Endodontic Practice - Summer 2016 Vol 9 No 2 by MedMark, LLC

WHERE SAFETY MEETS EFFICIENCY

clinical articles • management advice • practice profiles • technology reviews Summer 2016 – Vol 9 No 2

PROMOTING

EXCELLENCE

Successful anesthesia in acutely inflamed pulps

ENDODONTICS Practice profile

Dr. Garth Hatch

Dr. John Lordan

Management of a traumatic dental injury in a 7-yearold boy Dr. Marga Ree

Company spotlight Luman Dental, LLC

The reciprocating movement in endodontics Drs. Nicola Maria Grande, Gianluca Plotino, Hany Mohamed Aly Ahmed, Stephen Cohen, and Frédéric Bukiet

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1 Sigurdsson A et al. (2016) J Endod. (In Press). © 2016 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo, MULTISONIC ULTRACLEANING, and SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: sonendo.com/intellectualproperty. MM-0167 Rev 02

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-inchief 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 © FMC 2016. 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 2

fter a surge in technological development in the past few decades, and particularly in regard to the fast propagation of information online, it seems reasonable to attest that the overage of data has generated a more mature critical view of the pros and cons of new and old technologies. Clinicians, whether in general or specialist practice, are all expected to pursue continuing professional development in order to keep up-to-date. In endodontics, new materials, techniques, and equipment are matched by the ever-expanding spectrum of techniques and treatment modalities. The motivation question raised now is not “How does it work?” but more likely, “What is the benefit?” Before the Internet made information so accessible, when a new product was launched, a quick consideration was made by dentists and a fast adoption determined. The few who had access to information about the product opportunely used this asset as a distinguishing feature in their practices. But with the advent of the Internet and overall ease of obtaining information, clinicians now have different research tools that enable them to not only have contact with the new technologies, but above all, to assess the opinion of others with respect to the subject, meaning the new product, new technique, or new trend. The immediate benefit of this novel movement lies in the fact that people have now become more diligent and, therefore, less sensitive to tendencies and facade technology. In endodontics, as well as other areas that involve any research and development processes, new products and techniques overflow the specialized media. Although this is positive for essential improvements, it does not necessarily mean the product or technique is crucial for professional or patient benefit. In fact, new technology needs some degree of validation. It is prudent to be cautious when facing anything that lacks supportive evidence or that shows ambiguity. Explanations such as, “Well, it works in my hands,” or — even coming from the endodontic celebrities — “Because I said so” are not enough to assist in the decision-making process of which new techniques to adopt. The question is, Should only scientifically tested technology be added to the day-to-day practice? And if so, how long does it take to validate a process under academic conditions? The truth is that a new product or technique is rarely validated by prospective clinical studies, even after years of positive clinical and laboratory results. In most cases, new technologies start the process of being corroborated right after their launch, and the reality behind the scientific academic speech is that researchers are keen to clarify the benefits and advantages of one technique over the other just by the clinical interest in comparing results between the “old” and the proposed “new.” Scientific research is not the only source of reliable information when deciding on a new technology to be adopted. If so, it would take a lot of time and investment to renew our techniques, and it would be frustrating to wait for science to give its verdict. Knowledge of the specialty fundamentals, added to the confidence in reliable companies that invest in research and product development, gives us some level of security in starting the process of trying new products. New technologies and scientific studies have always walked side by side, creating a demand for each other. In a way, the calculated risk and responsible clinical application of new technologies, meaning those which show a solid base of science involved in the research and development process, have brought us where we are now, undoubtedly better than we were in the past. Under this fine balance between the developments of new technology and the evidence of results, our professional performance in the present time has not only flourished in terms of favorable clinical outcomes, but also allowed us to achieve our professional goals more contentedly, delivering better prognosis on the offered endodontic treatment and saving us time with which to enjoy our lives a little bit better.

Carlos Spironelli Ramos, DDS, MS, PhD, graduated in dentistry in 1987 in Brazil, then soon after received a scholarship to study in Japan. He finished his residency in endodontics in Brazil in 1990. From 1991 to 1993, he attended the master’s program in endodontics, receiving a Master of Science degree. He then began the PhD program in endodontics, completing it in 1997, the same year he published his first book. From 1995 to 2012, he worked as a professor of endodontics at the State University of Londrina, where he coordinated the endodontics sector. During this same time, he published three books and wrote more than a dozen chapters for various endodontics books. Professor Ramos is currently the R&D Endodontics Manager at Ultradent products in South Jordan, Utah. He performs many lectures, hands-on workshops, and conferences worldwide each year and has visited over 40 countries.

Endodontic practice 1

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TABLE OF CONTENTS

Financial focus Living with the choices we make

Practice profile Garth Hatch, DDS

Tony Robbins and Tom Zgainer discuss why you should understand how fees in your retirement plan investments will affect your future and that of your employees.................... 12

Case study Management of a traumatic dental injury in a 7-year-old boy Dr. Marga Ree treats a complicated dental trauma with a multidisciplinary approach......................................... 16

Creating Rock Stars in endodontics

Treatment of a non-vital central incisor with an open apex using a novel MTA-based repairing material Drs. Mario Luis Zuolo and Arthur de Siqueira Zuolo present clinical detection, diagnosis, and management of a non-vital central incisor with an open apex.......................................22

Clinical The envelope of motion and ProTaper NEXTâ&#x201E;˘

Company spotlight

Luman Dental, LLC This family-owned business focuses on exceptional customer experience, specialized products, and knowledgeable customer service â&#x20AC;&#x201D; at a reasonable price

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Dr. Michael J. Scianamblo examines the envelope of motion in root canal preparation with a current review of the literature....................................26

Volume 9 Number 2

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TABLE OF CONTENTS Technology

Product profile

GentleWave System by Sonendo®

NeoMTA Plus® and Grey MTA Plus® root and pulp treatment materials

Clean and disinfect even complex root canal anatomies with Sound Science® — and a revolutionary mechanism of action..........................................48

Continuing education Successful anesthesia in acutely inflamed pulps Dr. John Lordan examines how to achieve profound pulpal anesthesia in teeth with irreversible pulpitis .......................................................32

The reciprocating movement in endodontics Drs. Nicola Maria Grande, Gianluca Plotino, Hany Mohamed Aly Ahmed, Stephen Cohen, and Frédéric Bukiet provide a clinical perspective on the reciprocating movement in endodontics....................................37

Focus on files Efficient, flexible, universal, or flared? Assessing hand file options Dr. Rich Mounce discusses clinical relevance and uses for four hand file classes........................................44

Ask the right questions; invest in the right CBCT solution for your practice Jordan Reiss, Carestream Dental’s national sales director for 3D imaging, addresses some questions about CBCT imaging for the endodontic office...............................................50

MoraVision™ 3D: A paradigm shift in the ergonomics of dental imaging Dr. L. Stephen Buchanan offers his view of an innovative imaging technology.......................................52

Endo tips Problem-solving endodontics Dr. John Rhodes looks at locating canal orifices...................................55

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

Endospective Making the office a sanctuary Dr. Rich Mounce offers advice for calming a stressful environment ....................................................... 62

Small talk Blind spots and self-limiting beliefs Dr. Joel C. Small discusses ways to increase practice potential through awareness....................................... 64

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld, MA Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com

Endodontic insight

Industry news............... 57

MTAFlow™ — overcoming the boundaries of MTA clinical applications

Product profile

Dr. Carlos Spironelli Ramos discusses a beneficial advancement in endodontics....................................46

“MTA — Your way.” Predictable. Convenient. Affordable.................... 60

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MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.endopracticeus.com | www.medmarkaz.com

