarding apexification, the disadvantages of traditional, long-term, multiple-visit-requiring CaOH therapy include variability in treatment time, unpredictability of formation of apical barrier, difficulty in following up with patients, and delayed treatment.2,11-14 Overall, the results of several studies show that MTA plugs are effective in treating immature permanent teeth with necrotic pulps.19-21 The advantages of apexification with an MTA plug are reduced treatment time — one-visit apexification — and a more predictable barrier formation. The limitation, similar to that of CaOH therapy, is that placement of an apical plug does not account for continued root development along the entire root length.10-14,20,24 Complete root development requires a viable pulp containing cells that can differentiate into dentin-producing odontoblasts. Ongoing studies are aiming at identifying procedures and materials that allow pulp regeneration.3,8,9

Conclusions Successful treatment as described in this report suggests that MTA may be a better choice for apexification and apexogenesis treatments. EP

6. Hayashi M, Shimizu A, Ebisu S. MTA for obturation of mandibular central incisors with open apices: case report. J Endod. 2004;30(2):120-122. 7. Sarris, S, Tahmassebi JF, Duggal, MS, Cross IA. A clinical evaluation of mineral trioxide aggregate for root-end closure of non-vital immature permanent incisors in children-a pilot study. Dent Traumatol. 2008; 24(1):79-85. 8. Nosrat A, Seifi A, Asgary S. Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: a review and report of two cases with a new biomaterial. J Endod. 2011;37(4): 562-567. 9. Wang Y, Zhu X, Zhang C. Pulp revascularization on permanent teeth with open apices in a middle-aged patient. J Endod. 2015;41(9):1571-1575. 10. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod. 1999;25(3):197-205. 11. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review-part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27. 12. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review-part II: leakage and biocompatibility investigations. J Endod. 2010;36(2):190-202. 13. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review-part III: clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413. 14. Bakland LK Andreasen JO. Will mineral trioxide aggregate replace calcium hydroxide in treating pulpal and periodontal healing complications subsequent to dental trauma? A review. Dent Traumatol. 2012;28(1):25–32. 15. Bogen G, Kuttler S. Mineral trioxide aggregate obturation: a review and case series. J Endod. 2009;35(6):777-790. 16. Sarkar NK1, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod. 2005; 31(2):97-100. 17. Shokouhinejad N, Nekoofar MH, Iravani A, Kharrazifard MJ, Dummer PM. Effect of acidic environment on the pushout bond strength of mineral trioxide aggregate. J Endod. 2010;36(5):871–874. 18. Asgary S, Eghbal MJ, Parirokh M, Ghanavati F, Rahimi H. A comparative study of histologic response to different pulp capping materials and a novel endodontic cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(4):609–614. 19. Moore A, Howley MF, O’Connell AC. Treatment of open apex teeth using two types of white mineral trioxide aggregate after initial dressing with calcium hydroxide in children. Dent Traumatol. 2011;27(3):166–173. 20. Selden HS. Apexification: an interesting case. J Endod. 2002; 28(1): 44-45. 21. Cho SY, Seo DG, Lee SJ, Lee J, Lee SJ, Jung IY. Prognostic factors for clinical outcomes according to time after direct pulp capping. J Endod. 2013; 39(3): 327-331. 22. Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: a review. Br Dent J. 1997;183(7):241-6. 23. Walia T, Chawla HS, Gauba K. Management of wide open apices in non-vital permanent teeth with Ca(OH)2 paste. J Clin Pediatr Dent. 2000;25(1): 51-6. 24. Mente J, Hage N, Pfefferle T, Koch MJ, Dreyhaupt J, Staehle HJ, Friedman S. Mineral trioxide aggregate apical plugs in teeth with open apical foramina: a retrospective analysis of treatment outcome. J Endod. 2009;35(10):1354-1358.

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CASE STUDY

Management of a tooth with a large internal resorption defect Dr. Robert Slosberg’s patient returns to the office for her 18-month follow-up appointment Abstract A patient presented with advanced internal root resorption of tooth No. 9. The prominent location of this tooth meant the case would be a challenge from an esthetic standpoint; an implant-supported crown would have been cost-prohibitive, and veneers would have been necessary to give the patient satisfactory cosmetic results. This option required too much of a cost and time commitment from the patient. The initial treatment plan included filling the tooth with an orthodontic-grade root filling material to be followed by surgery. Visualization from a cone beam computed tomography (CBCT) scan provided accurate mapping of the defect, revealing the apical lingual perforation. Postoperatively, the CBCT scan confirmed the successful permeation of the filling material. This case could not have been treated successfully without the use of the CBCT, both pre- and postoperatively. Placing the medication to obturate the tooth was difficult, yet the CBCT scans provided guidance allowing for measurement of the progress throughout the case. Dental radiographs offer only a 2D representation of the 3D spatial relationship, while CBCT scans allow the clinician to see every angle of a case before they even begin to operate.

discovered during a routine periapical examination of tooth No. 9. Because of the prominent location, it was clear from an esthetic standpoint that it would be a challenge to replace the tooth. In fact, treatment options were heavily influenced by both esthetics and the finances of the patient. An implant-supported crown and veneers may not have given the patient a satisfactory esthetic result. Additionally, such extensive work would have required a greater financial commitment from the patient. The initial treatment plan was to fill the tooth with a conventional orthodonticgrade root filling material to be most likely followed by surgical debridement; at the time, it seemed that surgery was indeed the only option. However, as we would

discover, CBCT technology provided accurate mapping and obturation of the defect, eliminating the need for surgery, at least for now.

Figure 1: Pre-op clinical image

Figure 2: Pre-op clinical image showing labial positioning

Figure 3A: Pre-op radiograph 2-3-2014

Figure 3B: Off angle radiograph 2-3-2014

Clinical and radiographic examination The resorptive defect — the pathological process in which the tooth begins to dissolve — was initially diagnosed by radiograph; however, the CBCT scan showed the exact extent of the defect, as well as revealed an apical lingual perforation, which presented yet another challenge. • Medical history: Non-contributory • Diagnosis: Advanced internal root resorption • Immediate treatment plan: Canal obturation and filling

Introduction A healthy, asymptomatic 50-year-old female presented at my office in the spring of 2014, having been referred by her general practitioner. A resorption defect had been Robert Slosberg, DDS, an Atlanta native, received his Bachelor of Science in microbiology at the University of Georgia. He completed his dental training at the University of Tennessee. Following dental school, Dr. Slosberg continued his postdoctoral training at the University of Pennsylvania. He returned to Atlanta in 1990, founding Atlanta Endodontics in 1992. Dr. Slosberg is a specialist member of the American Association of Endodontists, the Georgia Association of Endodontists, the American Dental Association, the Georgia Dental Association, the Northern District Dental Society, and the Southern Endodontic study group. He has also worked with Zoo Atlanta and the Yerkes Regional Primate Research Center at Emory University. Dr. Slosberg has even performed a root canal on his beloved golden retriever, Madison.

18 Endodontic practice

Volume 9 Number 1

CASE STUDY

Figure 4: Pre-op sagittal slice

Figure 5: Pre-op axial slices

Figure 7: Measuring the defect

Figure 10: Ca(OH)2 PA

Figure 13: Clinical access enlargement

Figure 8: Initial access

Figure 9: Working length determination

Figure 11: Ca(OH)2 sagittal slice

Figure 14: Clinical image extension of access opening to facilitate obturation

Treatment A coronal access opening was made, and the tooth was packed with calcium hydroxide. This proved challenging as controlling placement of the calcium hydroxide was particularly difficult. A temporary filling Volume 9 Number 1

Figure 6: Pre-op coronal slice

Figure 12: Clinical image temporization

Figure 15: Clinical image obturation with bioceramic putty

was then placed, and the medication was changed over the course of 2 to 3 months. CBCT scans were taken postoperatively to determine where the medication was and where it wasn’t. On the advice of a colleague, the access opening was extended toward

Figure 16: EndoSequence BC RRM Putty

the lingual to facilitate the vertical condensation of the root filling material — in this case, Brasseler bioceramic mineral trioxide aggregate (MTA) cement. On top of the EndoSequence® BC RRM™ (Root Repair Material) and EndoSequence® BC Sealer™, Endodontic practice 19

CASE STUDY

Figure 17: Post-op radiograph 4-16-2014

Figure 21: Post-op coronal slice

Figure 18: Post-op axial slices

Figure 19: Post-op axial slice

Figure 22: Post-op clinical image composite restoration

Figure 23: Post-op clinical image

Figure 20: Post-op sagittal slice

Figure 24: Measuring the depth of the composite resin

a composite resin core buildup of exactly 10 mm deep was placed.

Results CBCT scans allowed for accurate mapping of the defect, and they were the only way to assess the effective permeation of the bioceramic putty.

Discussion Due to the many challenges this case presented, the mapping of the defect was shared among endodontic professionals — trusted colleagues, local study clubs, and endodontic online forums. The majority of the dental professionals recommended extraction and an implant-supported crown. Esthetics and finances directed this individualized treatment plan. Filling the tooth — even if it were maintained for up to 5 years — would allow the patient time to save enough money for an implant-supported crown. For ideal esthetics with an implantsupported crown, at least one or more veneers would most likely be necessary; therefore, a steep financial and time commitment would be required from the patient. Surgery was always an option, depending on the outcome of endodontic therapy. This case could not have been treated successfully without the use of CBCT scans. In fact, the patient was referred specifically to our practice because we are known for our use of CBCT technology. CBCT gives us additional information that conventional 2D radiographs cannot. In this case, it 20 Endodontic practice

Figure 25: 4-30-2014 re-evaluatiion

Figure 26: 4-30-2014 re-evaluatiion

facilitated both accurate mapping and obturation of the resportive defect. The scans can answer important questions such as “Can the defect be reached?” Once completed, CBCT answers, “How adequately was the tooth sealed?” In this particular case, CBCT scans were crucial in confirming the placement of the calcium hydroxide and the bioceramic resin. Placing the medication was a challenge, and CBCT scans measured the progress throughout the case. A CBCT scan can also be a professional’s worst critic. The scan will reveal, “You didn’t get the calcium, medication, or filling material here.” In conclusion, it was a CBCT scan that confirmed the successful condensation of the bioceramic putty used to seal the tooth, and surgery was avoided, at least, in the short term. The patient is asymptomatic and is due for a recall. In the modern endodontic office, CBCT is a powerful new tool to aid in the diagnosis and treatment of diseases involving the teeth and supporting structures. Dental radiographs

can only offer a 2D representation of the 3D spatial relationship. However, today’s specialists can understand that spatial relationship better with the advent of CBCT. Following a detailed clinical evaluation, including radiographs, it may be necessary to gain more information — information that only CBCT scans can provide. CBCT technology provides a complete visual image covering the axial, coronal, and sagittal planes. Additionally, the 3D rendering is also an excellent tool for patient education and can lead to increased case acceptance. The advent of CBCT and its subsequent introduction into the endodontic specialty have been a paradigm shift. The more scans I have reviewed, the more I realize just how important a 3D scan can be to comprehensive diagnosis; at this point, CBCT scans are taken for most of my endodontic cases, as they can solve the mysteries that are left uncovered by 2D radiography. Returning to the case at hand: “If it were your patient, what would you recommend? Volume 9 Number 1

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CASE STUDY Even more importantly, if it were your tooth, how would you want it treated?”

Lessons learned • Extending the access opening lingually was not ideal, though it was necessary to adequately condense the bioceramic putty. • In hindsight, the tooth could have been strengthened had a fiber post been placed along with composite resin. • Recent technological advancements in Endodontics have made treatment options possible, that were not available just a few years ago.

18-month recall At an 18-month recall appointment, the patient has remained asymptomatic. Clinically, probing depths were WNL, and the tooth has remained esthetically pleasing. On the new cone beam, the periapical area, as well as the lateral aspect of the sealed defect, is suggestive of periapical healing. No new defects were noted internally. The patient was dismissed and placed on a 1-year recall. A closer look at the CBCT scan, however, is suggestive of a resorptive defect on the buccal surface, approximately 11 mm from the incisal edge. What would you do next?

Figure 27: Follow-up radiograph

Figure 28: Follow-up radiograph

Figure 29: Microscope follow-up image

Figure 30: Follow-up image

Figure 31: Follow-up axial slices

Figure 32: Follow-up coronal slice

Figure 33: Follow-up sagittal measurement

Figure 34: Follow-up axial slices

Figure 35: Sagittal resorption defect

Figure 36: Axial resorption defect

22 Endodontic practice

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EDUCATOR PROFILE

William Leibow, DDS, MSD The fine art of endodontics

What can you tell us about your background? I graduated from Indiana University Dental School in 1974 and then Boston University of Graduate Dentistry under the guidance of Dr. Herbert Schilder in 1976 with a master’s degree in endodontics. I moved to Phoenix, Arizona, in 1976 and started private practice. I was the fifth-trained endodontist to start a practice in the state of Arizona. I practiced full-time and began teaching as needed in 2003 at the Arizona School of Dentistry and Oral Health (ASDOH) in Mesa, Arizona. When the clinic opened in 2005, I closed my practice and went to work for Roda and Sluyk Endodontics 2 days a week and taught in the clinic at ASDOH 3 days a week as co-director of endodontics, instructing students in the predoctoral endo clinic. In 2010, when one of my predoctoral students finished his residency in endodontics, I left the practice and became a full-time instructor at ASDOH, where I continue to teach today. I am responsible for all the preclinical didactic education, and my co-director, Gene Jasper, and four other endodontists oversee all the clinical endodontic treatment.

ASDOH Clinic entrance

What originally attracted you to the specialty of endodontics? I was attracted to endodontics because of control. I realized in dental school that you could do great work, and then the patient went home and a spouse or visiting relative would say, “Your teeth look ugly,” and it was back to the drawing board trying to please. Lab work was fun, but after talking to many dentists and as a student, I realized that labs could make mistakes, and work then needed to be redone. Dealing with esthetics and labs took away control. In endodontics, most patients expect the worst event of their dental experience. “There’s nothing worse than a root canal,” or “the last root canal I had was horrible.” So if the patient does have problems, then you live up to their expectations. However, most of the time, the procedure and postoperative discomfort is uneventful, and then you exceed their expectations. I have never had a patient come 24 Endodontic practice

Dr. Leibow teaching a case with a student and helping negotiate a difficult canal

back to the office saying my Aunt Mary was visiting, and she thinks my root canal doesn’t look good. If you do a good job of diagnosing and treatment, you will win most of the time. I am also very focused, and endodontics fits that portion of my personality.

What aspects of your training inspired you to add “educator” to your list of accomplishments? Initially, I did not have a desire to become an educator. After being in practice for several years, I came to the realization that I wanted to give back. The opportunity came when Dr. Dillenberg, the Dean of ASDOH, contacted

me about the new school and asked me to teach endodontics at the school. At first I said no, but after discussing the opportunity with the Dean and my wife, I agreed. Teaching would be a wonderful way to pass on my knowledge and a positive way to end a wonderful career. And so far, it has been a rewarding and great experience.

Who has inspired you as a clinician and an educator? My mentor, Dr. Herbert Schilder, was a great inspiration in my becoming a teacher. He was a phenomenal person who instilled in his students the drive to be the best and Volume 9 Number 1

EDUCATOR PROFILE

Top 10 favorites 1. 2. 3. 4. 5. 6.