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PRACTICE PROFILE

Garth Hatch, DDS Creating Rock Stars in endodontics What can you tell us about your background? I was born and raised in Riverside, California, and was the fourth of six children. My dad was a firefighter and loved what he did. My parents were always very supportive and encouraged us to do our best, serve others, and continue learning. Growing up, we didnâ&#x20AC;&#x2122;t have a lot of extras, but we always had what we needed, and there was plenty of love in our family. I received a BS in Exercise Physiology from Brigham Young University and received my DDS from Indiana University School of Dentistry. After graduation, I went into the U.S. Army Dental Corps and completed an AEGD 1-year program at Fort Jackson, South Carolina, and later received a Certificate in Endodontics from the U.S. Army Endodontic Residency Program at Fort Gordon, Georgia. After serving in the U.S. Army Dental Corps for 7 years, I purDrs. Garth Hatch, Chad Dawson, and Mathew Schafer chased an endodontic practice in Kennewick, Washington, and made the leap into private practice. The practice was near family, and we felt it would be a nice area to raise our four children. My lifetime goal was to own my own business, but it was scary to leave the security of the military and buy a practice during the Great Recession and in a challenging dental market. I had no backup plan, so I aggressively learned all I could about business, dental pracDr. Garth Hatch at the Dental Specialist Institute, LLC, booth at the AAE tices, marketing, team building, and exceptional customer service. I also hired great consultants and found marketing coordinator, and five dental assisterrific mentors to guide me during the tants. We have four treatment operatories process. Despite making many mistakes, and one CBCT consultation room. We are we took massive action and were able to currently working on adding an additional grow the practice by 60% the first year. The operatory and staff break room. practice continued to grow, and despite Friends began asking me how we were being very rewarded financially, I regretted able to grow the practice so fast, and I shared not having more time with my family and felt with them the systems, marketing strategies, like I was never truly able to leave the pracand staff team training we were using. Having tice. Weâ&#x20AC;&#x2122;ve since grown the practice from enjoyed sharing these strategies and with the a single practitioner practice to our current encouragement of friends, family, and my team of three full-time endodontists, an office practice partner, Dr. Chad Dawson, I launched manager, two receptionists, a part-time Dental Specialist Institute, LLC, in January 8 Endodontic practice

of this year. Our mission is to help endodontists, oral surgeons, and periodontists take their practices to the next level and gain more abundance and freedom in their personal lives. It also helps with my vision of giving back, as a portion of the business profits will be donated to charitable organizations, in particular the Salvation Army for their work in feeding the needy.

When did you become a specialist, and why? During my second year at Indiana University School of Dentistry, I had a fantastic endodontic instructor named Dr. Joseph Legan. He made endodontics enjoyable, and I decided that year I wanted to pursue a specialty program in endodontics. After completing 2 years in the U.S. Army Dental Corps, I fulfilled that dream and began an endodontic specialty residency at the U.S. Army Endodontic Residency Program in Fort Gordon, Georgia. I completed the program in 2007 and appreciate my awesome residency classmates and the program directors, Volume 9 Number 2

Is your practice limited solely to endodontics, or do you practice other types of dentistry? Our practice is limited solely to endodontics, both surgical and nonsurgical.

Why did you decide to focus on endodontics? I appreciate the precision of endodontics and the immediate gratification that is typical of alleviating our patients’ pain.

Do your patients come through referrals?

Within our practice and in life, I’m a huge believer in the concept of leverage and finding leverage points to improve efficiency, communication, and customerservice excellence. Leverage comes from practice systems, space, equipment, and most importantly, our human capital. The best clinicians in the world will struggle in private practice if they don’t have a welltrained, customer-service-minded, motivated team surrounding them.

What training have you undertaken? Aside from my formal training listed previously, I regularly participate in continuing education programs through local study clubs, online, and the American Association of Endodontists Annual Meetings. It’s

exciting to see all the advancements that are taking place in the dental market and to stay up-to-date with the latest advancements in treatment. I’ve also worked with some great consultants that helped me establish systems within the practice and how to focus on the key areas that affect and yield the greatest result. Dr. Ace Goerig and Todd Holmes with Endo Mastery were the first consultants I worked with, and I appreciate their guidance and systems they helped me establish in the practice. We’ve also worked with several other consulting companies within and outside of dentistry, including Fortune Management, Business Mastery with Tony Robbins, Speaking Empire, and the Scheduling Institute. Some of their systems weren’t a fit for a dental specialty practice, but we

The vast majority of our patients come through referrals from other dentists. With that said, we do see more self-referred patients who saw us in the past for a root canal and appreciate the care and customer service we provided. Some of these patients learned they needed another root canal and called us for the treatment. We are extremely grateful and honored to serve our referring dental offices and their patients.

How long have you been practicing endodontics, and what systems do you use? I’ve been solely performing endodontics since 2005. Clinically, I use the EdgeEndo® rotary files and have been very pleased with their performance. We also use the Brasseler USA® .02 taper RaCe™ files, EndoSequence® BC Sealer™ and BC RRMPutty™, and Dentsply TRUShape® files for certain cases. We also love our Zeiss OPMI® pico surgical microscopes and Carestream 8100 3D CBCT scanner.

Front desk crew and marketing coordinator Volume 9 Number 2

Columbia River Endodontics staff

Amazing dental assistants Endodontic practice 9

PRACTICE PROFILE

Drs. Anthony Joyce, Steve Roberts, and Stephanie Sidow for their great mentorship and encouragement.

PRACTICE PROFILE took the best strategies and adapted them within our practice. Quality consulting should be an investment that yields much greater returns than the cost of the program.

Who has inspired you?

What is the most satisfying aspect of your practice? Our practice is such an amazing team, and I look forward to waking up in the morning and seeing everyone at work. Each team member has certain roles and responsibilities that we take ownership of and areas of expertise, similar to a team of Navy Seals. We have a shared vision of the way we want to treat our patients, our referring offices, and how we want to interact with each other. When each team member has an area of

There are many individuals who have inspired me throughout my life, including my parents, my Savior, and other family members. My amazing wife, Alissa, and my children provide some of my greatest inspiration and support. I’ve also been blessed throughout my career with great mentors who have inspired me to do my best and find joy in serving others. Drs. Ace Goerig, John West, Syngcuk Kim, Joseph Legan, and Carl Newton have all inspired me with their willingness to teach and share in their wisdom. Drs. Michael Feldman, Elizabeth Perry, John Stuparitz, Kenneth Tittle, Brian Hornberger, Chris Smith, Richard Wittenauer, and all the other members of Root Masters Study Club have been wonderful sources of inspiration, collaboration, mentorship, and Ranae Boyer and Dr. Hatch at the AAE meeting dear friends.

responsibility and expertise, they become more engaged at work. Personal fulfillment levels tend to rise as does profitably. We also know how to support our team members and have each other’s backs. Our office staff truly is a team of Rock Stars, and I feel so grateful for them. The acronym Rock Stars stands for Results, Ownership, Customer Service Excellence, Kaizen, Systems, Team Player, Action, Resolve, and Serve. We share these concepts with our coaching clients, and how they can develop this Rock Star team culture within their practice.

Professionally, what are you most proud of? Our amazing office team, the support we receive from our referring offices, and the wonderful relationships we have with our referring doctors and their patients.

What do you think is unique about your practice? Our Rock Star team culture. These concepts truly guide our office culture, and how we interact with those we serve.

What has been your biggest challenge? Having enough time in the day to accomplish everything I’d like to get done and still maintain a good work/home life balance.

What would you have become if you hadn’t become a dentist? A physical therapist or something else in the healthcare field.

What is the future of endodontics and dentistry? Although I believe endodontics and dentistry in general have some major challenges heading our way with insurance companies, competition, massive student debt, and corporate dentistry, I believe the long-term outlook is very bright. As the baby boomers age, they are healthier, living longer, and want to maintain their smiles. I believe this will help keep endodontists willing to provide great care and exceptional customer service very busy.

What are your top tips for maintaining a successful specialty practice?

My family: wife Alissa and four children

10 Endodontic practice

I can sum this up with one word — RELATIONSHIPS. Specialty Practices, as in life, are all about the quality of our Volume 9 Number 2

What advice would you give to budding endodontists? Find some great mentors and coaches, and follow their advice. There’s no need to reinvent the wheel if you can model the strategies of highly successful practices. Whether you work with Dental Specialist Institute or another consulting company, quality coaching should be an investment that makes you more profitable, faster and with fewer headaches.

What are your hobbies, and what do you do in your spare time? After joining the U.S. Army Dental Corps, I began training in Brazilian Jiu-jitsu and fell

My practice partner, Chad Dawson, and I at a Seattle Seahawks game

in love with it. Aside from helping me stay fit, it’s taught me some neat lessons in using leverage and systems that apply to other areas of life. I also enjoy many activities with my family, including traveling, outdoor activities, fishing, gardening, and enjoying tasty food. Garth Hatch is President and Founder of Dental Specialist Institute, LLC. He can be reached at garth@dentalspecialisti.com or by calling 509-578-4454. EP

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

EdgeEndo® Files EndoSequence® BC Sealer™ Carestream CBCT Zeiss OMNI® pico microscopes Brasseler USA® .02 taper RaCe™ files DEXIS™ digital sensors PBS Endo® endodontic management software Having a practice newsletter Rock Star team training Celebrate the journey!

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OUTSTANDING SEALING PROPERTIES Resin-free - Made from pure calcium silicate and is monomer-free ensuring zero shrinkage1 Pure mineral formulation - will not stain2 Hydrophilic - Continues the sealing process in the presence of moisture High alkaline pH Strong Seal - Void-free, tight interface with outstanding adhesion to dentin3 and gutta percha points 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 2

Endodontic practice 11

PRACTICE PROFILE

relationships. We should continually ask ourselves, How can I improve my relationship with my referring dentists, their staff, our patients, and our own team? When you regularly ask this question and come up with meaningful answers and systems to implement these answers, your practice can’t help but be successful.

FINANCIAL FOCUS

Living with the choices we make Tony Robbins and Tom Zgainer discuss why you should understand how fees in your retirement plan investments will affect your future and that of your employees

s this article was written, the presidential campaign had officially started with the Iowa caucus now completed. In each of our states, we’ll soon enjoy the great individual privilege of choosing who we think will be the most suitable candidate in each party. When November 9 rolls around, and the results of the previous day’s election are confirmed, we’ll then have to live with the choices we made, or did not make, for the next 4 years. When it comes to our retirement planning, the choices we make today related to our investment options and their associated fees need to be made with a much longer time horizon in mind. Twenty to thirty years of life after active work has completed is now the norm. And if we intend to work another 10-25 years, the opportunity for the positive effects of compounding growth in your retirement savings will make all the difference in the quality of life we might enjoy in retirement. Different from what you might choose for yourself, be it a presidential candidate or a particular investment, if you are the sponsor of a retirement plan, your employees are counting on your decisions, and the ramifications of those choices good or bad. You are choosing for them, as they generally have no say so in the matter. And yet it’s their money, their future. It is a very significant responsibility often overlooked. We review hundreds of 401k plans per month, and while the employers are certainly well intentioned, so little is often understood regarding the effect of investment-related fees over time. A recent study found that the average total cost for a small business retirement plan declined to 1.46% over the past year, and that within this amount, the investment-related expenses typically borne by participants average 1.37%. This particular study defined small plans as those with 50 participants or $2.5 million in assets. However, if you own or work for a business that has fewer than 50 participants or 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

less than $2.5 million in plan assets, odds are you’re paying a substantial amount more in 401k fees. Plans in this demographic are defined as “micro” plans. It is not uncommon for the underlying investments in these plans to have expense ratios averaging between 1.50% and 2.50%. This has a major impact on retirement savings over time that can be difficult to decipher. Why is this important to you? While 1.00% may sound insignificant, the costs of your investments can have a staggering effect on your retirement savings over time. According to the Department of Labor (DOL), paying just 1 percentage point more in expenses over the course of 35 years could reduce a worker’s retirement savings by nearly 28%. For example, Bob is a participant in a plan offered by his employer with a 401k balance of $25,000 that earns 7% over the next 35 years. If Bob paid 0.50% in fees, even if he stopped making new contributions, his account would grow to $227,000 at retirement. But if he paid fees totaling 1.5%, the savings would rise to only $163,000, or 28% less. A startling statistic is that in a recent survey by the AARP, nearly 70% of participants in 401k plans believe they are paying no investment-related expenses or that their employer absorbs these fees. Nearly 40% of plan sponsors, the business owners bearing the fiduciary liability of the plan, who have chosen the providers and investments in the plan, do not know the average expense

ratios of the funds in the plan. Both figures are truly astonishing. A review of your own 401k fees and investment options should be a near-term action item. Plan sponsors are required by the Department of Labor to compare their current plans against alternatives on a regular basis to be sure all fees are reasonable and prudent. With the proliferation of lawsuits that exist — many very high-profile — recently in the news brought on by plan participants and almost always related to excessive fees or the use of proprietary funds in the 401k plan, it makes all sense to have a documented process and report of your findings in case a DOL examiner knocks on your door. We’ve made it easy for you to get a quick check to see how your plan compares to industry averages here: http://americasbest 401k.com/medmark. A couple of pieces of information are all we’ll need to complete the analysis. You’ll know right away if the path your retirement plan is heading is a place you’ll want to end up — or if a change will do you, and your employees who are counting on you, a world of good. Nothing is more important regarding your money than knowing how much you have, where it is, and if it is invested, how the costs of those investments will affect your future. Consider taking these steps for you, your family, and those you employ, who most likely do not even understand how your choices affect their future. EP Volume 9 Number 2

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COMPANY SPOTLIGHT

Luman Dental, LLC This family-owned business focuses on exceptional customer experience, specialized products, and knowledgeable customer service — at a reasonable price Overview Luman Dental, founded in 2013, is a small, family-owned business based in Scottsdale, Arizona, and founded on the concept of providing exceptional customer experience through specialized products and knowledgeable customer service and support at a reasonable cost. The company specializes in the supply, implementation, training, and support of cone beam computed tomography (CBCT) equipment and discounted sales of high-quality tissuegrafting biomaterials. Luman Dental focuses on creating long-term business partnerships through superior products, services, customer experience, and ongoing support.

Management and ownership Jeremy Luman is the founder, co-owner, and primary customer contact for Luman Dental. As the “face” of Luman Dental, Jeremy is the direct sales contact with customers and performs the CBCT installations and training. Jeremy has a variety of skills, experience, and education allowing him to provide unparalleled service to dental practitioners and their staff. He started as an assistant for an endodontic and implantology practice in 2004 and mastered all aspects of the practice, including chairside procedures, front-office billing and insurance, supply logistics, and marketing. During this time, Jeremy also began working with J. Morita CBCT equipment and Maxxeus™ Dental biomaterials. While working in the endodontic practice, Jeremy began to realize a need in the dental community of providing specialized products with knowledgeable customer service and support. Jeremy and his wife, Alisha, then formed Luman Dental, LLC, in 2013. He graduated with a bachelor’s degree with a focus in Biomedical and Health Ethics from Arizona State University. Alisha Luman is the co-owner and primary back-office contact for Luman Dental. Alisha has been working in the dental field for over 15 years. She began her career as a back-office assistant for 7 years before furthering her education by completing her registered dental hygienist (RDH) degree 14 Endodontic practice

Luman Dental owners, Jeremy and Alisha Luman

“I have had an exceptional experience working with Jeremy. His very competitive prices paired with his superior service and knowledge are truly unmatched!” — Shawn Anderson, DDS, Precision Endodontics, Murrieta, CA

from Carrington College. Alisha has been working as an RDH in a private practice for the past 5 years and now focuses on the back-office responsibilities at Luman Dental, including operations, marketing, scheduling, travel, and finance. Alisha shares the same passion for dentistry as her husband, Jeremy and enjoys helping provide dental practitioners with quality products and knowledge to help improve their practices and patient care.