My wife My standard poodles, George and Gracie My Corvette My life Arizona School of Dentistry and Oral Health DENTSPLY Tulsa Dental Specialties for all they do 7. Vortex Blue® files 8. Brasseler USA® EndoSequence® for pulp capping and root repair 9. Photography 10. Design For Vision loupes

to give back when the opportunity presented itself. In his last days, I met with him at his home in Boston; the smile and look on his face when I told him I was going to pass along his wisdom was a moment I will never forget. He was truly an inspiring individual.

What are your proudest moments in the clinical and teaching aspects of your life? I am most proud of the accomplishments of the students from ASDOH. They perform well in regional board exams in the area of endodontics and continue to share with me cases they have completed. The students are comfortable in calling or emailing me with questions and asking for advice after graduation. The fact that they trust me and know that I am there for them is very rewarding and satisfying. I am most happy when I hear that one of the students gets accepted into a residency program in endodontics. For the most part, dealing with these young clinicians keeps me connected and up-todate. Learning never ceases. The students have taught me not to be judgmental, to be patient, and not jump to conclusions as rapidly as I use to. 26 Endodontic practice

Far left: Simulation Lab doing a demonstration D2 class. Middle: Checking access in the Simulation Lab. Right: George and Gracie

What has been your biggest challenge in sharing information and educating endodontists?

Since I am not educating endodontists, but soon-to-be general dentists, the challenge is to make them understand what cases they should do, and when is it appropriate to refer. I explain to them over the years that one of the most difficult situations is when the young dentist who is trying to grow a practice treats a complex case, has problems, and ultimately, makes a referral to a specialist after several visits. As an endodontist, I would see that patient, fix the problem, and finish the case in one, or maybe two, visits. The patient would then ask why the general dentist didn’t refer them right away. Then they do not want to go back to that practice and ask for the name of another dentist. Rarely could I talk them out of it.

What would you have become if you had not become a dentist? I have no idea what I would have done if I hadn’t become a dentist. I just knew I needed to probably work for myself and have some control. Besides dentistry, I have a fine art photography business and sell art to dental practices for their offices and participate in some art fairs along with my wife who is an oil painter.

What are your top tips for maintaining a successful practice? To maintain a successful practice is all about relationships with both referring doctors and patients. When a patient trusts you, you can accomplish a great deal. Call patients in the evening to see how they are doing, and let them know you care. Don’t sell dentistry; let the patients decide. I never told a patient, if they asked, what I would do if I was the patient in the chair; I just advised them of all the possibilities and problems and let them decide. If I wouldn’t do it to myself, then I would never even offer that procedure as a possibility to the patient. When I took dentists out to lunch or met with them socially, I tried not to talk about just dentistry, and what I could do for them; I would try to get to know them better and build a relationship.

What are a few of your “tried-andtrue” materials and/or equipment? There are many different endodontic systems available today. My job is to pick a system and teach it to the students, make them proficient, and give them a good foundation to expand upon. As systems improve, we may over the course of a few years change instrumentation, but this proves to be costly if we have a large supply of files on hand. We recently began using Vortex Blue® (DENTSPLY Tulsa Dental Specialties) Rotary Files and are having great success. We have classes and lab sessions utilizing carrier-based obturation, Volume 9 Number 1

The students have taught me not to be judgmental, to be patient, and not jump to conclusions ...

so the students are familiar with the right and wrong way to utilize this technique. In our clinic, we use warm vertical condensation. The challenge is to stay current and be conscious of budget constraints. Also, in the fourth year after students fulfill their endo obligations to graduate, we will introduce them to WaveOne® reciprocation technology, if the opportunity arises. When I started teaching at ASDOH, DENTSPLY stepped up to the plate. They provided many educational opportunities and connections for me to start the program. We use Vortex Blue as our file system and AH Plus® ribbon as a sealer. This has increased the proficiency of the case for students, and they enjoy working with it. Although we have MTA and use it for some repair procedures, we also use EndoSequence® pulp capping and apex putty (Brasseler USA®) for its easeof-use and predictability. DENTSPLY has gone the extra mile for providing help and educational materials to make our program successful. The ProMark® Endodontic Motor is great. It allows both reciprocation and conventional rotary instrumentation. EP

EDUCATOR PROFILE

Learning never ceases.

Working in Simulation lab Volume 9 Number 1

Endodontic practice 27

CONTINUING EDUCATION

TotalFill® putty in action Drs. Kazim Mahmood, Obyda Essam, Mike Dodd, and Fadi Jarad present case studies that demonstrate the use of a new bioceramic material

ecent advances in endodontics have seen an increase in the use of bioceramic materials. Since its advent, there have been a series of sealers, pastes, and putties produced as an alternative to zinc oxide eugenol, calcium hydroxide, and resin-based systems.

Aims The aim of this case series is to demonstrate the use of a new bioceramic material (TotalFill® putty, Schottlander) to aid endodontic treatment. This will involve a review of nine cases treated using this material, including a mixture of open apices, resorption defects, and retrograde endodontic cases that were completed by a DCT and two endodontic postgraduate students from the restorative department at Liverpool Dental Hospital.

Educational aims and objectives

This clinical article aims to demonstrate the use of a new bioceramic material (TotalFill® putty, Schottlander) to aid endodontic treatment.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize how to use this bioceramic material in a case with open apices. • See how this material works with resorption defects. • Realize how this material can be used in retrograde endodontic cases. • Identify the composition of TotalFill putty and requirements for use. • Recognize the advantages and disadvantages of using this bioceramic material.

Case 1: open apex apical plug obturation UR1 A 32-year-old female patient presented with chronic periapical periodontitis affecting her non-vital immature UR1. Preoperative radiographs confirmed the presence of an open apex and a periapical radiolucency (Figure 1A). A TotalFill plug of 4 mm was provided followed by GP backfill and a definitive composite restoration (Figures 1B and 1C). There was 1 mm extrusion of the apical plug (Figure 1D).

Figure 1A: Case 1 – UR1 preoperative

Figure 1B: Case 1 – UR1 MAP

Figure 1C: Case 1 – UR1 plug

Case 2: internal root resorption defect UR2 A 16-year-old female patient attended with chronic periapical periodontitis affecting her UR2 with evidence of internal root resorption affecting the apical third of

Kazim Mahmood, BDS (Hons), MFDS (Glasgow), is a GKT graduate currently doing dental core training years 2/3 in restorative dentistry at Birmingham Dental Hospital. Prior to this, he completed his Dental Foundation (DF) training in Lancashire and a Dental Core Training (DCT) general duties post in Liverpool University Dental Hospital. Dr. Obyda Essam qualified from Newcastle University in 2010 with a Bachelor of Dental Surgery (BDS) and gained Membership of the Joint Dental Faculty at the Royal College of Surgeons (MJDF RCS Eng) in 2012. He is currently a lecturer and an honorary specialty registrar in endodontics at Liverpool University Dental Hospital. Dr. Mike Dodd was appointed clinical lecturer in restorative dentistry at Liverpool University Dental Hospital in 2013 and specialty registrar in endodontics in 2014. He divides his time between teaching undergraduates, undertaking clinical dentistry, and pursuing his research interests. Dr. Fadi Jarad is a senior lecturer and honorary consultant in restorative dentistry at the University of Liverpool. He is the director of professional doctorate in dental sciences (DDSc) postgraduate program. He is also the lead for the DDSc endodontic pathway and a joint teaching lead for restorative dentistry (BDS program).

Figure 1D: Case 1 – UR1 postoperative 28 Endodontic practice

Volume 9 Number 1

Figure 2B: Case 2 – UR2 working length

Figure 2C: Case 2 – UR2 plug

Figure 2D: Case 2 – UR2 postoperative

Figure 3A: Case 3 – UL1 preoperative

Figure 3B: Case 3 – UL1 working length

Figure 3C: Case 3 – UL1 plug

the root canal (Figure 2A). The initial treatment strategy involved obturating the canal conventionally with gutta percha (Figure 2B). This was deemed unsuccessful at follow-up, and a decision was made to provide a TotalFill putty apical plug to obturate the resorptive defect with a backfill of gutta percha (Figure 2C). A good quality obturation with minimal extrusion was achieved (Figure 2D).

Case 3: failed RCT and post crown UL1

A male patient attended with chronic periapical periodontitis, affecting his root canal treated and post crowned UL1 (Figure 3A). A decision was made to attempt to remove the post/crown and provide a re-root canal treatment. The master apical file exceeded 60K, and a TotalFill putty plug followed by a backfill GP obturation was provided (Figures 3B and 3C). The plug was well condensed with no extrusion.

Case 4: apicectomy LR1 and LL1 A 35-year-old male attended with chronic periapical periodontitis, affecting his LR1 and LL1 associated with failed root canal treatment (Figure 4A). In light of the good quality endodontic treatment already provided, it was decided to provide surgical endodontic treatment with a retrograde TotalFill putty plug on both teeth. The postoperative radiograph confirms the presence of a well-sealed 2 mm apical plug in both canals (Figure 4B).

Case 5: open apex apical plug obturation UR1 A 24-year-old male patient presented with chronic periapical periodontitis affecting Volume 9 Number 1

Figure 4A: Case 4 – preoperative

Figure 4B: Case 4 – postoperative Endodontic practice 29

CONTINUING EDUCATION

Figure 2A: Case 2 – UR2 preoperative

CONTINUING EDUCATION

Figure 5A: Case 5 – UR1 preoperative

Figure 5B: Case 5 – UR1 working length

Figure 5C: Case 5 – UR1 plug

Figure 5D: Case 5 – postoperative

Figure 6A: Case 6 – UR1 preoperative

Figure 6B: Case 6 – UR1 working length

Figure 6C: Case 6 – UR1 plug

Figure 6D: Case 6 – UL1 postoperative

his non-vital immature UR1. Clinically, the master apical file was 80K at a working length of 20.5 mm. A TotalFill plug of 5 mm was provided, and the remainder of the canal was backfilled with gutta percha (Figure 5C). Unfortunately there was 2 mm extrusion of the apical plug with no postoperative complications (Figure 5D). No symptoms were reported postoperatively.

Case 6: open apex apical plug obturation UL1 A 13-year-old female patient presented with chronic periapical periodontitis, affecting her non-vital immature UL1 (Figure 6A). A TotalFill plug of 5 mm was provided under microscopic guidance, and the remainder of the canal was filled with injectable gutta percha (Figures 6B and 6C). A coronal seal was provided with Vitrebond™ (3M) and a composite restoration. There was 1 mm extrusion of the apical plug (Figure 6D).

Case 7: failed post crown and reRCT UR1 A female patient attended with chronic periapical periodontitis associated with a failed post/crown and root canal treatment 30 Endodontic practice

Figure 7A: Case 7 – UL1 preoperative

Figure 7B: Case 7 – UR1 postoperative

of the UR1 (Figure 7A). A decision was made to attempt to remove the post crown and perform re-root canal treatment via an orthograde approach. The canal was obturated using TotalFill sealer and thermoplastic gutta

percha. The tooth was subsequently restored with a fiber post and replacement crown. The obturation of the root canal system is of a good standard terminating within 1 mm of the radiographic apex (Figure 7B). Volume 9 Number 1

Figure 8B: Case 8 – CBCT sagittal

Figure 8D: Case 8 – UR2 MAP

Figure 8C: Case 8 – CBCT axial

Figure 8E: Case 8 – UL2 mid-fill

Figure 8F: Case 8 – UL2 postoperative

Figure 9A: Case 9 – UR2 preoperative

Figure 9B: Case 9 – UR2 postoperative

Case 8: internal root resorption defect UL2 An 18-year-old male patient attended with chronic periapical periodontitis, affecting his UL2, which was also suffering from internal resorption in the mid third (Figure 8A). CBCT investigation revealed the extent and position of the lesion (Figures 8B and 8C). Further management involved the provision of root canal treatment with gutta percha obturation with TotalFill sealer used to obturate the resorptive defect (Figures 8D and 8E). The radiographic result confirmed a well-obturated root canal system/defect (Figure 8F).

Case 9: perforation repair UR2 A 26-year-old male patient attended with chronic periapical periodontitis, affecting his UR2, which also had evidence of a root perforation in the coronal third of the canal on the Volume 9 Number 1

Endodontic practice 31

CONTINUING EDUCATION

Figure 8A: Case 8 – UR2 preoperative

CONTINUING EDUCATION

Table 1: The percentage cell viability after application of TotalFill compared to MTA and AH+

mesial aspect (Figure 9A). Further management involved use of TotalFill putty to seal the perforation with subsequent obturation with gutta percha. Radiographs confirmed presence of a well-obturated canal and defect sealed with TotalFill putty (Figure 9B).

Biocompatibility

The cases treated show evidence that TotalFill is a valuable alternative to existing materials with a wide range of clinical indications and excellent radiographic and clinical

Table 1 shows the percentage cell viability after application of TotalFill compared to MTA and AH+, highlighting the excellent biocompatibility of the material whereby after 3 days, there was 100% cell viability.

results evident through its use.

Results and discussion TotalFill putty consists of calcium silicates, zirconium oxide, tantalum peroxide, calcium phosphate monobasic, and fillers. It is provided in a pre-loaded jar, pre-mixed, and can be directly applied. It sets upon exposure to moisture, is insoluble, radiopaque, and does not shrink on setting. The working time is up to 30 minutes. Setting time is a minimum of 2 hours, although it can take longer in extremely dry canals. There is no requirement to add liquid as sufficient moisture is provided by the apical tissues and dentinal tubules. Its consistency is such that it permits manipulation and placement with hand instruments without the need for a carrier unlike conventional MTA materials. There are several advantages to this material. It has excellent handling characteristics and a shorter setting time than MTA. Its consistency is very much like temporary material Cavit® in that it adheres well to hand instruments and is very easy to pack. Its biocompatibility is similar to that of MTA (AlAnezi, et al., 2010) and, when set, produces a highly crystalline structure 32 Endodontic practice

that enhances fibroblast adhesion and subsequent biomineralization (Jhingzhi, et al., 2011). Furthermore, during setting, the material produces a pH of 12, creating a highly alkaline and antibacterial environment further facilitating complete disinfection of the root canal system, and the sealer variant of TotalFill has been shown to have less microleakage than resin-based systems such as AH Plus® (Parwar, et al., 2014). Additionally, the omission of heavy metal oxides found in MTA eliminates the risk of tooth discoloration postoperatively. The main drawbacks are the cost and perhaps the increased risk of apical

extrusion in open apices cases. In this case series, there was more evidence of extrusion compared with MTA. The material does require less force to compact into an effective apical barrier, and perhaps due to its different handling capabilities coupled with limited operator experience, it makes it more likely to be extruded.

Conclusion The cases treated show evidence that TotalFill is a valuable alternative to existing materials with a wide range of clinical indications and excellent radiographic and clinical results evident through its use. EP

REFERENCES 1. Alanezi AZ, Jiang J, Safavi KE, Spangberg LS, Zhu Q. Cytotoxicity evaluation of EndoSequence root repair material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(3):e122-5. 2. Ma J, Shen Y, Stojicic S, Haapasalo M. Biocompatibility of two novel root repair materials. J Endod. 2011;37(6):793-798. 3. Parwar S, Pujar MA, Makandar SD. Evaluation of the apical sealing ability of bioceramic sealer, AH plus & Epiphany: An in vitro study. J Conserv Dent. 2014;17(6): 579-582. 4. TotalFill premixed bioceramic endodontic materials {Brochure]. La Chaux-de-Fonds, Switzerland: FKG Swiss Endo; Savannah, Georgia: Brasseler USA Dental; 2013.

Volume 9 Number 1

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TotalFill速 putty in action MAHMOOD, ET AL.

1. TotalFill putty consists of ________, calcium phosphate monobasic, and fillers. a. calcium silicates b. zirconium oxide c. tantalum peroxide d. all of the above 2. The working time (of TotalFill putty) is up to __________. a. 30 minutes b. 60 minutes c. 90 minutes d. 2 hours 3. Setting time of (TotalFill putty) is ____, although it can take longer in extremely dry canals. a. a minimum of 30 minutes b. a minimum of 1 hour c. a minimum of 2 hours d. a minimum of 4 hours 4. There is no requirement to add liquid as sufficient moisture is provided by _________. a. the apical tissues b. dentinal tubules c. calcium phosphate d. both a and b

Volume 9 Number 1

5. Its consistency is such that it permits manipulation and placement with ________ without the need for a carrier unlike conventional MTA materials. a. a syringe b. hand instruments c. rotary instrumentation d. forceful compaction 6. It (TotalFill putty) has excellent handling characteristics and a _____ setting time than MTA. a. shorter b. longer c. more consistent d. more defined 7. Its biocompatibility is similar to that of MTA, and when set, produces a ________ that enhances fibroblast adhesion and subsequent biomineralization. a. highly crystalline structure b. radiolucent material c. eugenol-like substance d. liquid 8. Furthermore, during setting, the material produces a pH of ________, creating a highly

alkaline and antibacterial environment further facilitating the complete disinfection of the root canal system, and the sealer variant of TotalFill has been shown to have less microleakage than resin-based systems such as AH Plus. a. 2 b. 4 c. 6 d. 12 9. The main drawbacks are the cost and perhaps the increased risk of ___________ in open apices cases. a. infection b. apical extrusion c. tooth discoloration d. cell inviability 10. The material does require ________ to compact into an effective apical barrier, and perhaps due to its different handling capabilities coupled with limited operator experience, it makes it more likely to be extruded. a. more force b. more liquid c. less force d. rotary instrumentation

Endodontic practice 33

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Foraminal enlargement analysis Drs. Frederico Canato Martinho, Ricardo Machado, Professor Carlos Henrique Ferrari, and Leticia Aguiar analyze the benefits and risks of intentional foraminal enlargement, considering the impact both locally and systemically

n recent years, endodontics has seen a considerable paradigm shift as a result of technical and scientific developments. However, the concept of shaping and cleaning (Schilder, 1974) remains one of the pillars of the specialty especially when dealing with infected canals. Historically, the literature has demonstrated how anatomical complexities make it so difficult to adequately shape and clean the root canal system, especially the apical one-third (Paqué, et al., 2009; Paqué, et al., 2010). Furthermore, in some cases, endodontic infection extends beyond the limits of the apical constriction, for example, to the apical foramen or beyond (extraradical biofilm) (Noiri, et al., 2002; Chavez De Paz, 2007; Ricucci, Siqueira Jr, 2010). In these situations, intentional foraminal enlargement may be performed to decrease the microbial load to levels more favorable for repair (Borlina, et al., 2010). Previous studies have shown encouraging results for intentional foraminal enlargement, enabling more efficient mechanical action of instruments and the chemical action of irrigating solutions (de Souza Filho, et al., 1987). Therefore, the purpose of this paper was to perform a critical literature review by analyzing the likely benefits and risks of intentional foraminal enlargement, considering the impact both locally and systemically.

Local effects Anatomical considerations Undeniably, pulp necrosis and periradicular lesions are an indication that the entire length of the root canal is contaminated (Ricucci, Siqueira Jr 2010, Tronstad, et al., 1990; Nair, et al., 2005, Siqueira, Rôças 2008). For this reason, the literature

Educational aims and objectives

This clinical article aims to make a critical analysis, based on the literature, to assess the advantages and disadvantages and the local and systemic risks related to the intentional enlargement of the apical foramen.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize that there is no scientific evidence to support intentional foramen enlargement in humans. • Recognize that the methodological design of future studies for performing this procedure should be undertaken with caution, because the literature consulted in this paper reiterates that intentional foraminal enlargement poses both local and systemic risks.

has postulated that apical patency can clear the apical foramen and promote microbiological disruption in this area, using a small caliber instrument to lightly touch the walls of the apical foramen (Buchanan, 1989; Cailleteau, Mullaney, 1997; Flanders, 2002; Souza 2006; Coutinho–Filho, et al., 2012; Mounce, 2015). However, intentional foraminal enlargement is performed with different techniques and instruments and consists of the mechanical enlargement of the apical foramen for the purpose of decontamination by excising infected dentin and cementum (Borlina, et al., 2010; Silva, et al., 2013). Accurate intentional foraminal enlargement requires the shape and diameter of the apical foramen to be accurately assessed and measured. Clinically, this would seem to be impossible (Dummer, et al., 1984; Abarca, et al., 2014). Conventional endodontic instruments are unable to perform this, because of the oval shape of the apical foramen (Goldberg, Massone, 2002; Marroquín, et al., 2004; Herrera, et al., 2011; Akisue, et al., 2014). Consequently, adequate cleaning cannot be achieved (Wu,

Carlos Henrique Ferrari, DDS, is a PhD endodontic student at São Jose dos Campos Dental School, State University of São Paulo – UNESP, São Jose dos Campos, São Paulo, Brazil. Frederico Canato Martinho, DDS, MSc, PhD, is a professor of endodontics at São Jose dos Campos Dental School, State University of São Paulo – UNESP, São Jose dos Campos, São Paulo, Brazil. Ricardo Machado, DDS, MSc, PhD, is a professor of multidisciplinary clinic I and II and supervised stage in multidisciplinary clinic I (endodontics), Paranaense University – UNIPAR, Francisco Beltrão, Paraná, Brazil. Leticia Aguiar is a graduate student from Paranaense University – UNIPAR, Francisco Beltrão, Paraná, Brazil.

34 Endodontic practice

et al., 2000; Marroquín, et al., 2004; Abarca, et al., 2014). Several clinical studies have shown a high frequency of instrument fracture in the apical third when anatomically complex and narrow canals are present (Ehrhardt, et al., 2012; Madarati, et al., 2013). Moreover, especially when dealing with posterior teeth, the apical foramen may be located laterally to the anatomical apex (Pineda, Kuttler, 1972), and intentional foraminal enlargement may predispose to weakening of the tooth with a higher incidence of fracture. Another factor limiting foraminal enlargement is the clinician’s inability to achieve apical potency of the apical foramen in some situations. This may occur because of abrupt curvatures, the existence of two or more main apical foramina, apical deltas, or complete or incomplete isthmuses (Meder– Cowherd, et al., 2011; Verma, Love, 2011; Villas–Bôas, et al., 2011). Considering all the facts and appreciating that foraminal enlargement is a plausible idea from a microbiological standpoint, it cannot always be performed. In controlled clinical studies with robust samples and appropriate inclusion and exclusion criteria (Imura, et al., 2007; Ricucci, et al., 2011; Liang, et al., 2013), there have been no reports of intentional foraminal enlargement in the clinical protocols adopted. Nonetheless, the success rates of these studies are high even in cases of pulp necrosis with radiographically visible periradicular disease (Imura, et al., 2007; Ricucci, et al., 2011; Liang, et al., 2013). Volume 9 Number 1

Volume 9 Number 1

cements (Strindberg, 1956; Engstrom, 1964; Yusuf, 1982; Nair, et al., 1990; Sjögren, et al., 1990; Orstavik, Hörsted–Bindslev, 1993). It is important to consider the hypothesis that the greater the enlargement of the apical foramen, the greater the possibility of extrusion of any substance used in the root canal (Hülsmann, Hahn, 2000). Nevertheless, more research is required to confirm this hypothesis.

Systemic effects Patients who are taking or have taken bisphosphonates recently Bisphosphonates are drugs used to treat bone diseases and prevent tumor metastasis (Moinzadeh, et al., 2013). Their extensive use is directly related to osteonecrosis of the jaw after performing dental procedures (Katz, 2005; Sarathy, et al., 2005; Edwards, et al., 2008; Moinzadeh, et al., 2013). Since these drugs are widely used today, dentists should be knowledgeable about some likely effects that can influence the prognosis of the treatment. Specifically related to endodontics, some important precautions should be borne in mind: • Antiseptics, such as chlorhexidine, must be used to reduce the bacterial load of the oral cavity (Cousido, et al., 2010) and the risk of bacteremia, due to possible injury to soft tissues during the course of treatment (Moinzadeh, et al., 2013) • Anesthetics with vasoconstrictors should be avoided because the vasculature is compromised, constituting a greater risk for osteonecrosis, as bisphosphonates exert an antiangiogenic effect (Tarassoff, Csermak, 2003; Soltau, et al., 2008; Moinzadeh, et al., 2013). • Special care must be taken to reduce damage to the gingival tissue (Kyrgidis, Vahtsevanos, 2009; Moinzadeh, et al., 2013) • Filling techniques must be prioritized to pose the lowest risk of overfilling and overextension (Liang, et al., 2011; Moinzadeh, et al., 2013) According to Katz (2005) and Edwards, et al., (2008), one of the main precautions in relation to patients who are making use or have recently made use of this class of drug is to establish a working length near the apical constriction and to decrease the extrusion of debris and exacerbated inflammatory reactions during and after treatment. Even foraminal patency should be avoided (Moinzadeh, et al., 2013) because it can considerably increase the chances of bacteremia (Debelian,

et al., 1995; Moinzadeh, et al., 2013). These statements are based on bisphosphonates interfering directly with the bone remodeling process and inhibiting the chemical mediators of the inflammatory process (Katz, 2005; Edwards, et al., 2008). When considering the need for endodontics in patients who are or have been using bisphosphonates recently, it seems obvious that intentional foraminal enlargement is a completely contraindicated procedure. Patients with coagulation disorders or using anticoagulants Homeostasis in healthy patients is associated with four main factors: • Blood vessel walls • Blood platelets • The coagulation system • The fibrinolytic system Blood vessel constriction is the first stage, followed by platelet adhesion and aggregation, and by fibrin deposition. In the next stage, the coagulation process is regulated by physiological anticoagulants. Activation of fibrinolysis is triggered by the presence of fibrin and tissue plasminogen activator-types at the site of fibrin formation, a process regulated by physiologic inhibitors such as 2-antiplasmin, histidine-rich glycoprotein, and plasminogen activator inhibitor (DeLoughery, 1999; Scully, Wolff, 2002). This process is completely different in patients with a coagulopathy or taking anticoagulants because of the risk of excessive bleeding, even from a gentle stimulus. Gingival bleeding during tooth cleaning may cause these patients to neglect their oral health, thus increasing the risk of periodontal disease and caries. For this reason, dentists should be knowledgeable about the impact of blood disorders or the use of anticoagulants in treating these patients (Johnson, Leary, 1988; Shapiro, McKown, 1990; Gupta, et al., 2007). In patients with coagulation disorders or taking anticoagulants, and needing tooth extraction, conventional endodontic treatment or retreatment should be the preferred option whenever possible. However, the shaping and cleaning process must be confined to the limits of the root canal (Chohayeb, 1981), and intentional foraminal enlargement would be completely contraindicated. Patients with a high risk of bacteremia Several systemic complications from oral infections have been reported. Some of the most common include bacterial endocarditis; myocardial infarction; cerebral abscess; bone, antral, and bloodstream Endodontic practice 35

CONTINUING EDUCATION

Extrusion of sodium hypochlorite, calcium hydroxide, and filling materials Sodium hypochlorite is the most widely accepted and used irrigant solution worldwide (Stojicic, et al., 2010; Zou, et al., 2010; Wong, et al., 2014; Guneser, et al., 2015). Nonetheless, it has a highly adverse effect after extrusion into the periradicular tissues or maxillary sinus, or when injected into the gingival mucosa (Pashley, et al., 1985; Gatot, et al., 1991; Ehrich, et al., 1993; Kavanagh, et al., 1998; Kleier, et al., 2008; de Sermeño, et al., 2009; Wang, et al., 2010; Kerbl, et al., 2012). The most common consequences of this type of accident are the following: (Hulsmann, Hahn, 2000; Serper, et al., 2004). • severe pain • instant inflammation of the affected area • swelling extended to the face, lips, and infraorbital region • hemorrhage descending from the root canal • interstitial hemorrhage with skin and mucosa bruising • secondary infection • paresthesia The use of calcium hydroxide as an interappointment dressing can have adverse consequences if it is accidentally extruded beyond the apical foramen (Fava, 1993; Marais, Van Der Vyver, 1996). Fava (1993) as well as Marais and Van der Vyver (1996) reported cases of calcium hydroxide extrusion into the maxillary sinus, causing acute pain and a foreign body reaction. Ahlgren, et al., (2003), reported a case of calcium hydroxide extrusion into the mandibular canal with acute pain and paresthesia. Other adverse consequences associated with the extrusion of calcium hydroxide are neural injury (Olsen, et al., 2014), severe periradicular inflammation requiring the extraction of the involved tooth (Hanson, Macluskey, 2013), and the persistence of periradicular lesions (Ionnidis, et al., 2010). Certain filling materials (mainly solids) are also responsible for several extrusion-related complications, such as radiographically visible foreign body reactions, flare-ups, and postoperative pain exacerbated by the activation of an inflammatory response (Oliet, 1983; Rowe, 1983; Georgopoulou, et al., 1987; Siqueira, 2003; Nair, 2004; Saleh, et al., 2004; Seltzer, Naidorf, 1985; Gluskin, 2005; Köseoglu, et al., 2006; González-Martín, et al., 2010; Faria-Júnior et al., 2013; Alves, et al., 2014). All materials extruded beyond the apical foramen are irritating to the periradicular tissues to a greater or lesser extent. There is no scientific evidence warranting the intentional extrusion of irrigating solutions, pastes, and

CONTINUING EDUCATION infections (Baumgartner, et al., 1976; McGowan, 1982; Bender, Montgomery, 1986; Debelian, et al., 1994; Murray, Saunders, 2000; Scully, et al., 2003). During endodontic treatment, the shaping and cleaning procedure has the potential to contaminate the bloodstream and the lymphatic system with bacteria (Bender, et al., 1960; Baumgartner, et al., 1976; Seymour, et al., 2000; Fouad, 2009). Blood samples collected from patients during and after endodontic treatment of teeth with pulp necrosis revealed the presence of the same bacteria in both the root canal system and the bloodstream (Heimdahl, et al., 1990; Debelian, et al., 1995; Debelian, et al., 1998; Savarrio, et al., 2005). Therefore, microorganisms from the root canal can be carried to and then settle in locations distant from their place of origin (Fouad, 2009). The extrusion of debris during shaping and cleaning of the root canal system has

frequently been shown, regardless of the systems and techniques used (Reddy, Hicks, 1998; Bürklein, Schäfer, 2012; Koçak, et al., 2013; Kirchhoff, et al., 2015). Tinaz, et al., (2005) conducted a study for the specific purpose of correlating debris extrusion and the apical limit of instrumentation. It compared the extrusion of debris during manual and rotary instrumentation in teeth that had intentionally enlarged apical constriction and apical foramen. Fifty-two teeth were divided into two groups with 26 specimens each, in accordance with the instrumentation technique used (manual instrumentation using K-files or rotary instrumentation using ProFile .04 taper series 29). The teeth were further divided into two subgroups, with intentional enlargement of the apical foramen by K-files No.15 and No. 30, 2 mm beyond the apical foramen. The irrigating solution was 2.6% sodium hypochlorite. No statistically significant differences

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Abarca J, Zaror C, Monardes H, Hermosilla V, Muñoz C, Cantin M. Morphology of the physiological apical foramen in maxillary and mandibular first molars. Int J Morphol. 2014;32(2):671-677.