Products, services, and support Luman Dental, LLC, is a nationwide dealer for small equipment and for the leader in 3D imaging, J. Morita CBCT, a firm that offers superior detail, clarity, and

Luman family Volume 9 Number 2

Volume 9 Number 2

Tissue Services, a non-profit tissue bank out of Dayton, Ohio. Maxxeus Dental is registered with the FDA and accredited by the American Association of Tissue Banks. Products include Maxxeus demineralized bone matrix (DBM) putty, resorbable membranes, specialty grafts, bone particulates, and bone augmentation materials. Maxxeus Dental product brochures are also provided.

has sold, installed, and provided postinstallation support of a variety of CBCT machines nationwide. They are able to offer advice and training on other aspects of the dental practice, including chairside procedures, front-office billing and insurance, software applications, supply logistics, and marketing and continue to attend CE courses for CBCT, RCT, and implants.

Additional product and services knowledge

Customer service and support

Luman Dentalâ&#x20AC;&#x2122;s team has worked directly with both J. Morita CBCT and Maxxeus Dental biomaterials while assisting in an endodontic and implantology practice and

Maxxeus vial

Luman Dental, LLC, offers personalized, professional customer service and support, with direct access throughout the sales process, installation, and postinstallation. The firm offers fast and easy referral of financing options and provides competitive rates. Luman Dental has formed many professional relationships within the dental community and is happy to provide fellow doctor referrals for Luman Dental products and services insight and feedback. For more information, call 480-236-0080 or visit www.lumandental.com. EP This information was provided by Luman Dental.

Endodontic practice 15

COMPANY SPOTLIGHT

quality manufacturing. CBCT has become increasingly important in treatment planning and diagnosis in implant dentistry, and CBCT scanners are being used for many other beneficial uses, such as in the fields of oral surgery, endodontics, periodontics, and orthodontics. Luman Dental strongly advocates incorporating CBCT in the specialty dental practice to enhance treatment planning and outcomes. The company advises on the type of CBCT machine that works best for the practice and situation, as well as where to place the machine in existing and newly built offices to accommodate construction needs and safety requirements. CBCT training also provides Luman Dentalâ&#x20AC;&#x2122;s personalized instructions, J. Morita product brochures, as well as site evaluation, planning, installation, and training on all J. Morita products, including a wide variety of dental equipment and imaging machines sold by Luman Dental. In addition, as a nationwide dealer for Maxxeus Dental biomaterials, Luman Dental is able to provide better cost savings on high-quality tissue grafts from Community

CASE STUDY

Management of a traumatic dental injury in a 7-year-old boy Dr. Marga Ree treats a complicated dental trauma with a multidisciplinary approach Introduction According to various studies on prevalence and incidence of dental trauma, approximately 20%-30% of all children have sustained some type of a traumatic dental injury to their permanent teeth. Adequate management of dental trauma is crucial for the long-term prognosis of a permanent tooth. Endodontic, restorative, and periodontal aspects must all be taken into consideration during treatment planning. Treatment of young permanent teeth with pulp involvement represents both an endodontic and a restorative challenge. If pulp vitality is lost before root formation is completed, a root with thin dentinal walls may remain, which is more prone to fracture. After finishing endodontic treatment, an adequate restorative follow-up treatment with the aim of reinforcing the tooth is crucial for long-term survival. Therefore, minimally invasive endodontic and restorative treatment is to be preferred.

Case study A 7-year old patient was referred for diagnosis and treatment of two maxillary central incisors. A couple of weeks prior, he was involved in a traffic accident, at which time, two upper central incisors were damaged. According to the treatment report of the oral surgeon, tooth

Since 1980, Marga Ree, DDS, MSc, has had a private practice in Purmerend, which for the past 17 years has been dedicated to endodontics. Dr. Ree obtained her degree in dentistry from the University of Amsterdam in 1979. For the next 5 years, she was a part-time staff member of the department of Cariology Endodontology Pedodontology, as well as being a clinical instructor in the central dental clinic of the University of Amsterdam. In 1998, she entered a postgraduate program in endodontics, which she completed in 2001 with a Master of Science degree. Since that time, she has lectured widely and taught hands-on courses throughout the Netherlands and abroad. She is the primary author of several articles published in national and international journals and has contributed to several books on endodontics and restorative dentistry. Disclosure: Dr. Ree acknowledges having received no compensation for this article.

16 Endodontic practice

Figure 1: Clinical picture showing a rigid splint and crown fractures of teeth No. 8 and No. 9

No. 8 showed a complicated crown-root fracture, and tooth No. 9 showed an uncomplicated crown fracture and was luxated. The oral surgeon repositioned tooth No. 9 and applied a rigid splint. In addition, an attempt was made to cover the exposure site with composite. The patient was referred to the family dentist, and endodontic treatment of tooth No. 8 was recommended, if needed. The patient was referred to our office 2 weeks after the acciFigure 3: Preoperative radiograph Figure 2: Preoperative radiograph of teeth No. 7 and No. 8 showing a dent took place. At the time of showing a crown-root fracture of widened PDL of tooth No. 8 tooth No. 8 and a widened PDL of consultation, the splint had been tooth No. 9 in place for 2 weeks (Figure 1). The main complaint of the patient was sensitivity to percussion and palpation. to provide a hermetic seal. Radiographically, His medical history was noncontributory. a crown-root fracture of tooth No. 8 and a widened periodontal ligament (PDL) of teeth The splint impeded adequate oral hygiene. No. 8 and No. 9 were visible (Figures 2-3). Clinical examination revealed an uncomplicated crown fracture of tooth No. 9 that It was decided to remove the splint and re-evaluate the condition of both central was not sealed with composite. The fracture site of tooth No. 8 was partly covered by incisors. After removal of the splint, it was obvious that the pulp had been exposed to composite, but the bonding was insufficient Volume 9 Number 2

Volume 9 Number 2

CASE STUDY

the oral environment for 2 weeks, resulting in pulp necrosis (Figures 4-5). Tooth No. 9 responded positively to pulp tests, and the mobility was within normal limits. There was reasonable doubt about the reliability of the pulp test in tooth No. 9, and we suspected that the radiolucency associated with No. 9 was a sign of pulp necrosis (Figure 6). The preoperative diagnosis was a complicated crown-root fracture and apical periodontitis of tooth No. 8, and an extrusive luxation of No. 9. Treatment plan was root canal treatment in tooth No. 8 and highly likely in also in tooth No. 9, followed by restorative treatment with adhesive composite restorations. Local anesthesia was administered, and the teeth were isolated with a rubber dam. After working length determination with LightSpeed™ instruments (Figure 7) (marketed in its current form by Kerr Corporation, Orange, California), and mechanical and chemical debridement with 6% sodium hypochlorite (Vista Dental Products, Racine, Wisconsin), an interappointment dressing of calcium hydroxide (UltraCal® XS; Ultradent, South Jordan, Utah) was applied, and the tooth was temporized (Figure 8). Three weeks later, a composite core (LuxaCore; DMG, Hamburg, Germany; DMG America, Englewood, New Jersey) was placed in tooth No. 8, while preserving the endodontic access cavity. Because the palatal outline of the fracture site was located deep under the gingiva, a gingivectomy was performed using an electrosurge. After application of retraction paste (3M, St. Paul, Minnesota), a dry work field was created, and a core form (Kuraray Noritake Dental Inc., Okayama, Japan) was applied, acting as a matrix. A pulp test in tooth No. 9 yielded a negative response, and the radiolucency associated with tooth No. 9 had increased in size. Root canal treatment was started, and the diagnosis apical periodontitis of tooth No. 9 was confirmed. After mechanical and chemical debridement of tooth No. 9, an interappointment dressing of calcium hydroxide was applied, and the tooth was temporized (Figure 9). Four weeks later, the patient returned for finishing treatment. He was completely asymptomatic. After removing the calcium hydroxide by alternating 6% sodium hypochlorite (Vista Dental Products, Racine, Wisconsin) and 17% EDTA (Vista Dental Products, Racine, Wisconsin) ultrasonically activated, working length determination was repeated using LightSpeed instruments. The author follows a rule of thumb that if an apical foramen is equal or larger than a hand file or LightSpeed instrument No. 70 (= 0.70 mm), a hydrophilic

Figure 4: After removal of the splint, the extent of the fractures is clearly visible

Figure 6: Radiolucency associated with tooth No. 9 in conjunction with a positive pulp test