20. de Sermeño RF, da Silva LA, Herrera H, Herrera H, Silva RA, Leonardo MR. Tissue damage after sodium hypochlorite extrusion during root canal treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108(1):e46-49.

Ahlgren FK, Johannessen AC, Hellem S. Displaced calcium hydroxide paste causing inferior alveolar nerve paraesthesia: report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;6(6):734-737.

21. de Souza Filho FJ, Benatti O, de Almeida OP. Influence of the enlargement of the apical foramen in periapical repair of contaminated teeth of dog. Oral Surg Oral Med Oral Pathol. 1987;64(4):480-484.

Akisue E, Gratieri SD, Barletta FB, Caldeira CL, GrazziotinSoares R, Gavini G. Not all electronic foramen locators are accurate in teeth with enlarged apical foramina: an in vitro comparison of 5 brands. J Endod. 2014;40(1): 109-112

22. Debelian GJ, Olsen I, Tronstad L. Bacteremia in conjunction with endodontic therapy. Endod Dent Traumatol. 1995;11(3):142-149.

Alves FR, Coutinho MS, Gonçalves LS. Endodontic–related facial paresthesia: systematic review. J Can Dent Assoc. 2014;80: e13.

Beer R, Baumann MA. Color atlas of dental medicine: Endodontology. New York: Thieme;1999.

Baumgartner JC, Heggers JP, Harrison JW. The incidence of bacteremias related to endodontic procedures I. Nonsurgical endodontics. J Endod. 1976;2(5):135–40.

Bender IB, Montgomery S. Nonsurgical endodontic procedures for the patient at risk for infective endocarditis and other systemic disorders. J Endod. 1986;12(9):400-407.

Bender I, Seltzer S, Yermish M. The incidence of bacteremia in endodontic manipulation: preliminary report. Oral Surg Oral Med Oral Pathol. 1960;13:353–360.

Borlina SC, de Souza V, Holland R, Murata SS, Gomes-Filho JE, Dezan Junior E, Marion JJ, Neto Ddos A. Influence of apical foramen widening and sealer on the healing of chronic periapical lesions induced in dogs’ teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(6): 932-940.

10. Brunson M, Heilborn C, Johnson DJ, Cohenca N. Effect of apical preparation size and preparation taper on irrigant volume delivered by using negative pressure irrigation system. J Endod. 2010;36(4):721–724. 11. Buchanan LS. Management of the curved root canal. J Calif Dent Assoc. 1989;17(4): 18-25, 27. 12. Bürklein S, Schäfer E. Apically extruded debris with reciprocating single-file and full-sequence rotary instrumentation systems. J Endod. 2012; 38(6):850-852. 13. Cailleteau JG, Mullaney TP. Prevalence of teaching apical patency and various instrumentation and obturation techniques in United States dental schools. J Endod. 1997;23(6): 394-396. 14. Chavez de Paz LE. Redefining the persistent infection in root canals: possible role of biofilm communities. J Endod. 2007;3(6):652-662. 15. Chohayeb A. Endodontic therapy in the hemophiliac patient. N Y State Dent J. 1981;47(6):326-327. 16. Cousido MC, Tomás Carmona I, García-Caballero L, Limeres J, Alvarez M, Diz P. In vivo substantivity of 0.12% and 0.2% chlorhexidine mouthrinses on salivary bacteria. Clin Oral Investig. 2010;14(4):397-402. 17. Coutinho-Filho TS, Gurgel-Filho ED, Souza-Filho FJ, Silva EJ. Preliminary investigation to achieve patency of MB2 canal in maxillary molars. Braz J Oral Sci. 2012;1(3): 373-376. 18. Cruz A, Vera J, Gascón G, Palafox-Sánchez CA, Amezcua O, Mercado G. Debris remaining in the apical third of root canals after chemomechanical preparation by using sodium hypochlorite and glyde: an in vivo study. J Endod. 2014;40(9):1419-1423. 19. de Melo Ribeiro MV, Silva-Sousa YT, Versiani MA, Lamira A, Steier L, Pécora JD, de Sousa-Neto MD. Comparison of the cleaning efficacy of self–adjusting file and rotary systems in the apical third of oval-shaped canals. J Endod. 2013;39(3):398-401.

36 Endodontic practice

23. Debelian GJ, Olsen I, Tronstad L. Systemic diseases caused by oral microorganisms. Endod Dent Traumatol. 1994;10(2):57-65. 24. Debelian GJ, Olsen I, Tronstad L. Anaerobic bacteremia and fungemia in patients undergoing endodontic therapy: an overview. Ann Periodontol; 1998;3(1):281-287. 25. DeLoughery TG. Hemostasis and thrombosis. 3rd ed. New York: Springer International Publishing; 1999. 26. Dummer PM, McGinn JH, Rees DG. The position and topography of the apical canal constriction and apical foramen. Int Endod J. 1984;17(4):192-198. 27. Edwards BJ, Hellstein JW, Jacobsen PL, Kaltman S, Mariotti A, Migliorati CA. Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy: an advisory statement from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2008;139(12):1674-1677. 28. Ehrhardt IC, Zuolo ML, Cunha RS, De Martin AS, Kherlakian D, Carvalho MC, Bueno CE. Assessment of the separation incidence of mtwo files used with preflaring: prospective clinical study. J Endod. 2012;38(8):1078-1081. 29. Ehrich DG, Brian JD Jr, Walker WA. Sodium hypochlorite accident: inadvertent injection into the maxillary sinus. J Endod. 1993;19(4):180-182. 30. Engstrom B. Correlation of positive culture with the prognosis for root canal treatment. Odontol Revy. 1964;15:257-270. 31. Faria-Júnior NB, Tanomaru-Filho M, Berbert FL, Guerreiro-Tanomaru JM. Antibiofilm activity, pH and solubility of endodontic sealers. Int Endod J. 2013;46(8):755-762. 32. Fava LR. Calcium hydroxide paste in the maxillary sinus: a case report. Int Endod J. 1993;26(5):306-310. 33. Flanders DH. Endodontic patency. How to get it. How to keep it. Why it is so important. NY State Dent J. 2002;68(3):30-32. 34. Fouad AF. Endodontic microbiology. Iowa: Wiley-Blackwell; 2009. 35. Gatot A, Arbelle J, Leiberman A, Yanai-Inbar I. Effects of sodium hypochlorite on soft tissues after its inadvertent injection beyond the root apex. J Endod. 1991;17(11):573-574. 36. Georgopoulou M, Sikaras S, Anastasiadis P. Pain after obturation of the root canals. Hell Stomatol Chron. 1988;32(4):249–254. 37. Gluskin A. Mishaps and serious complications in endodontic obturation. Endodontic Topics. 2005;12(1):52-70. 38. Goldberg F, Massone EJ. Patency file and apical transportation: an in vitro study. J Endod 28(7):510-511. 39. González-Martín M, Torres-Lagares D, Gutiérrez-Pérez JL, Segura-Egea JJ. Inferior alveolar nerve paresthesia after overfilling of endodontic sealer into the mandibular canal. J Endod. 2010;36(8):1419-1421. 40. Guneser MB, Arslan D, Usumez A. Tissue dissolution ability of sodium hypochlorite activated by photon-initiated photoacoustic streaming technique. J Endod. 2015;41(5):729-732. 41. Gupta A, Epstein JB, Cabay RJ. Bleeding disorders of importance in dental care and related patient management. J Can

between using manual and rotary instrumentation were found in relation to the extruded debris. However, both techniques showed a strong tendency to produce greater amounts of debris when the apical constriction and the apical foramen were intentionally enlarged. Hence, instrumentation beyond the apical foramen should be avoided in patients at high risk for bacteremia, considering the greater risk of systemic spread of microorganisms (Debelian, et al., 1995; Seymour, et al., 2000; Siqueira, Rôças, 2008; Hülsmann, Schäfer, 2009; Baumann, Beer, 2011).

Conclusion The difficulties in performing suitable shaping and cleaning of root canals, especially in the final millimeters, has been proven consistently (Paqué, et al., 2009; Paqué, et al., 2010; Haapasalo, et al., 2005; Hulsmann, et al., 2005; de Melo Ribeiro, et al., 2013; Cruz, et al., 2014). Consequently, a wider Dent Assoc.2007;73(1):77-83. 42. Haapasalo M, Endal U, Zandi H, Coil J. (2005) Eradication of endodontic infection by instrumentation and irrigation solutions. Endodontic Topics. 2005;10:77-102. 43. Hanson CJ, Macluskey M. Irreversible local sequelae of inadvertent extrusion of calcium hydroxide intra-canal medication: a case report. Oral Surgery. 2013;6(3):161-164. 44. Heimdahl A, Hall G, Hedberg M, Sandberg H, Söder PO, Tunér K, Nord CE. Detection and quantitation by lysis–filtration of bacteremia after different oral surgical procedures. J Clin Microbiol. 1990;28(10):2205-2209. 45. Herrera M, Ábalos C, Lucena C, Jiménez-Planas A, Llamas R. Critical diameter of apical foramen and of file size using the Root ZX apex locator: an in vitro study. J Endod. 2011;37(9):1306-1309. 46. Holland R, Nery MJ, de Mello W, de Souza V, Bernabé PF, Otoboni Filho JA. Root canal treatment with calcium hydroxide: II. Effect of instrumentation beyond the apices. Oral Surg Oral Med Oral Pathol. 1979;47(1):93-96. 47. Hülsmann M, Hahn W. Complications during root canal irrigation – literature review and case reports. Int Endod J. 2000;33(3):186–183. 48. Hulsmann M, Peters O, Dummer P. Mechanical preparation of root canals: shaping goals, techniques and means. Endodontic Topics. 2005;10: 30–76. 49. Hülsmann M, Schäfer E. Apical patency: fact and fiction – a myth or a must? A contribution to the discussion. Endodontic Practice Today. 2009;3(4):285–307. 50. Imura N, Pinheiro ET, Gomes BP, Zaia AA, Ferraz CC, SouzaFilho FJ. The outcome of endodontic treatment: a retrospective study of 2000 cases performed by a specialist. J Endod. 2007;3(11):1278-1282. 51. Ioannidis K, Thomaidis V, Fiska A, Lambrianidis T. Lack of periradicular healing and gradually increasing swelling two years after intentional extrusion of calcium hydroxide into periapical lesion: report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(6): e86-91. 52. Johnson WT, Leary JM. Management of dental patients with bleeding disorders: review and update. Oral Surg Oral Med Oral Pathol. 1988;6(3):297-303. 53. Katz H. Endodontic implications of bisphosphonate-associated osteonecrosis of the jaws: a report of three cases. J Endod. 2005;31(11):831-834. 54. Kavanagh C, Taylor J. Inadvertent injection of sodium hypochlorite into the maxillary sinus. Br Dent J. 1998;185(7):336-337. 55. Kerbl FM, DeVilliers P, Litaker M, Eleazer PD. Physical effects of sodium hypochlorite on bone: an ex vivo study. J Endod. 2012;38(3):357-359. 56. Kirchhoff AL, Fariniuk LF, Mello I. Apical extrusion of debris in flat-oval root canals after using different instrumentation systems. J Endod. 2015;41(2):237-241. 57. Kleier DJ, Averbach RE, Mehdipour O. The sodium hypochlorite accident: experience of diplomates of the American Board of Endodontics. J Endod. 2008;34(11):1346-1350. 58. Koçak S, Koçak MM, Sağlam BC, Türker SA, Sağsen B, Er Ö. Apical extrusion of debris using self–adjusting file, reciprocating single–file, and 2 rotary instrumentation systems. J Endod. 2013;39(10):1278-1280. 59. Köseoğlu BG, Tanrikulu S, Sübay RK, Sencer S. Anesthesia following overfilling of a root canal sealer into the mandibular canal: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(6):803-806.

Volume 9 Number 1

et al., 2010). Even considering the positive results of these studies, there is no way to infer that this procedure will have the same positive biological responses in humans. According to the precepts of scientific evidence-based dentistry, certain criteria must be respected and followed prior to any interventions in humans. First, laboratory studies should be performed to construct a plausible hypothesis to be tested in vivo. Then in vivo animal studies should be performed to observe any toxic or harmful potential of the substances, drugs, or intervention. Ultimately, longitudinal, controlled clinical studies are needed to observe the results and confirm possible advantages or disadvantages related to the previously considered hypothesis (Seymour, et al., 2003; Miller, Forrest, 2009; Kwok, et al., 2012). When it comes to the question of intentional foraminal enlargement, there is no scientific evidence to support its use. To

60. Kwok V, Caton JG, Polson AM, Hunter PG. Application of evidence-based dentistry: from research to clinical periodontal practice. Periodontol 2000. 2012;59(1):61-74.

80. Orstavik D, Hörsted-Bindslev P. A comparison of endodontic treatment results at two dental schools. Int Endod J. 1993;26(6):348-354.

61. Kyrgidis A, Vahtsevanos K. Risk factors for bisphosphonaterelated osteonecrosis of the jaws. J Oral Maxillofac Surg. 2009;67(11):2553–2554.

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

62. Liang YH, Jiang LM, Jiang L, Chen XB, Liu YY, Tian FC, Bao XD, Gao XJ, Versluis M, Wu MK, van der Sluis L. Radiographic healing after a root canal treatment performed in single-rooted teeth with and without ultrasonic activation of the irrigant: a randomized controlled trial. J Endod 2003;39(10):1218-1225. 63. Liang YH, Li G, Wesselink PR, Wu MK. Endodontic outcome predictors identified with periapical radiographs and cone-beam computed tomography scans. J Endod. 2011;37(3):326-331. 64. Madarati AA, Hunter MJ, Dummer PM. Management of intracanal separated instruments. J Endod. 2013;39(5):569-581. 65. Marais JT, van der Vyver PJ. Invasion of the maxillary sinus with calcium hydroxide. J Dent Assoc S Afr. 1996;51(5):279-281. 66. Marroquín BB, El–Sayed MA, Willershausen-Zönnchen B. Morphology of the physiological foramen: I. Maxillary and mandibular molars. J Endod. 2004;30(5):321-328. 67. McGowan DA. Endodontics and infective endocarditis. Int Endod J. 1982;5(3):127-131. 68. Meder-Cowherd L, Williamson AE, Johnson WT, Vasilescu D, Walton R, Qian F. Apical morphology of the palatal roots of maxillary molars by using micro–computed tomography. J Endod. 2011;37(8):1162-1165. 69. Miller SA, Forrest JL. Translating evidence–based decision making into practice: appraising and applying the evidence. J Evid Based Dent Pract. 2009;9(4):164-182. 70. Moinzadeh AT, Shemesh H, Neirynck NA, Aubert C, Wesselink PR. Bisphosphonates and their clinical implications in endodontic therapy. Int Endod J. 2013;46(5):391-398. 71. Mounce R. Achieving and maintaining apical patency in endodontics: optimizing canal shaping procedures. Gen Dent. 2015;63(1):14-15. 72. Murray CA, Saunders WP. Root canal treatment and general health: a review of the literature. Int Endod J. 2000;33(1):1-18. 73. Nair PN. Pathogenesis of apical periodontitis and the causes of endodontic failures. Crit Rev Oral Biol Med. 2004;15(6):348-381.