Figure 5: A complicated crown-root fracture has been exposed to the oral environment for 2 weeks and has resulted in pulp necrosis

Figure 7: A LightSpeed instrument is used to determine working length

Figure 8: Interappointment dressing of calcium hydroxide and a temporary restoration

calcium silicate-based sealer in conjunction with gutta percha is to be preferred. Traditional obturation methods do not provide an effective seal. They may shrink on setting, have little or no adhesion to dentin, and are not dimensionally stable when they come in contact with moisture, leading to dissolution and leakage over time. In recent years, new materials have been developed that overcome some of these shortcomings. Since 2008, three premixed Figure 9: Both central incisors are Figure 10: Gauging the apical forabioceramic products have been dressed with calcium hydroxide men with LightSpeed instruments ® available: EndoSequence BC Sealer™, EndoSequence® Root Repair Material™ (RRM) Paste, and Root oxide, tantalum oxide, calcium phosphate Repair Material™ (RRM) Putty (Brasseler monobasic, and fillers) have excellent USA®, Savannah, Georgia). Recently, these mechanical and biological properties, and materials have also been marketed under good handling properties. They are hydrothe name of TotalFill® (FKG Dentaire SA, La philic, insoluble, radiopaque, aluminum free, Chaux-de-Fonds, Switzerland). and high pH, and require moisture to harden. The manufacturer states that the three The working time is more than 30 minutes, forms of bioceramics are similar in chemical and the setting time is 4 hours in normal composition (calcium silicates, zirconium conditions, depending of the amount of Endodontic practice 17

CASE STUDY

Figure 11: Radiograph showing cone fit

Figure 12: (left to right) A demonstration of how a small piece of a bioceramic cement is tapped down the root canal using paper points. Close to the apex, the paper point in this case (narrow canal) was no longer inverted. After the first portion of the cement is secured apically, more material can be added, depending on the overall treatment plan. Courtesy of Artendo Enterprises Inc. This image was previously published in an article by Haapasalo, et al., titled “Clinical use of bioceramic materials,” in Endodontic Topics, 2015; 32:97-117, and is reused with permission of Dr. Markus Haapasalo.

moisture available. To date, over 100 studies have been published on premixed bioceramic materials in endodontics. The vast majority have shown that the properties are similar to mineral trioxide aggregate (MTA).1-3 The apical foramen of tooth No. 8 was gauged to be a size 0.70 mm, and tooth No. 9 was gauged to be a size 0.90 mm (Figure 10). After a final irrigation, the canals were dried with paper points. Gutta-percha cones taper .02 were fitted in the canals, and cut back 2 mm from working length (Figure 11) to create room for a hydrophilic calcium silicate putty, EndoSequence Root Repair Material Putty (Brasseler, Savannah, Georgia), which was applied with a Dovgan MTA gun (Hartzell and Son, Concord, California). The putty was applied by delivering it in small portions in the root canal and tapping it in an apical direction with paper point of different diameters (Figure 12). After verifying the position of the apical plugs with a radiograph, gutta-percha cones were buttered with EndoSequence BC Sealer and gently placed in the canals with a continuous movement (Figure 13). Then the gutta-percha cones were seared off with a tip of a MaxPack (Obtura Spartan, Algonquin, Illinois) to create room for a fiber-reinforced composite post (Figure 14). Many studies have shown that the use of fiber posts can increase the fracture resistance of immature, endodontically treated teeth,4-7 provided no additional tooth structure is removed to accommodate the post. Subsequently, the dentin of the root canal walls and the pulp chamber was conditioned with Ultra-Etch® (Ultradent, South Jordan, Utah), SA primer, and Clearfil™ Photo Bond (Kuraray Noritake Dental Inc., Okayama, Japan). After conditioning the surface of the quartz fiber posts (D.T. Light-Post®, RTD, 18 Endodontic practice

In addition to a good endodontic treatment using preferably a bioactive material, repair with minimally invasive restorative dentistry is paramount, and may hopefully result in a long-term tooth survival.

Figure 13: EndoSequence RRM Putty has been applied as an apical plug, and the gutta-percha cones buttered with EndoSequence BC Sealer have been placed

Figure 14: Post space has been created in the coronal half of the root canals

Saint Egreve, France) with Ceramic Primer (Kuraray, Kuraray Noritake Dental Inc., Okayama, Japan), they were cemented in the canals with LuxaCore, a composite core material (DMG, Hamburg, Germany; DMG America, Englewood, New Jersey). After the

Figure 15: Postoperative radiograph showing the root-filled teeth restored with fiber posts and composite resin

composite had fully set, the posts were cut back 2 mm under the cavo-surface, and covered with a hybrid universal composite (Tetric Ceram®, Ivoclar Vivadent, Schaan, Lichtenstein; Amherst, New York) (Figure 15). Finally, the patient was referred to a Volume 9 Number 2

The Dental Trauma Guide The Dental Trauma Guide, http://www.dentaltraumaguide.org, is a non-profit website dedicated to optimizing worldwide treatment of dental trauma. The website is developed in cooperation between the Copenhagen University Hospital and the International Association of Dental Traumatology (IADT). The latest update was carried out in 2014. The website is very user-friendly, and its use is strongly recommended by the author.

Follow-up Radiographic and clinical examination after 20 months revealed complete resolution of the radiolucencies (Figure 19) and two healthy teeth in full function. The patient remained completely asymptomatic; he and his parents were very satisfied on the cosmetic and functional aspects of the composite restorations; and there were no signs of wear (Figure 20).

Conclusion This case shows that a complicated fracture in a young patient can be successfully treated with a multidisciplinary approach. In addition to a good endodontic treatment Figure 16: Clinical picture of a LuxaCore buildup in tooth No. 8

Figures 17A-17D: Wax-up made in the laboratory. A putty mold made over the wax-up was used to buildup the composite restoration in different layers, starting with a palatal shell Volume 9 Number 2

Endodontic practice 19

CASE STUDY

restorative dentist for a definitive cosmetic restoration in both central incisors (Figure 16). At the restorative treatment procedure, the bulk of the buildup in tooth No. 8 was removed, but the cervical part, which was located subgingivally, was left in place. The teeth were restored using a minimally invasive layering technique, after a wax-up was made by the laboratory (Figures 17A-17D). The patient and his parents were very satisfied with the result (Figures 18A-18D).

CASE STUDY

Figures 18A-18D: Final result. Restorative work carried out by Dr. Caroline Werkhoven, Amsterdam

F igure 19: At 20 months, the lesions have decreased in size, and the patient is asymptomatic

using preferably a bioactive material, repair with minimally invasive restorative dentistry is paramount and may hopefully result in a long-term tooth survival. Common treatment planning, knowledge of each other’s areas of work, and regular communication make interdisciplinary approach an exciting and educational experience for all parties and may result in optimal care for our patients. EP 20 Endodontic practice

Figure 20: Clinical picture at 20 months, showing two healthy central incisors in full function

REFERENCES 1. Ree MH, Schwartz R. Clinical applications of bioceramic materials in endodontics. Endodontic Practice US. 2014;7(4):32-40. 2. Prati C, Gandolfi MG. Calcium silicate bioactive cements: Biological perspectives and clinical applications. Dent Mater. 2015;31(4):351-370. 3. Dawood AE, Parashos P, Wong RH, Reynolds EC, Manton DJ. Calcium silicate-based cements: composition, properties, and clinical applications. J Investig Clin Dent. 2015 Oct 5. doi: 10.1111/jicd.12195. [Epub ahead of print] Review. 4. Desai S, Chandler N. The restoration of permanent immature anterior teeth, root filled using MTA: a review. J Dent. 2009 Sep;37(9):652-657. 5. Cauwels RG, Lassila LV, Martens LC, Vallittu PK, Verbeeck RM. Fracture resistance of endodontically restored, weakened incisors. Dent Traumatol. 2014 Oct;30(5):348-55. 6. Brito-Júnior M, Pereira RD, Veríssimo C, Soares CJ, Faria-e-Silva AL, Camilo CC, Sousa-Neto MD. Fracture resistance and stress distribution of simulated immature teeth after apexification with mineral trioxide aggregate. Int Endod J. 2014 Oct;47(10):958-66. 7. Dikbas I, Tanalp J, Koksal T, Yalnız A, Güngör T. Investigation of the effect of different prefabricated intracanal posts on fracture resistance of simulated immature teeth. Dent Traumatol. 2014 Feb;30(1):49-54.

Volume 9 Number 2

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B-4640-EP-04.16

CASE STUDY

he treatment of immature necrotic teeth with non-vital pulps and open apices often presents a challenge to the clinician. Cleaning and shaping the thin canal walls, controlling the infection, and performing a satisfactory sealing of the apex sometimes are not possible.1 In most cases, the treatment involves the induction of apical closure by apexification procedures to allow more favorable conditions for the conventional treatment.2 Traditionally, calcium hydroxide has been the material of choice used to induce the formation of an apical hard tissue barrier before placing the permanent filling.3 Although many studies have reported favorable outcomes when this treatment is followed,4-7 some disadvantages have also been reported. The use of calcium hydroxide apical barriers has been associated with some problems, such as unpredictability of apical closure,8 risk of re-infection due to leakage in the provisional fillings,9 and risk of root fracture as a result of the long-term application of calcium hydroxide.10-11 Furthermore, poor patient compliance also has a negative influence on the prognosis of traditional apexification procedures.12

Mario Luis Zuolo, DDS, MSc, practices at Endodontic Specialists in Sao Paulo, Brazil. He has a Masters in Molecular Biology from UNIFESPPaulista School of Medicine, Sao Paulo, Brazil, and is a Professor in the graduate department of Endodontics, Professor in the Endodontics Programming at EAP-APCD, Sao Paulo, Brazil. Dr. Zuolo lectures globally on endodontics. The author of numerous publications since 1998, most recently co-wrote Reintervention in Endodontics, published by Quintessence in 2014. Arthur de Siqueira Zuolo, DDS, MSc, graduated from the University of Sao Paulo (USP), Faculty of Dentistry in Ribeirão Preto, Brazil, in 2010. He has a postgraduate degree in Endodontics from New York University in New York and a Masters and Specialist in Endodontics by Faculty of Dentistry at São Leopoldo Mandic, Campinas, Brazil. Dr. Zuolo is also an Adjunct Professor of Endodontics Specialty at APCD, Sao Paulo, Brazil. He has a private practice in Sao Paulo, Brazil, and is a co-author of the book Reintervention in Endodontics, published by Quintessence in 2014.

22 Endodontic practice

With the advent of the mineral trioxide aggregate (MTA), a calcium silicate-based biocompatible non-absorbable material, another option of treatment has been proposed.13 This material has the ability to set in a short period of time and in the presence of moisture. It solidifies into a hard structure in less than 3 hours.14 This property, along with its capacity of inducing cementum-like hard tissue when used in the periradicular tissues,15 allows its use in the immediate obturation of open apex.16-18 Several studies show that apexification with MTA has a high success rate with less visits and in less time to completion.18-21 Also, in a study that compared clinical and radiographic results of apexification with MTA or calcium hydroxide, all of the cases sealed with MTA healed, whereas in the calcium hydroxide cases, two out of 15 remained with the disease.9 However, MTA also has some disadvantages. Because of its consistency, its manipulation and placement in the site of repair can be challenging.22 Additionally, its use can cause discoloration of the tooth, and it should be used with caution when in esthetic zones.23 A novel material MTA REPAIR HP — “High Plasticity” MTA (Angelus®, Londrina, PR, Brazil) was recently introduced with the intent to improve some of those characteristics.24 This new formula maintains all the chemical and biological properties of the original MTA; however, it changes its physical properties of manipulation, resulting in a greater plasticity, and therefore facilitating manipulation and insertion. Additionally, its formula uses a different radiopacifier calcium tungstate (CaW04) that, according to the manufacturer, does not cause staining of the root or dental crown.24 In this report, we present clinical detection, diagnosis, and management of a nonvital central incisor with an open apex, using a novel MTA-based repairing material.

Case report A 12-year-old male patient with a noncontributory medical history presented for examination with chief complaint of pain in the tooth No. 11. Clinical examination

showed that the tooth had been restored with a temporary filling and responded with pain to percussion and palpation and also presented a discrete edema in the area. There was no probing defect or sinus tract stoma. According to the patient, a root canal treatment had been started in the tooth approximately 12 months before. In the radiographic examination, a radiopaque material inside the canal a few millimeters short of the apex could be noticed. Also, in the radiograph, it could be seen that the apex was not completely formed and presented a periapical lesion (Figure 1). A clinical diagnosis of pulpless tooth with unsatisfactory previously initiated therapy and symptomatic apical periodontitis was established. The treatment plan was to initially perform the cleaning and shaping of the canal and to place a calcium hydroxide dressing. Then after 1 to 2 weeks, with the regression of the symptoms, we would perform an apical barrier with a new MTA-based material, obturate the tooth, and restore it. The treatment plan was presented to the patient’s parents, who agreed to it. After the consent form was signed, 1.8 mL of local anesthesia (lidocaine 2% with epinephrine 1:100.000) was administrated, the restoring material was removed, and endodontic access corrected. After rubber dam isolation, the material inside the canal was removed with proper irrigation using a 2.5% sodium hypochlorite solution (Formula e Ação, São Paulo, SP, Brazil) and a CPR-7® ultrasonic tip (Obtura Spartan® Endodontics, Algonquin, Illinois) After the removal of the material in the canal, Largo burs (No. 2 and No. 3) were used to prepare the first two-thirds of the canal. Then the apical foramen was located with the aid of an apex locator (Raypex®, VDW, Munich, Germany), and working length (WL) was established at the “0.0” and confirmed with a radiograph. Instrumentation proceeded using stainless-steel K-type hand files in a crown-down technique until a size No. 80 hand file achieved the WL. Between each change of file, copious irrigation with 2.5% sodium hypochlorite solution was Volume 9 Number 2

made. Comparison of the CBCT images was performed, and bone healing and apical closure of the open apex could be observed (Figures 4-5).

Discussion

Figure 1: Initial radiograph showing tooth No. 11 with an open apex and a periradicular lesion

Figure 2: Radiograph after the first appointment with calcium hydroxide-based paste in the canal

Previous clinical studies in humans have demonstrated that an apical barrier of MTA can be used with success in the technique

Figures 3A-3B: Radiographs during obturation. 3A. Observe the position of the apical barrier pointed by arrows. 3B. Final obturation and restoration

Figures 4A-4B: Cone beam computed tomography (CBCT). 3A. Axial view just after the MTA HP placement. 3B. Axial view at 9-month follow-up period. Observe the bone formation, including the cortical plate Volume 9 Number 2

Endodontic practice 23

CASE STUDY

used as an irrigant (approximately 100 mL throughout the whole treatment). During the procedure, passive ultrasonic irrigation (PUI) was performed for 1 minute several times to assure complete removal of the prior material and to maximize the irrigation technique. After the completion of instrumentation, the canal was irrigated with 5 mL EDTA 17% (Formula e Ação, São Paulo, SP, Brazil) for 3 minutes and a final rinse with 5 mL saline solution. A calcium hydroxide-based paste was placed in the canal as an interappointment dressing, and the tooth was temporarily restored (Figure 2). After 10 days, the patient came to the clinic to conclude treatment. The tooth was asymptomatic, and the area was no longer swollen. The temporary filling was removed, the calcium hydroxide paste was removed from the canal using 2.5% sodium hypochlorite solution, and PUI as described before. Hand file No. 80 was used again at WL. The canal was then irrigated with 5 mL of EDTA 17% (Formula e Ação, São Paulo, SP, Brazil) for 3 minutes to remove smear layer, and 5 mL of saline solution was used for final rinse. The canal was dried with paper points, and MTA HP (Angelus, Londrina, Brazil) was manipulated according to manufacturer instructions and placed with the aid of pluggers (B&L Biotech Inc., Fairfax, Virginia) in the last 3 mm of the root canal, forming an apical plug. After 10 minutes, the material was set, and the tooth was obturated using BC Sealer™ (Brasseler USA®, Savannah, Georgia) and gutta-percha cones with lateral condensation technique (Figure 3). The pulp chamber was cleaned with a sponge soaked in 70% alcohol, and the access cavity was restored using composite (Figure 4). A high-resolution CBCT was requested to the patient immediately after treatment so it could be used for comparison later in the follow-up. The patient presented for recall 1 month later without any symptoms. Postoperative radiographic and clinical evaluations were performed at 3, 6, and 9 months. The tooth was asymptomatic, and the area did not have any signs of inflammation. After 9 months, another tomographic exam was

CASE STUDY

Figures 5A-5B: Cone beam computed tomography (CBCT). 5A. Sagittal view just after the MTA HP placement. 5B. Sagittal view at 9-month follow-up period. Reformulation of the cortical plate is visible as well as partial apical closure.