82. Paqué F, Ganahl D, Peters AO. Effects of root canal preparation on apical geometry assessed by micro-computed tomography. J Endod. 2009;35(7):1056-1059. 83. Pashley EL, Birdsong NL, Bowman K, Pashley DH. Cytotoxic effects of NaOCl on vital tissue. J Endod. 1985;11(12):525-528. 84. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol. 1972;33(1):101-110. 85. Reddy SA, Hicks ML. Apical extrusion of debris using two hand and two rotary instrumentation techniques. J Endod. 1998;24(3):180-183. 86. Ricucci D, Russo J, Rutberg M, Burleson JA, Spångberg LS. A prospective cohort study of endodontic treatments of 1,369 root canals: results after five years. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(6):825-842. 87. Ricucci D, Siqueira Jr JF. Biofilms and apical periodontitis: study of prevalence and association with clinical and histopathologic findings. J Endod. 2010;36(8):1277-1288. 88. Rowe AH. Damage to the inferior dental nerve during or following endodontic treatment. Br Dent J. 1983;155(9):306-307. 89. Saleh IM, Ruyter IE, Haapasalo M, Ørstavik D. Survival of Enterococcus faecalis in infected dentinal tubules after root canal filling with different root canal sealers in vitro. Int Endod J. 2004;37(3):193-198. 90. Sant’Anna Júnior A, Cavenago BC, Ordinola-Zapata R, De-Deus G, Bramante CM, Duarte MA. The effect of larger apical preparations in the danger zone of lower molares prepared using the Mtwo and Reciproc systems. J Endod. 2014;40(11):1855-1859. 91. Sarathy AP, Bourgeois Jr SL, Goodell GG. Bisphosphonate– associated osteonecrosis of the jaws and endodontic treatment: two case reports. J Endod. 2005;31(10):759-763. 92. Savarrio L, Mackenzie D, Riggio M, Saunders WP, Bagg J. Detection of bacteraemias during non-surgical root canal treatment. J Dent. 2005;33(4):293-303.

74. Nair PN Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after “one-visit” endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(2):231-252.

93. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2):269-296.

75. Nair PN, Sjögren U, Krey G, Sundqvist G. Therapy-resistant foreign body giant cell granuloma at the periapex of a root-filled human tooth. J Endod. 1990;16(12):589-595.

95. Scully C, Wolff A. Oral surgery in patients on anticoagulant therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(1):57-64.

76. Noiri Y, Ehara A, Kawahara T, Takemura N, Ebisu S. Participation of bacterial biofilms in refractory and chronic periapical periodontitis. J Endod. 2002;28(10):679-683.

96. Seltzer S, Naidorf IJ. Flare–ups in endodontics: I. Etiological factors. J Endod. 1985;11(11):472-478.

77. Oliet S. Single-visit endodontics: a clinical study. J Endod. 1983;9(4):147-152. 78. Olivieri JG, Stöber E, García Font M, González JA, Bragado P, Roig M, Duran-Sindreu F. In vitro comparison in a manikin model: increasing apical enlargement with K3 and K3XF rotary instruments. J Endod. 2014;40(9):1463-1467. 79. Olsen JJ, Thorn JJ, Korsgaard N, Pinholt EM. Nerve lesions following apical extrusion of non-setting calcium hydroxide: A systematic case review and report of two cases. J Craniomaxillofac Surg. 2014;42(6):757–762.

Volume 9 Number 1

94. Scully C, Ng YL, Gulabivala K. Systemic complications due to endodontic manipulations. Endodontic Topics. 2003;4:60-68.

97. Serper A, Ozbek M, Calt S. Accidental sodium hypochloriteinduced skin injury during endodontic treatment. J Endod. 2004;30(3):180-181.

date, no randomized clinical trial has been conducted with longitudinal follow-ups, evaluating the success rates of endodontic treatments or retreatments where the apical limits of instrumentation were established for the apical foramen or beyond. On the other hand, high success rates have been reported for apical limits of instrumentation established close to the apical constriction in controlled clinical studies with robust samples and appropriate inclusion and exclusion criteria (Imura, et al., 2007; Ricucci, et al., 2011; Liang, et al., 2013). From a scientific perspective, it is obvious that the impacts of intentional foraminal enlargement on the success of endodontic therapy should be evaluated. However, the methodology of these studies should be even more carefully designed, insofar as the literature reviewed in this paper reiterates that this procedure poses both local and systemic risks to the patient. EP Dent Assoc. 1990;70(1):28-31. 101. Silva EJ, Menaged K, Ajuz N, Monteiro MR, Coutinho-Filho Tde S. Postoperative pain after foraminal enlargement in anterior teeth with necrosis and apical periodontitis: a prospective and randomized clinical trial. J Endod. 2013;39(2):173-176. 102. Siqueira JF Jr. Microbial causes of endodontic flare-ups. Int Endod J. 2003;36(7):453-463. 103. Siqueira JF Jr, Rôças IN (2008) Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod. 2008;34(11):1291-1301. 104. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long–term results of endodontic treatment. J Endod. 1990;16(10):498-504. 105. Soltau J, Zirrgiebel U, Esser N, Schächtele C, Totzke F, Unger C, Merfort I, Drevs J. Antitumoral and antiangiogenic efficacy of bisphosphonates in vitro and in a murine RENCA model. Anticancer Res. 2008;28(2A):933-941. 106. Souza RA. The importance of apical patency and cleaning of the apical foramen on root canal preparation. Braz Dent J. 2006;17(1):6-9. 107. Stojicic S, Zivkovic S, Qian W, Zhang H, Haapasalo M. Tissue dissolution by sodium hypochlorite: effect of concentration, temperature, agitation, and surfactant. J Endod. 2010; 36(9):1558-1562. 108. Strindberg LZ. The dependence of the results of pulp therapy on certain factors: an analytic study based on radiographic and clinical follow-up examinations. Univeristy of Michigan: Mauritzon; 1956. 109. Tarassoff P, Csermak K. Avascular necrosis of the jaws: risk factors in metastatic cancer patients. J Oral Maxillofac Surg. 2003;61(10):1238-1239. 110. Tinaz AC, Alacam T, Uzun O, Maden M, Kayaoglu G. The effect of disruption of apical constriction on periapical extrusion. J Endod. 2005;31(7):533-535. 111. Tronstad L, Barnett F, Cervone F. Periapical bacterial plaque in teeth refractory to endodontic treatment. Endod Dent Traumatol. 1990;6(2):73-77. 112. van der Sluis LW, Shemesh H, Wu MK, Wesselink PR. An evaluation of the influence of passive ultrasonic irrigation on the seal of root canal fillings. Int Endod J. 2007;40(5):356-361. 113. Verma P, Love RM. A Micro CT study of the mesiobuccal root canal morphology of the maxillary first molar tooth. Int Endod J. 2011;44(3):210-217. 114. Villas-Bôas MH, Bernardineli N, Cavenago BC, Marciano M, Del Carpio-Perochena A, de Moraes IG, Duarte MH, Bramante CM, Ordinola-Zapata R. Micro–computed tomography study of the internal anatomy of mesial root canals of mandibular molars. J Endod. 2011;37(12):1682-1686. 115. Wang SH, Chung MP, Cheng JC, Chen CP, Shieh YS. Sodium hypochlorite accidentally extruded beyond the apical foramen. J Med Sci. 2010;0: 61-65. 116. Wong DT, Cheung GS. Extension of bactericidal effect of sodium hypochlorite into dentinal tubules. J Endod. 2014;40(6):825-829.

98. Seymour RA, Lowry R, Whitworth JM, Martin MV. Infective endocarditis, dentistry and antibiotic prophylaxis; time for a rethink? Br Dent J. 2000;189(11):610-616.

117. 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.

99. Seymour RA, Preshaw PM, Thomason JM, Ellis JS, Steele JG. Cardiovascular diseases and periodontology. J Clin Periodontol. 2003;30(4):279-292.

118. Yusuf H. The significance of the presence of foreign material periapically as a cause of failure of root treatment. Oral Surg Oral Med Oral Pathol. 1982;54(5):566-574.

100. Shapiro A, McKown C. Oral management of patients with bleeding disorders. Part 1: Medical considerations. J Indiana

119. Zou L, Shen Y, Li W, Haapasalo M. Penetration of sodium hypochlorite into dentin. J Endod. 2010;36(5):793-796.

Endodontic practice 37

CONTINUING EDUCATION

variety of techniques have been recommended to achieve more effective action from endodontic instruments (Olivieri, et al., 2014; Sant’Anna Júnior, et al., 2014) and irrigating solutions (van der Sluis, et al., 2007; Brunson, et al., 2010). There are occasions when endodontic infection extends beyond the limits of the apical constriction — i.e., to the apical foramen or even beyond (extraradicular biofilm) (Noiri, et al., 2002; Chavez De Paz, 2007; Ricucci, Siqueira Jr, 2010). In these situations, intentional foraminal enlargement is designed to reduce the microbial load in these areas to levels more favorable for repair (Borlina, et al., 2010). However, it must be pointed out that, to date, there have been only animal studies comparing the success rates between intentional foraminal enlargement and conventional instrumentation limits (close to the apical constriction) (Holland, et al., 1979; Borlina,

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Foraminal enlargement analysis FERRARI, ET AL.

1. Undeniably, _____ is/are an indication that the entire length of the root canal is contaminated. a. pulp necrosis b. periradicular lesions c. foraminal shrinkage d. both a and b 2. However, intentional foraminal enlargement is performed with different techniques and instruments and consists of the mechanical enlargement of the apical foramen for the purpose of decontamination by excising _________. a. the apical foramin b. infected dentin c. cementum d. both b and c 3. Conventional endodontic instruments are unable to perform this (accurate intentional foraminal enlargement), because of the ________ of the apical foramen. a. oval shape b. round shape c. location d. fragility 4. This may occur (the clinicianâ&#x20AC;&#x2122;s inability to achieve apical potency of the apical foramen in some

38 Endodontic practice

situations) because of ________, or complete or incomplete isthmuses. a. abrupt curvatures b. the existence of two or more main apical foramina c. apical deltas d. all of the above 5. ______ is the most widely accepted and used irrigant solution worldwide. a. Sodium hypochlorite b. Chlorhexidine c. Ethylenediaminetetraacetic acid (EDTA) d. Tetracycline 6. ______ are drugs used to treat bone diseases and prevent tumor metastasis. a. Antibiotics b. Bisphosphonates c. NSAIDs d. Calcium hydroxides 7. Their (bisphosphonates) extensive use is directly related to ___ after performing dental procedures. a. faster healing times b. better disinfection c. osteonecrosis of the jaw d. foreign body reaction

8. When considering the need for endodontics in patients who are or have been using bisphosphonates recently, it seems obvious that intentional foraminal enlargement is ________. a. a completely contraindicated procedure b. a recommended procedure c. often the treatment of choice d. the treatment with the least amount of detrimental effects 9. In patients with coagulation disorders or taking anticoagulants, and needing tooth extraction, ________ should be the preferred option whenever possible. a. conventional endodontic treatment b. retreatment c. intentional foraminal enlargement d. both a and b 10. Blood samples collected from patients during and after endodontic treatment of teeth with pulp necrosis revealed _________ in both the root canal system and the bloodstream. a. the presence of the same bacteria b. the absence of all bacteria c. antibiotic resistant d. a high sodium content

Volume 9 Number 1

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hree features are critical when it comes to endodontic 3D imaging: high-resolution images, easy-to-use software, and an intuitive interface. The ultra-compact CS 8100 3D from Carestream Dental delivers in all three of these areas, so endodontists can easily incorporate CBCT imaging into their workflow. With four selectable fields of view, ranging from 4 cm x 4 cm to 8 cm x 9 cm, the CS 8100 3D can be collimated to the region of interest — allowing doctors to comply with CBCT recommendations issued by the American Association of Endodontists (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR).

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is easily shared with referrals for improved colleague collaboration. For further convenience, CS 3D Imaging software uses an open format for compatibility with third-party software. Patient education and communication is an important component of CBCT imaging. With the CS 3D imaging software, endodontists can easily review images with patients so they are better able to understand the proposed treatment plan — resulting in improved case acceptance.

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Greater resistance to cyclic fatigue

Increased torque strength

Cyclic fatigue is the leading cause of file separation.1 Vortex Blue rotary files offer a remarkable leap forward in resistance to cyclic fatigue.2 The numbers say it all: • Minimum of 65% improvement in cyclic fatigue resistance over M-Wire NiTi.2 • Minimum of 99% improvement in cyclic fatigue resistance over standard NiTi (Maximum results up to 353% better). It’s a new standard in durability for shaping curved canals with confidence.

shape memory, while conforming to natural In rotary file design, increased cyclic curvatures. fatigue resistance usually comes with a tradeoff in torque strength. Vortex Blue rotary files are different. In addition to significantly REFERENCES greater resistance to cyclic fatigue, they offer 1. Ya Shen, Gary Shun-pan Cheung, Zbuan Bian, Bin Peng. “Comparison of Defects in ProFile and ProTaper Systems at least a 42% higher peak torque strength after Clinical Use.” Journal of Endodontics, Vol. 32, No. 1, (2006), pp. 61-65. increase over M-Wire NiTi2 (Maximum results 2. Source: Internal testing. Data on file. up to 126% better). That’s strength you can count on. It’s more than a shade better. It’s the color of optimum performance — with greater resistance to cyclic fatigue, Visit DENTSPLY Tulsa at Booth No. 401 increased torque strength, and reduced

Endodontic Practice US At Endodontic Practice US, we are dedicated to bringing our readers the most relevant information in the endodontic space. We want to spread the word — and now you can have the opportunity to read all about it — free for a year. Sign up for our weekly eNewsletter and get access to 12 months of free CE credits and a digital subscription to Endodontic Practice US.