Figures 6A-6C: Angelus MTA REPAIR HP. 6A. Capsule with the powder. 6B. Liquid. 6C. The material after proper manipulation

of apexification of teeth with open apices. El Meligy, et al., (2006), ran a clinical trial comparing the use of calcium hydroxide and MTA in 30 teeth of 15 patients who had lost pulp vitality by caries or trauma. The conventional technique of apexification with calcium hydroxide was performed in one tooth, whereas the barrier technique with MTA was applied to the other tooth in the same patient. The teeth were then followed up for 3, 6, and 12 months, revealing that two of the teeth filled using calcium hydroxide failed, while none of the teeth filled with MTA showed clinical or radiographic signs of pathology. Simon, et al., (2007), carried out a prospective clinical trial in 57 teeth of 50 patients with open apices treated with MTA plug and definitive filling of the canal and observed success in 81% of the cases. In this case report, the use of a modified MTA (MTA-BIOCERAMICS-based highplasticity reparative cement) has shown a good clinical result considering the short follow-up period observed. Comparison of tomographic images just after the placement of the MTA barrier and after a 9-month period has demonstrated bone formation and closure of the apical portion with hard tissue. It should be noted that a radiolucent area also could be seen at this time. Such pattern of healing could be classified as incomplete healing according to Molven, et al., (1996). From a clinical point of view, the handling and placement of the MTA REPAIR HP was easier than the conventional MTA. According to the manufacturer, the difference is in the 24 Endodontic practice

replacement of distilled water (from the conventional Angelus MTA) by a liquid that contains water and another organic plasticizer that gives the new product high plasticity24 (Figure 6). The other manufacturer claim that the new MTA does not promote dental discoloration could not be studied since the material was placed in the apical portion of the canal. The importance of case reports is the demonstration of what is possible in our patients using scientific-based clinical protocols of treatment. Reports from clinical practitioners have played important roles in the field of dentistry but should be validated using adequate laboratory and clinical research studies. In conclusion, the clinical protocol using the new MTA REPAIR HP, described in this case report, enabled the successful apexification of a central incisor in a young patient. EP REFERENCES 1.

Trope M. Treatment of immature teeth with non-vital pulps and apical periodontitis. Endod Topics. 2006;14:51–59.

Rafter M. Apexification: a review. Dent Traumatol. 2005;21(1):1-8.

Granath LE. Some notes on the treatment of traumatized incisors in children. Odont Rev. 1959;10:272.

4. Morfis AS, Siskos G. Apexification with the use of calcium hydroxide: a clinical study. J Clin Pediatr Dent. 1991;16(1):13–19. 5. Kleier DJ, Barr ES. A study of endodontically apexified teeth. Endod Dent Traumatol. 1991;7(3):112–117. 6.

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):51–56.

Dominguez Reyes A, Munoz Munoz L, Aznar Martin T. Study of calcium hydroxide apexification in 26 young permanent incisors. Dent Traumatol. 2005;21(3):141-145.

Sübay RK, Kayataş M. Dens invaginatus in an immature maxillary lateral incisor: a case report of complex endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(2):e37-41.

9. El-Meligy OA, Avery DR. Comparison of apexification with

mineral trioxide aggregate and calcium hydroxide. Pediatr Dent. 2006;28(3):248-253. 10. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol. 2002;18(3):134–137. 11. Andreasen JO, Munksgaard EC, Bakland LK. Comparison of fracture resistance in root canals of immature sheep teeth after filling with calcium hydroxide or MTA. Dent Traumatol. 2006;22(3):154–156. 12. Heling I, Lustmann J, Hover R, Bichacho N. Complications of apexification resulting from poor patient compliance: report of case. ASDC J Dent Child. 1999;66(6):415–418. 13. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod. 1999;25(3):197–205. 14. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J Endod. 1995;21(7):349–353. 15. Shabahang S, Torabinejad M, Boyne PP, Abedi H, McMillan P. A comparative study of root-end induction using osteogenic protein-1, calcium hydroxide, and mineral trioxide aggregate in dogs. J Endod. 1999;25(1):1–5. 16. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study. Int Endod J. 2007;40(3):186–197. 17. Steinig TH, Regan JD, Gutmann JL. The use and predictable placement of mineral trioxide aggregate in one-visit apexification cases. Aust Endod J. 2003;29(1):34–42. 18. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod. 2008;34(10):1171-1176. 19. 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. 20. Nayar S, Bishop K, Alani A. A report on the clinical and radiographic outcomes of 38 cases of apexification with mineral trioxide aggregate. Eur J Prosthodont Restor Dent. 2009;17(4):150–156. 21. Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endod. 2008;34(7):812–817. 22. Seltzer S, Sinai I, August D. Periodontal effects of root perforations before and during endodontic procedures. J Dent Res. 1970;49(2):332–339. 23. de Chevigny , Dao TT, Basrani BR, Marquis V, Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: the Toronto study — phases 3 and 4: orthograde retreatment. J Endod. 2008;34(2):131-137. 24. Angelus. MTA REPAIR HP. http://angelus.ind.br/MTA-REPAIRHP-292.html. Accessed April 4, 2016. 25. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery — radiographic findings 8 to 12 years after treatment. J Endod. 1996;2(5):264-268.

MTA HP product is under FDA approval and will be launched in the US and Canada during 2016.

Volume 9 Number 2

CLINICAL

The envelope of motion and ProTaper NEXT™ Dr. Michael J. Scianamblo examines the envelope of motion in root canal preparation with a current review of the literature Introduction Schilder (1974) was the first clinician to provide a detailed discussion of the root canal preparation referring to the procedure as cleaning and shaping and to outline specific design objectives, which included a continuously tapering shape, maintenance of the original anatomy, an apex that is as small as practical, and conservation of tooth structure. This continuously tapering space was acquired using hand instrumentation with alternating reamers and files. Each instrument was pre-curved, which dictated alternate or intermittent contact with the canal walls and created what Schilder called an “envelope of motion.” This intermittent contact not only produced continuously tapering shapes, but also minimized both the transportation of the original canal and the opportunity for instrument breakage. Close examination of Schilder’s envelope of motion reveals that although these instruments rotated axially, they cut along a precessional axis, much like a spinning top (Figure 1A). Weine, et al., 1975, used clear acrylic blocks to evaluate the effectiveness of various instrumentation techniques, but their conclusions were somewhat disconcerting. They found that utilization of standard instruments in either reaming and/or filing produced preparations that were irregular in shape and were not continuously tapering. The narrowest part of the canal, the so-called “elbow,” was located at a point coronal to the apex or foramen. In addition, the foramen often displayed transportation, which was called the “apical zip.” These characteristics Michael J. Scianamblo, DDS, is an endodontist and the developer of Critical Path Technology. He is a postgraduate and fellow of the Harvard School of Dental Medicine and has served as a faculty member of the University of the Pacific and the University of California, Schools of Dentistry in San Francisco. He has also served as president of the Marin County Dental Society, the Northern California Academy of Endodontists, and the California State Association of Endodontists. He has presented numerous lectures nationally and internationally, and is a recognized author in endodontics, dental materials, and instrumentation. He maintained a private practice in endodontics in San Francisco and Marin County, California, since 1978. His career is currently dedicated to instrument development, and he has been awarded seven U.S. patents and two international patents with several pending.