Receive your free 1-year digital subscription at our booth If you are unable to stop by our booth, you can take advantage of this offer by visiting http://endo-us.link/aaesubscribe and entering the following code: 1YR16AAE

Visit Endodontic Practice US at Booth No. 738 40 Endodontic practice

Special Advertising Section | Volume 9 Number 1

EdgeEndo® is saving your future EdgeTaper Platinum™

Your Edge to mastering your future

The latest innovation, EdgeTaper Platinum has twice the resistance to cyclic fatigue than ProTaper® Gold and six times more than ProTaper®, more flexibility and is half the cost at $24.95/six pack. “I know you will find EdgeTaper Platinum a better file than ProTaper® Gold, used the same way, and you will save $20K-$30K per year!” — Dr. Charles Goodis

Imagine how you could elevate your practice and your life by using the world’s premier NiTi Rotary Files at half the price, saving you $20K, $30K, or more per year. By buying EdgeEndo®, you use the best files, and if you invest the money you save over 20 years, that could be worth over $2 million — yes, million dollars! That means you could retire earlier, help pay for your children’s college, or have the financial future you dreamed. Don’t let Big Endo take your dream. Visit EdgeEndo® at Booth 626, and live your dream buying EdgeEndo®! Retire earlier with EdgeEndo®. Booth 626. edgeendo.com

EdgeSequel Sapphire™ Launching at AAE 16 and just as amazing, EdgeSequel Sapphire has twice the resistance to cyclic fatigue as Vortex® Blue, 8 times Vortex® and Sequence®, and more flexibility. At $18.88/4 pack, it’s half the price. “Again, I know you will find it’s a better file than Vortex® Blue, Vortex®, and Sequence®, used the same way, and you will save $20k$30k per year!” — Dr. Charles Goodis

Visit EdgeEndo® at Booth No. 626

We’re now in the Kerr family! Everything you need to know... Why the new name? SybronEndo has always been dedicated to providing innovative products, services, training, and educational support. In fact, over the last 15 years, SybronEndo has been a proud member of the American Association of Endodontics Foundation with $325,000 in pledges. So, in 2016 and onward, this same dedication will be under a new name: Kerr Endodontics. As part of the KaVo Kerr Group, we have realigned our dental offerings to include SybronEndo as a part of the Kerr family of companies with all the products you know and love, plus more! The realignment will dramatically streamline access to the full Kerr portfolio to support your practice. Now more than ever, we can meet your needs.

Who is Kerr? For nearly 125 years, Kerr has been serving the comprehensive needs of the endodontic community in pursuit of

enhancing oral health. In addition to Kerr Endodontics and Kerr Rotary, offerings also include Kerr Restoratives and Kerr TotalCare. As part of the Kerr family, we are developing best-in-class, patient-based solutions so that in partnership with those we serve, together we’re more.™ You are at the core of everything we do. From new products to new names, we make sure you’re always kept up-to-date.

Volume 9 Number 1 | Special Advertising Section

As the year progresses, please let us know how we can help you improve the success of your practice. We look forward to seeing you in San Francisco! Hear our story and take advantage of exclusive AAE promotions.

Visit Kerr at Booth No. 417 Endodontic practice 41

AAE PREVIEW

PREVIEW

NTAT edle hnologica issors and ION hold l / l o y r a n dv er tra e de in anced in edle hold strum , Lasc ers on an AAE PREVIEW Old e h n a t l will s.** y new sciss *max imum o g r 50% i s s v c a a e disco issor t the nd n you a unt o eedl s ff any A o A r 1 E All N Lasch need . Pro e-hol al ne mo e ders edle le ho e e h o d lder o upnd f Laschalle trade AAE special o lder* r s r scis Hold in/trade t Apri sor. P romo l 9 rade m e or ne

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Visit the Laschal booth to trade in your old, worn-out Castroviejo scissors and/or needle holders and trade up to Laschal’s technologically advanced instruments. For each scissors or needle holder trade in, Laschal will give you a 50% discount on any new scissors or needle holder. Old scissors and needle holders for trade must be presented at the AAE. Promo ends April 9, 2016, at 6 p.m. *Maximum 50% discount off any 1 Laschal needle holder or scissor. No limit to the number of instruments traded. Promo based on Laschal SRP. See page 55 for more information.

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Ultradent

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Endo-Eze® EVOS™ Endodontic Motor, Endo-Eze® EVOS™ Contra-Angle,and Endo-Eze® Genius™ Files

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120 K isco A between the safety of reciprocation venu e, Suefficiency and the of rotary, thanks to ite R, PO Bo x 3(Endodontic the Endo-Eze EVOS Vari92, M ount Kiscwhich able Operating System) motor, o, NY allows for easy movement between the10549 |

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two modes. The EVOS motor is an electric, motor-driven handpiece intended for root canal preparation procedures in the endodontic field. The device consists of a control unit, featuring an LCD screen with a selection of settings. The unit includes a foot pedal, allowing clinicians to selectively activate/deactivate the motor at will. Preprogrammed 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 contraangle intended for use during endodontic 42 Endodontic practice

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 Phon e: 914 -949while retaining strength in order to 8577 | Fax: provide superior instrumentation. The 914-6 83-39 38 | W Endo-Eze Genius files were designed eb: w ww.la schaldspecifically for use with the EVOS motor ental.can be used in both reciprocation and com and rotary mode. To learn more about, or to purchase the Endo-Eze EVOS endodontic motor, the EVOS contra-angle, or the Genius files, visit booth No. 424 at the AAE treatment. The EVOS contra-angle can meeting, call 800-552-5512, or visit rotate in both rotary and reciprocation ultradent.com. mode, depending on the motor settings. The EVOS contra-angle can be used with the EVOS motor and Genius files, but is also compatible with other endodontic systems Visit Ultradent at Booth No. 424 on the market.

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Special Advertising Section | Volume 9 Number 1

Come by Booth No. 720! XDR RADIOLOGY, your complete 2D imaging solution! Featuring the Anatomic Sensor in sizes 1 and 2 — top-tier imaging without the top-tier price. XDR’s sensors help you visualize your No. 6 and No. 8 files without filter enhancement. Our sensor’s rounded and beveled corners increase patient comfort. The sensor’s distinctive white face affords you and your staff increased intraoral visibility for better radiographs each time. The sleek button on its hermetically sealed shell allows for easy cleaning; in fact, the sensor is totally immersible — XDR’s cord plugs directly into your computer. Our unique Kevlar reinforcement helps protect against typical cord damage. But if accidents happen, the cord can be replaced for much less than

the cost of a new sensor. XDR’s overnight loaners will keep your practice going. At XDR, live human beings are available to help you. Our superb and understanding technical support is a given. Our dentist-owners design our sensors with every decision based on clinical practice and science.

Every endodontist as well as every office team member matters. Every call counts. Come by Booth No. 720 for Show and New Grad Specials! Visit www.XDRradiology. com, or call 844-XDR-7000.

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Endodontic practice 43

AAE PREVIEW

PREVIEW

FOCUS ON FILES

Safe-ended hand files: What, when, how, why Dr. Rich Mounce discusses the benefits of safe-ended files

espite the widespread adoption of powered (rotary and reciprocating) nickel-titanium instruments, stainless steel hand files (SSHFs) are an indispensible part of the endodontic armamentarium. While more time consuming and prone to iatrogenic misadventure, globally, SSHFs are still the predominant means to shape canals due primarily to their economy. This article was written to describe the specific attributes provided clinically by the use of safe-ended hand files and to feature Mani safe-ended K and H files (SEC-O K and SEC-O H files, respectively). While there are other marketplace options, the author uses Mani hand files confidently, hence the products referenced are Mani. SSHFs vary by manufacturing process (ground versus twisted), design, and functional use characteristics. SSHFs vary considerably within the instrument class by design and physical characteristics. These variations include material of manufacture (nickel-titanium or stainless steel), pitch, cross section, taper, tip configuration, length, and handle design, among many characteristics. K files are the universal standard for canal negotiation, shaping, and recapitulation of root canal systems. They are generally used with a quarter turn “watch-winding” motion and vertical pull. Despite their function, K files possess limitations, primarily their lack of stiffness in negotiation of curved and calcified canals, and tip design. SSHFs are square in cross section up to a size 40. Above a size 40, their cross section is triangular. The difference is not academic. Up to a size 40, the square cross section provides greater rigidity to enhance canal negotiation. (The cross section becomes triangular above a size 40 to provide greater flexibility to offset what

Rich Mounce, DDS, is an endodontist who has lectured and written globally in the specialty of endodontics. He is a consultant for Mani Dental and receives an honorarium for his work. 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 and MounceEndo.com.

44 Endodontic practice

Figure 1A: Graphic of the standard Mani K file tip

Figure 1B: Graphic of the “safe-ended” Mani SEC-O K file tip

Figure 2A: Graphic of the standard Mani H file tip

Figure 2B: Graphic of the “safe-ended” Mani SEC-O H file tip

otherwise would be a very stiff hand file with limited clinical functionality.) Despite these cross-sectional differences, clinically, above approximately size 20, due to their stiffness, using K to prepare canals invites risk of canal transportation, especially in the apical third. In essence, K files are not stiff enough in the small sizes (6-20) and too stiff in the larger sizes (above 20). Alternatively, to shape canals rather than to negotiate them, K Flex® type files (Mani Flexile Files) are triangular in cross section in all sizes (15-40). The triangular cross section provides a more flexible hand file option where needed (relative to K files) in the smaller sizes (15-40). Modifying the tip configuration of a K or H file provides similar changes in functionality and clinical usefulness. Mani SEC-O K and H files are distinguished from standard K files due to a “safe-ended” tip. Standard K files have an “active” (cutting) tip. Specifically, the tip of a standard K file is quite sharp due to the acute transition from the tip to the fluting. An active tip results in an increased possibility of ledging and canal transportation. Due to the active cutting tip, as the file is moving around a curvature, it tends to become engaged preferentially against the outer canal wall as it rounds the curve leading to possible transportation. Alternatively, a safe-ended file has a rounded transition at the junction of the

tip and the fluting. As a result, the file tip is less likely to “dig into” the canal wall and initiate canal transportation. While using a safe-ended tip is not a guarantee to avoid transportation, it provides a relative protection without decreasing the functionality of the K or H file. In essence, the clinician is able to perform all of the same clinical actions and yet minimize the risk of transportation present using a cutting tip. As a result, one option for the clinician is to use SEC-O K (and H files) exclusively to minimize the risk of canal transportation and simplify ones armamentarium at a minimal cost increase per file. Safe-ended K files are especially valuable in avoiding transportation when using a reciprocating handpiece (NSK ER-10, MounceEndo) to power K files in the creation of the glide path (Figures 1-3).

H files H files, with either a cutting tip (Mani H files) or safe-ended hand files (Mani SEC-O H) are both used to grasp canal obstructions (often gutta percha but possibly separated files and/or carriers) and deliver them coronally through application of an upward force. Clinically, to deliver this upward force, the clinician must first bypass the obstruction with a K file (or its equivalent — possibly a “stiff” Mani D Finder). Once bypassed, the H file is inserted beyond the obstruction, and the aforementioned upward force is delivered Volume 9 Number 1

FOCUS ON FILES

Figure 3A: Mani SEC-O K Files

Figure 3B: Mani SEC-O H Files

using the engaged flutes of the H file. Notably, once the obstruction is bypassed, and the H file inserted beyond the obstruction, the H file is often tightly bound along its entire length. The possibilities for apical canal transportation with an active cutting tip are very real in this environment if using an H file. Use

Figure 4: Clinical case performed utilizing the principles and techniques discussed in the article (image courtesy of Dr. David McCarty, Colorado Springs, Colorado)

of a Mani SEC-O H file provides a relative measure of safety against apical transportation in such circumstances. This article has addressed the indications for safe-ended hand K and H files in the form of Mani SEC-O K and Mani SEC-O H files. Emphasis has been placed on the benefits of

eliminating the cutting feature of an “active” hand file tip and using a “safe-ended” tip, resulting in less canal transportation in the apical third. Reduced canal transportation is correlated with cleaner canals, less postoperative pain, and enhanced clinical outcomes. I welcome your feedback. EP

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Volume 9 Number 1

Endodontic practice 45

ENDODONTIC INSIGHT

Converting from ProTaper Universal to ProTaper Gold: “Why, how, and is it for me?” Dr. John West delves into an advance in NiTi technology Introduction The great endodontist is curious, collaborative, and courageous.1 The likely reason you are reading this article is mainly because of one of the three “c” words in my opening sentence: curious. Every endodontist and every endodontic clinician in the world wants to distinguish himself or herself; to set them apart from the rest of the pack. Characteristics of a great endodontist include having good bedside manner, understanding your job is to help grow the success of the referring dentist, and being a brilliant diagnostic and treatment plan decision-maker. The most critical distinction, however, is the quality of your technical skills. For referring restorative dentists, this is what truly matters. Clinical performance is the metric by which dentists measure the quality of your endodontic skills. This article is about the consistent quality of endodontic radicular shaping resulting in predictable and appropriate preparations for the structural root anatomy which surrounds and reflects the original canal size, shape, and contours. The great endodontist is like a great master: His/her learning is founded on curiosity. You are always a student, and you are always willing to “test” new products, technologies, and techniques against your current best skills and practices. You are always in the internal conversation: “Am I missing anything that can enhance both my standard of care and/or my level of care?” ProTaper Gold has redefined the way we shape and experience root canal system’s John West, DDS, MSD, is founder and director of the Center for Endodontics in Tacoma, Washington. He graduated from the University of Washington Dental School and received his MS degree and endodontic certificate at Boston University, where he was awarded the Alumni of the Year Award. He is an educator, a clinical visionary, and inventor with focus on interdisciplinary endodontics. He has authored several textbook chapters and is an editorial board member for Endodontic Practice US, Journal of Esthetic and Restorative Dentistry, and the Journal of Microscope Enhanced Dentistry. Dr. West is lead author of “Endodontics and Esthetic Dentistry” in Ron E. Goldstein’s 2016 Esthetics in Dentistry, 3rd edition. He can be reached at 800-900-7668, via email at johnwest@centerforendodontics.com, or visit centerforendodontics.com.

46 Endodontic practice

Figure 1: ProTaper Gold Rotary Shaping and Finishing Files: (Shapers SX, S1, S2, and Finishers F1, F2, F3). ProTaper Gold (PTG) is the simplest, most efficient, and yet most versatile rotatory system in the world. The reason is that the clinician has three different shaping choice successions depending on the canal intended to be shaped: 1) Full file series: Progress though Shapers until first Finisher that cuts radicular shape, fit cone, pack; 2) Two file series: S2 and select anticipated Finisher, confirm shape is cut by inspecting dentin in apical flutes, fit cone, pack; 3) Single file series: Select anticipated Finisher file, proceed gently though multiple Follow/Brush progressive passes until apical shape is cut, fit cone, pack

radicular preparations.2 The world’s No. 1 Rotary System has just gotten better. Advances in NiTi metallurgy technology have, indeed, revolutionized endodontic shaping files. This article will walk you through a game-changer technology that will profoundly improve your ease and efficiency of clinical canal preparation. After over 1 year of our 100% converting from ProTaper Universal (PTU) to ProTaper Gold (PTG), I can tell you neither I nor my two sons, Jason and Jordan, with whom I practice, have never looked back. And believe me; we have wanted from time to time to revert back to PTU because we have thousands of opened ProTaper Universal files that cannot be returned for Gold! Try as we might, however, we haven’t had an endodontic situation yet where it was better to substitute the old metallurgy of PTU for the new, more flexible metallurgy of PTG! This article may, at first glance, appear to be self-serving because I was one of the original ProTaper Designer Team members along with Dr. Cliff Ruddle and Professor Pierre Machtou, and we have financially benefited from the sales of the world’s No. 1 Rotary System. But this article is not about money;

it is instead about my personal journey of liberation from the previous fears and concerns of NiTi shaping. In 1995, the idea of progressive/regressive tapers on a single file was a desired geometry in the endodonticshaping world that would provide decisive and intentional progressive or sectional shaping of the radicular endodontic preparation. At the time, endodontics needed a Rotary System that gave the dentist control of the Rotary shaping versus the file being in control. Progressive tapers allow for selective shaping where fixed tapered files cut wherever the file choses, not where the clinician choses. Understanding the geometries and Directions for Use (DFU) of ProTaper Shapers versus Finishers has allowed clinicians worldwide to produce predictable, elegant, and anatomically correct shapes. Perhaps even more important than the shaped preparations, however, is that clinicians are reporting they are in control of the procedure and preparation. The ProTaper value has been sustainable and growing in spite of dozens and dozens of NiTi file systems that have come and gone over the last 15-plus years. Now copycats are pouring in, and comparisons by Volume 9 Number 1

My journey of converting from ProTaper Universal to ProTaper Gold I will now walk you through my own journey from ProTaper Universal to ProTaper Volume 9 Number 1

Gold and how you too can discover the same competency, consistency, safeness, control, and confidence I have enjoyed. The experience of my endodontic day has completely changed. I still produce the same PTU shapes, but they are safer and actually better. The shapes more precisely replicate the original root canal system flow. But the biggest difference is what I feel in my gut — patient after patient. As my son, Dr. Jordan West, first described this feeling over a year ago, “PTG has changed my experience of shaping curved, calcified canals from Fear to Fun!” Fun is the best word I can think of to describe what it is like treating one PTG endodontic patient after another. The enjoyment level has skyrocketed because I AM fearless. Looking from a different perspective, I believe the PTG feeling can be summarized in a single word: Energy. You will notice a palpable difference before, during, and at the end of your day. Instead of feeling emotionally wasted due to fear of breakage, you will be emotionally energized. Your staff and patients will notice, but most of all, the person in the mirror will be smiling back at you during and at the end of the day because you are a safe Shaping Master. How can this be true, John West?

Why convert to ProTaper Gold? The why of gold technology is simple for three reasons: 1. Improved shapes that are structurally appropriate for predictable cleaning disinfection, conefit, and obturation. 2. Safer shapes because Gold metallurgy allows files to “follow” existing canal walls and carve only the necessary dentin to replicate the shape of the Finishing file. ProTaper Universal, being somewhat stiffer, had a tendency to “plow” a shape versus to sculpt a shape. 3. Greater efficiency since less “work” or shaping has to occur. Being able to experience newfound skill and confidence in safe and predictable shaping produces a confidence, a swagger, and an ease that had not been possible until now.

Three PTU/PTG conversion patient examples Let me share three learning patients who stick in my memory. First, I vividly remember Bill (Figures 2A and 2B). Bill presented with a pulpitis in his mandibular right first molar. I took one look at Bill’s pretreatment image when I was then in my PTU era, and I could

not seem to escape my self-talk that went something like this: “I do not want to break a file!” In a real way, I dreaded the day Bill was going to return for the clean, shape, and pack visit. When he did return, I must have used a dozen or more new PTU S1’s and S2’s for fear I would break one. I had a good Glidepath and even used the Shapers manually to be safer. I usually don’t sweat, but I was sweating. I could not get away from my negative thoughts about breaking a file. When I came to the F1, I never could get up enough courage to “follow” the F1 to the S1/S2 length. If you look at the final result, you can tell that I never did use a Finishing File, and my radicular preparation is undershaped. I now fast-forward to patient Dorothy a few months ago. I was now deep into my ProTaper Gold conversion and had long forgotten Bill’s molar (Figures 2C and 2D). While Dorothy’s mandibular right first molar was similar to Bill’s, my experience was completely different from his. There was no fear or even a conversation about fear. I didn’t even think about it. The PTG performed flawlessly, F1 was easily and confidently “followed” to length, and only one PTG F1 was used. The dentin-filled apical flutes of the PTG F1 confirmed F1 shaping was finished, and the conefit validated the shaped canal was ready for flawless 3D obturation. Notice the appropriate size, shape, and flow of Dorothy’s four canal preparations. And the best thing of all, I experienced an ease and confidence in Dorothy’s treatment. I felt liberated from the fear of fracture and energized with the joy of control. There was a real sense of freedom. The third patient who was telltale for me was Rodney. As endodontists, we know one of the most challenging canal anatomies to shape is an abrupt apical turn or hook. Blocking or ledging can often result. The endodontist may be able to slip and slide to length with a small manual file, but when the Rotary files are used, everything can fall apart (Figure 2E). Notice the PTG S1 resides properly at the radiographic terminus. The Rotary PTG F1 “follows” to exactly the same PTG S1/S2 position, and the mesial conefit resides in the perfectly shaped apical cradle (Figure 2F). Oblique and perpendicular posttreatment images confirm preservation of the position of the original portal of exit (POE) — i.e., there is no apical internal or external POE transportation. And yes, no fear! These three patient examples illustrate the process of my journey from PTU to PTG. Endodontic practice 47

ENDODONTIC INSIGHT

independent studies have begun in a quest to fetter out the clinical truths. This is fertile ground for endodontic residents who are looking to write a master’s thesis. Meanwhile, I encourage all clinicians to perform head-tohead comparisons evaluating performance, quality, and predictability of the newcomers. The great endodontists know that the best education in the world is their own. For the endodontists who perform at their highest standard of care, their choice of “tools” and technique always have simple and profound metrics: Performance, quality, clinical results, and company support often trump cost. After all, if your files cost you $50 versus $25, and the treatment fee is $1,000 (plus or minus), then saving $25 is false economy. This false focus on cost of production is profoundly true if you have not done your homework to test the quality of a cheaper product. The biggest value the endodontist has to protect, nurture, and grow is his/her reputation. Dentists can look at your pretreatment and posttreatment images, and they know the difference between “Wow” and “What the heck; I could have done that myself,” or worse yet, the general dentist may even think that “I could have done better than that.” When the dentists cannot detect a difference, what value are you to them? They may as well keep the treatment in-house! How can you blame them? OK, if it is not about the money, and it is not self-serving, why should I write an article about conversion from ProTaper Universal to ProTaper Gold? The answer is simple: I want YOU to enjoy the newfound confidence that I and many others have discovered shaping canals with a forgiving yet more efficient metal. It is not good enough that my sons and I can do these things. It only matters that YOU can do these things, and I believe you can do whatever you decide to do. I have lost my fear of the catastrophic spontaneous fracture that has happened to all of us from time to time even with a perfect Glidepath, new files, a light touch, and an unhurried treatment appointment time. Though we are all capable of breaking any NiTi file, those days are over for me as well as anyone who dares to get out of the way of your ego or whatever artificial wall is stopping you from taking your safe and predictable endodontics to a new level.

ENDODONTIC INSIGHT

Figure 2: From Fear to Fun. 2A-2B. Pretreatment and posttreatment of shaped canal in my ProTaper Universal (PTU) era. Note that a PTU F1 was never “followed” to length due to my fear of file breakage. I only shaped apically with S1 and then S2. 2C-2D. Treatment result from my PTG era. PTG F1 was confidently “followed” to length in each of the four molar canals, followed by conefit, and then easy obturation. The fear of breakage and the energy used up by that fear never crossed my mind nor does it ever anymore. The PTG Finishers have clinically proven to me that they are reliable and safe. They easily and predictably crawl along smooth dentin walls with the greatest of ease. 2E. Abrupt apical distal hook of mandibular second molar followed by PTG S1. Preservation of portal of exit (POE) in a severe apical curve is one of endodontic’s biggest technical challenges. 2F. Distal conefit follows shaped F1 apical curve. 2G-2H. Oblique and perpendicular posttreatment images further validating no internal or external transportation of root canal system, including last 2 millimeters of the distal canal

The challenge is to decide to “just do it!” Once the PTU to PTG plan is implemented, for those who proceed, it is truly practice altering.

How to convert to ProTaper Gold? This part of testing the transition from PTU to PTG is easy. I will also describe the nuances of how to use the PTG Shapers versus Finishers. PTG nuances In order to demonstrate PTG versatility, I have chosen to demonstrate in a maxillary molar with a double “S” curve. The root and its canal travel both distal and buccal (Figures 3A and 3B). The clinical goal is to preserve the position of the radicular POE and can be measured by the radiographic image at conefit. Careful attention is paid to the technique for holding the electric headpiece during Shaping and Finishing. For many endodontists, this is an entirely new muscle memory. The index finger is 48 Endodontic practice

Figure 3: How to hold the Handpiece for Shaper Brushing/Following and Finisher Following/Brushing? 3A. PTG test tooth: Double “S” turn of maxillary molar DB canal. Canal makes 90 degree turn to the distal (right). 3B. Canal simultaneously turns to the buccal in another 90 degree turn. Test canal is therefore characterized by two 90 degree “S” turns in two different dimensions! 3C. For maxillary teeth, hold PTG handpiece (any electric handpiece at 300 rpm and maximum torque) as if it were a cigar between index and middle finger in order to prevent directing and pushing or pecking with index finger. The progressive geometries of PTG combined with the simple weight of the electric handpiece are sufficient to Brush/Follow as demonstrated using PTG S1. No pushing is required or desired. 3D. For mandibular teeth, the handpiece can be cradled by the thumb on one side and the index and middle finger on the other side. Then once again preventing the dangerous directing or pushing of the index finger Volume 9 Number 1

expand the Glidepath by removing coronal radicular restrictive dentin where present. First, gently follow PTG S1 into canal and then Brush laterally and Follow to length (Figures 4A and 4B). If length is not easily reached, remove file, clean flutes, irrigate, and proceed until length is reached. Remove PTG S1 from the preparation, and inspect flutes. Typically, flutes will be filled in the coronal portion of S1 confirming coronal restrictive radicular dentin is removed (Figure 4C). Proceed in the same PTG S1 Brush/Follow manner with PTG S2 (Figures 4D and E). Inspect S2 flutes after “following” to length, and note restrictive radicular dentin is typically removed where intended at midroot (Figure 4F). 5. Finish: Follow PTG F1 into canal until dentin is engaged, and then Brush out. Repeat Follow/Brush method (opposite of Shapers which is Brush/Follow) until length is reached (Figure 5D). If apical flutes are free or partially free of dentin as seen in Figure 5D, this is your cue to proceed with PTG F2 in exactly the same way as PTG F1 until length is reached (Figure 5H). The lack of dentin in the apical flutes indicates the F1 prep is incomplete; it is NOT finished. This is your indicator to proceed with F2. After the Follow/ Brush repetition to length, remove

PTG technique 1. Start: Purchase or trade in a dozen unopened PTU packages for PTG packages (Figure 1). 2. Access: Remove chamber dentinal triangles to design unfettered access into root canal system preferably using the forgiving PTG SX, which has an extraordinary capacity to cut where the dentists want to cut versus a stiffer PTU SX type file that cuts more indiscriminately against multiple, or worse yet, all walls, including walls near furcal danger. 3. Glidepath: Prepare a Glidepath using a loose No. 10 or No. 15 manual file or expand with mechanical ProGlider to length confirming the reproducible Glidepath is secure and ready for PTG rotary. 4. Shape: Shape with PTG Shapers S1 and/or S2. Shapers are used to

F2 and inspect apical flutes for proof that F2 apical flutes contain dentin which confirms the F2 shape is present, and the F2 canal preparation is finished and ready for conefit (Figure 5I). Radiographic image confirms proper conefit (Figure 5J). After final disinfection cleaning protocol, obturate root canal system.

Is ProTaper Gold for me? Take the PTG challenge. The easiest and simplest way to test PTG against your current preferred NiTi system is to load two banker sponges (one 21 mm and one 25 mm) and place in only one of your treatment operatories for at least a week. Use them for all cases in that operatory (Figure 6). Take notes on how PTG performs against your current preferred file system. Remember, the best education in the world is your own. At the end of the week, it will not matter what I have said; what the endodontic reps have said; what the advertisements have said; or what the literature has said. You will know the truth. Your truth!

Take-aways This article is completely biased. Why? The reason for my bias is that my goal is to share with you, the reader, a little bit about my PTU to PTG journey. I have had a few journeys over my four decades of wanting to perform at my highest level, but none have been more satisfying and rewarding than this one. And now I invite you to have your own PTG experience.

Figure 4: Proper PTG Shaper technique: Brush/Follow. 4A. Brush or paint against outside of canal wall with S1. 4B. Follow S1 deeper into canal and repeat to length. 4C. Inspect flutes for position of dentin shavings and evidence of removed restrictive radicular dentin. 4D-4F. Continue S2 shaping in same order and motions (Brush/Follow) to length, and inspect S2 flutes proving restrictive dentin removal is complete and ready to proceed to Finishers Volume 9 Number 1

Endodontic practice 49

ENDODONTIC INSIGHT

the most dangerous finger in Rotary as well as Reciprocation. Cradle the handpiece for both maxillary and mandibular teeth. Hold the handpiece as if it were a cigar between the index finger and middle finger as seen in a patient’s maxillary tooth (Figure 3C) or between the index finger and thumb for the mandibular teeth (Figure 3D). In this way, your finger and/or hand DO NOT direct the handpiece, and the file is left to freely “follow” the Glidepath to length. The weight of the handpiece is sufficient to urge the Shapers and Finishers to do what they are designed to do.

ENDODONTIC INSIGHT

H. Figure 5: Proper PTG Finisher technique: Follow/Brush. 5A-5D. Follow/Brush to length with S1. In animation, apical flutes are lacking dentin shavings that, if removed, flute inspection would be cue to automatically and necessarily advance to PTG F2. 5E-5H. Follow/Brush PTG F2 to length. 5I. “S” shaped test canal demonstrates dentin loading in apical flutes confirming F2 shape is complete. 5J. F2 PTG NanoFlow Conefit indicates proper shape, ready for cleaning disinfection, and ready for obturation. (Note: Figure animations courtesy of Advanced Endodontics, Santa Barbara, California)

“Education is the most powerful weapon which you can use to change the world.” — Nelson Mandela Figure 6: Implementation of the PTG Challenge. Load two banker sponges with SX, S1, S2, F1, F2, and F3; one sponge with 21 mm files and one with 25 mm files. Place both banker sponges in ONE of your treatment operatories, and leave it there. For a week compare the PTG operatory with you current preferred NiTi files. Take notes about your compared experience, and at or before the end of your week, you will know the answer to “Is ProTaper Gold for Me?”

50 Endodontic practice

Take-home message: Remember to Brush then Follow on your way down the canal with the Shapers, and do the opposite with the Finishers: Follow then Brush your way out. Change can be difficult, but discovering truth through understanding and your own education can make the journey of change

not only possible, but also rewarding and blissful. EP

REFERENCES 1. West J. Three Guidelines for Becoming a Great Endodontist. AAE scientific presentation; April 2015; Seattle, Washington. 2. West JD. Ni-Ti Goes GOLD: “Ten Clinical Distinctions.” Dent Today. 2015;34(4):66-71.

Volume 9 Number 1

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Ultradent Products, Inc., proudly introduces the Ultradent mobile app Ultradent Products, Inc., proudly announces the launch of the Ultradent app, available in the iTunes® app store. The app ensures Ultradent customers will never miss a deal, as they can log in using their mobile device at any time, and see ongoing promotions unique to them. The app also links with Ultradent’s online store, allowing customers to take care of all of their shopping needs seamlessly. Ultradent plans to expand the mobile app’s offerings in the coming months — making shopping, education, and product news accessible in one, easy-to-use mobile application. To download the Ultradent Deal Finder mobile app, please visit https://itunes.apple.com/us/app/ultradent-by-ultradentproducts/id1053260724?mt=8, or search “Ultradent” in the iTunes app store. *Mobile App deals available to U.S. customers only

NuCalm® all-natural relaxation system attains 500,000 patient milestone Researchers at Solace Lifesciences, Inc., based in Wilmington, Delaware, have developed a modern solution to age-old dental phobia: the NuCalm® technology — an all-natural, drug-free approach to stress relief that makes the patient more receptive to the dentist by mimicking the body’s natural process of deep relaxation. NuCalm’s four-step system — in development since 2002 — can be administered in a couple of minutes. It includes 1) NuCalm proprietary cream; 2) microcurrent stimulation; 3) headphones that play music embedded with proprietary software; 4) eye mask. The deep relaxation state occurs within minutes. In stages, the patient’s mind wanders, breathing slows down, and the body feels heavy and still. After a NuCalm dental appointment, patients feel refreshed, relaxed, and focused. There is no recovery time. For more information, visit www.nucalm.com

Volume 9 Number 1

DEXIS™ Eleven software drives efficiency in and out of the operatory DEXIS, LLC, a brand of the KaVo Kerr Group, announced its latest software release — DEXIS™ Eleven. Customers will benefit from a range of workflow improvements, including drag-and-drop tooth numbering, enhanced security, and fewer clicks for case presentation. Building on the solid foundation of DEXIS Imaging Suite, DEXIS Eleven simplifies tooth numbering and reduces the number of clicks required for case presentation and common workflows. The software also provides peace of mind through security improvements, always-on Cloud Backup of patient images, and the ability to access images from anywhere through CloudVu. The tooth number dialogue allows the user to assign tooth numbers using drag-and-drop functionality. With this new feature, the user can easily move imported and intraoral camera images into predefined tooth number bins. Users retain the ability to assign a specific tooth number if needed. The new History View feature sorts and displays patient images by date to allow for a faster search when viewing past images. For more information, current DEXIS owners can visit www. dexis.com/upgrade to schedule their upgrade to DEXIS Eleven.

Vista offers AutoSyringe™ and 3cc color-coded syringes Vista Dental Products introduced AutoSyringe™. This patent-pending device makes irrigation easy, convenient, and affordable. AutoSyringe™ replaces the standard luer-lock syringe and significantly decreases the number of irrigating tips used. AutoSyringe™ is a cordless, compact (sized comparable to a 12cc syringe), battery-operated device that provides a consistent, controlled flow of endodontic solutions. Three adjustable flow rate settings ensure safe apical pressure throughout every procedure. AutoSyringe™ features a quick-connect, 20 ml reservoir that is easily filled with the medicament of one’s choice. In addition, Vista Dental Products is now offering 12cc and 3cc color coded syringes. Vista’s Color-Coded luer-lock syringes provide a fast and easy way to organize and identify irrigants and solutions, helping to reduce incidences of syringe swap. A box of Vista’s ColorCoded Syringes cost no more than a box of standard luerlock-style syringes. Vista ColorCoded Syringes are latex-free and available in four easy to identify colors: blue, red, yellow, and white. To find out more, visit vista-dental.com, or call 877-418-4782.

Endodontic practice 51

TECHNOLOGY

Is your practice good enough? Sonendo® discusses a system for disinfection and cleaning with minimal instrumentation

efore you answer, think about what that term is really saying. Being good enough might sound fine — until you dig a little deeper. When you are good enough, you meet all the expectations that people have, but you never rise above the competition. You get through each working day, but you never get ahead. And you seldom hear complaints, but you don’t get much praise either. That’s as true in endodontics as it is anywhere else. The status quo has served our discipline reasonably well for decades. Even with incremental changes to our procedures, the basic idea behind a root canal therapy — file, debride, irrigate, fill — has changed very little. And we have declared the resulting level of clean that results to be “good enough.” We have recognized that sometimes root canal therapies fail. Sometimes smear layer goes unchecked, and bacteria and biofilm can be left behind. We have accepted these results as part of the inevitable risks associated with root canal treatments. And very seldom have we asked ourselves whether “good enough” could be better. Sonendo® has asked that question. The GentleWave® System is the answer.

The GentleWave® System: disinfection and cleaning with minimal instrumentation Why are we calling the GentleWave® System a breakthrough? Because Sonendo is rethinking endodontics at its very foundation — the idea that extensive instrumentation is required to clean and irrigate the root canal. Each year sees the introduction of improved NiTi files into the endodontic market, and alterations to the instrument shape, flexibility, and strength have all led to marginally better outcomes for the clinician. The underlying principle behind these improvements, however, has remained the same. We are still filing our way into the root canal to clean and irrigate. Sonendo saw the potential for a new way to achieve even better outcomes. Sonendo’s GentleWave® System eliminates most of the files and instruments used in a conventional root canal therapy and introduces something entirely 52 Endodontic practice

Fluids and energy reach into the apical third, removing the biofilm that is a primary cause of reinfection and failure in root canal therapy. The result is a level of disinfection that goes a long way toward preventing the need for retreatments over time — and provides you with the power to save even more teeth for your patients.

The GentleWave® System: beyond good enough for patients and practices

This mandibular right second molar was diagnosed with a large carious lesion invading the pulpal space and irreversible pulpitis with normal periradicual tissue. Post procedure image from GentleWave® root canal therapy1

new — patented Multisonic Ultracleaning™ technology. With Multisonic Ultracleaning™ technology, years of research and development have come to fruition, and it represents a change in the way we think about endodontics. Multisonic Ultracleaning™ technology replaces nearly all of the instrumentation used in conventional RCTs and still delivers superior levels of cleaning and disinfection that leads to fast healing2 for your patients. Here’s how it works: the GentleWave® System treatment instrument generates a powerful vortex of treatment fluid and broad spectrum acoustic energy, surging through the entire root canal system from crown to apex. Along the way, the technology removes smear layer, bacteria, and biofilm, even in microscopic areas such as isthmi, lateral canals, and dentin tubules, where the potential for treatment failure often lies.

How about your practice’s bottom line? Would you say that it’s “good enough?” (Would anybody?) Introducing the GentleWave® System in your practice can deliver even better outcomes there as well. Even if you are at capacity in your billable hours throughout the day, it is still possible to increase the number of patients you see. That’s because the GentleWave® System gives you the power to perform most root canal therapies in just one visit. Instead of performing the shaping and cleaning one day, and the obturation on another day, you can perform minimal shaping, a Multisonic Ultracleaning™ treatment, and obturation all in one billable session.3 This boost in your treatment efficiency can have a real impact on your ability to increase revenues as you are able to take on more referrals, which are becoming increasingly challenging. As new, billable patients come in the door, your revenues could increase by as much as 30%.3

Volume 9 Number 1

Never accept good enough The GentleWave® System provides you the power to provide higher levels of cleaning and disinfection, fast healing, and the ability to offer unparalleled results in just one treatment session, and it does all this with minimal instrumentation. It’s a breakthrough that your patients will notice, especially if they have undergone a root canal therapy in the past. It’s a breakthrough that referring

TECHNOLOGY

The GentleWave® System not only affords you the time to take on referrals, but also provides your practice with a treatment option that truly sets you apart. The GentleWave® System gives you a demonstrably clear differentiator as general practitioners make their referral decisions. Multisonic Ultracleaning™ technology delivers a treatment option that is backed by years of case reports, peer-reviewed clinical outcomes, and in vitro research.

general practitioners will notice. And with the ability to make a difference in your bottom line, it’s a breakthrough that your accountant will notice. At sonendo.com, you can see the many ways that the GentleWave® System and its patented Multisonic Ultracleaning™ technology can take your practice far beyond the current industry standard. From clinical results to patient testimonials, you will discover how Sonendo innovations offer results that are far beyond the average — and far beyond “good enough.” EP

REFERENCES 1. Image courtesy of Tyler F. Baker, DDS, MS 2. Sigurdsson A, Khang TL, Woo SM, Rassoulian SA, McLachlan K, Abbassi F, Garland RW. Six-month healing success rates after endodontic treatment using the novel GentleWave™ System: the PURE prospective multi-center clinical study. J Clin Exp Dent. In Press. 2016. 3. Conﬁdential patient chair-time analysis over 2 months.

This information was provided by Sonendo®.

GentleWave® System treatment instrument

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Hydrophilic - Continues the sealing process in the presence of moisture 1. K. Bentley, S. Janyavula, D. Cakir, P. Beck, L.C. Ramp, J.O. Burgess. "Mechanical and Physical Properties of Vital Pulp Materials". School of Dentistry, University of Alabama at Birmingham, Birmingham, AL. 2. Data on file. 3. A. Atmeh, F. Festy, A. Banerjee, F. Mannocci, T. F. Watson. "Mineral Interaction Zone; A Chemo-morphological Chracterization of The Dentine-Biodentine Interface". 2012. King's College London Dental Institute, Biomaterials, Biomimetrics and Biophotonics, London, UK.

Volume 9 Number 1

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Endodontic practice 53

ENDOSPECTIVE

Written “must haves” for the modern endodontic practice Dr. Rich Mounce emphasizes the importance of operational documents

he value of having written goals, office manuals, and practice checklists cannot be overstated. These seminal documents lay out the practice goals and the steps needed to achieve them. Much like a plane needs a flight plan and a destination, our practices need goals and a means to get there. Without written plans, we are buffeted by headwinds that can either push us off course or make achieving our desired end point much more difficult. While many of us consider ourselves clinicians first and foremost, we are also small business owners and/or associates and in a leadership position in our practice environments. Leadership, among many attributes, requires a written plan over which to marshal support for the goals of the office. The written documents we must have as leaders, owners, and managers in our small businesses include primarily: 1. An office manual (which includes, among other material, a statement of the corporate vision and values; procedure descriptions and needed armamentarium; all job descriptions, HR policies, and procedure checklists (of all of the daily, weekly, monthly, quarterly, and yearly tasks that must be accomplished at every level in the practice). 2. A marketing plan 3. A strategic plan that includes a SWOT (strengths, weaknesses, opportunities, threats) analysis (done yearly) and business forecast These documents must be written; they cannot remain in our imagination.

Rich Mounce, DDS, is an endodontist and has lectured and written globally in the specialty of endodontics. He is a consultant for Mani Dental and receives honorarium for his work. 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 or MounceEndo.com.

54 Endodontic practice

Unwritten, they are wishes and have no power. We cannot buy these documents off the shelf. While someone else’s material can be a starting place, they need to be closely aligned with our own personal goals and values. These materials cannot be delegated. Any major bookstore or online Amazon search will provide ample resources to gain source material to start these documents. A clinician might think that his/her practice is successful and profitable at the present time, so why do these tasks? Success leaves clues. No Fortune 500 company in the United States exists without these documents both written and updated continually. The landscape we practice in is ever-changing. For example, who in 1991 (when I began practicing endodontics as a specialist) could have foreseen these events? • The economic crashes that have kept many in practice now because they have not saved enough for retirement • The rise of implants • The rise of corporate dentistry, which generally does not refer patients out for endodontics • The rise of Sonendo® While an answer to each of the economic threats we face as owners is beyond the

scope of this column, to stick one’s head in the sand and believe that things will continue as they are without change is naive and in an economic sense, quite dangerous. At an operational level, many of the troublesome daily issues that arise can be alleviated with clear and consistent written expectations of our staff. Clearly defined and frequently reviewed policies and checklists will prepare the staff for everything from a medical emergency and its management all the way through the simple detail of who changes the toilet paper in the patient bathroom among many such similar mundane tasks. Written practice documents might be thought of as the U.S. Constitution, a document that sets out the rights and responsibilities of the government in relation to its citizens. While it can be modified by consent of the governed, at any given time, it is the North Star of the Nation. Our practices need such a North Star that clearly defines who we are, what we stand for, and how we are going to get there. Continuous reevaluation and renewal of these documents as circumstances change allow the clinician to adjust course as needed to meet current threats and take advantage of opportunities. I welcome your feedback. EP Volume 9 Number 1

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SMALL TALK

Practice integrity, part II: selling the experience Dr. Joel Small discusses the value of viewing the practice through the eyes of the patient

n part I of my Practice Integrity series, I explored the meaning of integrity in the context of fulfilling clinicians’ stated and implied promises to our patients and referral sources. In part II of this series, I will address integrity in the context of a state of completeness or wholeness. Bestselling author Patrick Lencioni addresses the topic of organizational integrity in his book, The Advantage. According to Lencioni, “Organizational health is about integrity, but not in the ethical or moral way that integrity is defined so often today. An organization has integrity when it is whole, consistent, and complete, that is, when its management, operations, strategy, and culture fit together and make sense.” This holistic view of organizational health can be applied to a dental practice, or any business for that matter. Being whole, consistent, and complete is often overlooked as critical success factors for our practice’s health and ultimately our success and longevity, and yet to view our practice in this manner is to see ourselves as our patients see us. This ability to see our practice in terms of our patient’s experience is a gift that is possessed by the most successful practitioners. As an endodontist, I have had a unique opportunity to see my referring doctors’ offices through the eyes of their referred patients. From personal experience, I have consistently found that the most satisfied patients view their referring offices as a single-functioning unit that is consistent in meeting their expectations and needs. Less satisfied patients view the referring office

Joel C. Small, DDS, MBA, FICD, 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.

56 Endodontic practice

“It is important to remember that our practice culture is a reflection of a mutually shared vision and values that are foundational to our business strategy, operating procedures, and organizational wholeness.” as fragmented and often make distinctions between their satisfaction and dissatisfaction with various aspects of the practice. Again, the same observation applies to any business in the service industry. Take, for example, an automobile dealership that has an exceptional sales team but a service/repair department that provides poor customer service. Most of the dealership’s customers will have a diminished overall impression of the dealership due to an inconsistent customer experience, and many will choose to do business elsewhere in the future. If the dealership’s management fails to see the business from a holistic viewpoint, they may focus on sales alone, never considering their declining customer retention rate. Over time, the dealership will experience an increase in customer dissatisfaction and a decrease in sales as its overall reputation declines. Dentists, like other business owners, often fail to have a holistic view of their practice. Being perfectionists and meticulous clinicians, we tend to spend an inordinate amount of our time, effort, and resources on developing our clinical skills with less regard to developing our ideal practice culture that has proven critical to our patients’ overall experience. It is important to remember that our practice culture is a reflection of a mutually shared vision and values that are foundational

to our business strategy, operating procedures, and organizational wholeness. With the right people and a strong culture, there is an overriding sense of purpose and commitment to providing seamless service and the best possible customer experience. Please don’t misunderstand me; I also believe that we should continually work to upgrade our clinical skill, but the underlying question remains: Are we selling dental procedures or a patient experience, and bottom line, which one puts patients in our chair? According to noted authorities, it is the patient’s experience that is the overriding factor that determines our practice’s success even in these most competitive times. I have found that our greatest disconnect as healthcare professionals and service providers occurs when we attempt to sell a product while our patient/customer is looking to buy an experience. Our patients have no concept of procedural perfection, but they unquestionably recognize what constitutes a pleasant experience. Given this, it would seem prudent for us to become more aware of the need for practice integrity or completeness as a means of meeting our patient’s need of an overall positive experience. Taking the time to explore our practice from a holistic perspective will allow us to see our practice as our patients see it and will pay lasting dividends. EP Volume 9 Number 1

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