26 Endodontic practice

were felt to result from the elastic memory of instruments and a predilection to straighten as they are migrated around curves. To alleviate this problem, Weine suggested removing the flutes from the outer surface of pre-curved files. Coffae and Brilliant (1976) corroborated the work of Schilder demonstrating that tapering preparations were more efficacious in the removal of debris from the root canal system when compared to parallel preparations. They also demonstrated that the serial use of files in a step-back modality were more effective in producing tapering shapes. Abou Rass, et al., 1980, also engaged in a discussion of anti-curvature filing to minimize the problems described by Weine. This method, however, advocated the removal of conspicuous amounts of tooth structure from the outer walls of the curve of a root canal system, which arguably, would weaken the outer wall. In another attempt to maintain the contour of the canal without transporting the apical foramen, Roane, et al., 1985, described a technique for root canal preparation called “balanced force.” The technique was a variation of reaming, which included “back-turning” the file in a counter-clockwise direction. Purportedly the restoring force or elastic memory of the file, as described by Weine, was overcome when pitted against dentinal resistance. However, Blum, Machtou, and others (1997) found that these techniques were a predisposing factor to instrument breakage. Walia (1988) was the first experimenter to discuss the use of nickel-titanium rotary instruments in endodontics, which has changed the landscape of endodontic cavity preparation immeasurably. The earliest investigators, including Glosson, et al., 1995, and Esposito, et al., 1995, suggested that nickel-titanium rotary instruments were superior to hand instrumentation in maintaining the original anatomy and required fewer instruments. However, Schafer, et al., 1999, found that nickel-titanium instruments with traditional cross sections and sizes left all curved canals poorly cleaned and shaped,

Figure 1A: A schematic of Schilder’s envelope of motion using a curved file with a specific arc length. Note that although the instrument is rotated axially, the instrument can only cut along the greater curvature of the file (indicated by the point of contact) or via a precessional axis, much like a spinning top

whereby tooth structure was removed almost exclusively from the outer wall of the curve. Kum, et al., 2000; Calberson, et al., 2002; and Schafer and Florek (2003) stated that the greatest failing of current NiTi designs is the continued predisposition to torsional and/or cyclic fatigue and breakage. Nickel-titanium instruments are predominately right-handed cut and with a right-handed helix. Thus, they can act like a screw as they rotate in the canal, predisposing them to entrapment or binding, and accompanied by cyclic fatigue and breakage (Scianamblo, 2005, and Yao, 2006). Numerous investigators have tried to mitigate these problems. The “variable taper” system described by Maillefer (1998) and marketed as ProTaper® was specifically designed to mitigate binding. The variable taper feature has become one of the most widely used systems in the world. Cheung (2005) and Spanaki-Voredi, et al., 2006, however, demonstrated that these instruments were still subject to flexural failure and spontaneous fracture. Remarkably, in examining the earliest designs, many investigators could not find a statistically significant difference between the effectiveness of any one instrument over another (Kum, et al., 2000; Peters, et al., 2001; and Ahlquist, et al., 2001). Volume 9 Number 2

Heretofore, all endodontic instruments have a center of rotation and a center of mass that are identical, which dictates a linear trajectory and path of motion. Intuitively, a file design with an axis of rotation, which is coincident with the center of mass, maximizes the restoring force of the file and minimizes flexibility. And files manufactured from nickel-titanium maximizes the restoring force further. The work of Peters, et al., 2001, indicates that this restoring force prevents these instruments from contacting the entire anatomy of the root canal preparation, leaving as much as 35% of the internal anatomy of the canal untouched, and the preparation poorly centered and unclean. In evaluating these problems, it became clear that a review of Herbert Schilder’s requirements for an ideal endodontic cavity preparation would be necessary to design a new file. Ideally a design that would mimic Schilder’s envelope of motion would mitigate these problems. Again referring to Figure 1A, it becomes apparent that Schilder’s envelope of motion was created using a unique method of manipulating the root canal file, whereby each pre-curved instrument that revolved within the canal walls could only cut in the greatest portion of the curve. Thus, as each instrument was inserted into deepest portion of the canal, although the rotation was around a central axis, the cutting itself was occurring around a precessional axis. As an example, Figure 1B demonstrates how a series of seven successively larger instruments could be used to expand the cutting envelope, but again notice that cutting is done intermittently and along a precessional axis or via mechanical waves. Our objective, then, was the development of Volume 9 Number 2

Figure 2: A schematic demonstrating the orientation of the cutting flutes of Protaper Next. Note the offset rectilinear cross section, which permits intermittent cutting along a precessional axis, much like Schilder’s envelope of motion

new method of canal enlargement that would mimic this concept. Although this idea was conceptual (Figure 2), the machine tool capabilities of Maillefer Dental Products or Dentsply International (Ballaigues, Switzerland) made this concept a reality. More than a dozen prototypes were engineered and tested over an 8-year period, which led to the development of what was originally called “swaggering files,” now called X-files and embodied in the ProTaper NEXT™ design. In referring to Figure 2, it can seen that the cutting edges of the file are oriented such that they cut in the perimeter of the cutting envelope or precessionally, enabling intermittent cutting. It can also be seen how a design like this might mitigate binding and the predisposition for breakage, while improving hauling or debris removal.

Performance ProTaper NEXT was designed to mimic Schilder’s envelope of motion by offsetting a rectilinear cross section, which revolves (6-7 revolutions) around the central axis. These revolutions are also called pitch. In Figure 3, the central or rotational axis of the X-file is shown by Axis 1. Axis 2 follows the center of mass or geometric center of the X-file. The

Figure 3: A schematic of the profile and dual axis of Protaper Next. Axis 1 is the central or rotational axis and axis 2 is the cutting or precessional axis. The distance X between the two axes decrease continuously from shank to tip, where the axes meet, leaving the tip completely centered. The offset center of mass, inherent in this design, enables the X-file to cut precessionally. Precession describes a motion whereby a body is spinning; however, the body of the object is spinning about another axis Endodontic practice 27

CLINICAL

Figure 1B: A schematic demonstrating the enlargement root canal utilizing pre-curved instruments and employing Schilder’s strategy for creating the envelope of motion. Note that the first instruments are directed to toward the apical segment, while the last instruments are directed toward the orifice of the canal. The confluence of the prepared segments produces the continuously tapering shape characteristic of this technique

amount of offset between the center of rotation and the center of mass is defined by the distance between these two axes and varies along the length of the file or distance X. When observed during operation, precession of the X-file gives the appearance of a traveling wave (Scianamblo, 2005, 2006, 2011, and 2015). What is essential to the design of the X-file is that the undulating nodes and precessional axis of the X-file circumscribes an envelope of motion similar to Schilder’s pre-curved file (Figure 1A). What is also essential to the design of the X-file is that the offset cross section mitigates the restoring force, similar to Roane’s balanced force technique, which should improve centering. This is dictated by Newton’s laws for the mass moment of inertia and the parallel-axis theorem. Simply stated, the resistance to bending and distortion of a given lamina or cross section can be increased or decreased exponentially, as the distance of the centroid (center of mass) from the central axis is varied. The testing of the X-files has demonstrated that offsetting the center of mass produces not only efficient cutting instruments, but also instruments that remained exceptionally well centered, minimizing transportation (Pasqualini, et al., 2015; Burklein, et al., 2015; Saber, et al., 2015; Zhao, et al., 2104; and Elnaghy, et al., 2014) and corroborated clinically (Figures 4, 5, 8, and 9). For further analysis, we will define each arc as a wave of amplitude X as shown in Figure 6. The total distance traveled by any point on the arc can then equal 2X, which defines the cut diameter. Thus, the cutting envelope associated with any node along the instrument’s profile is potentially twice as wide as the instrument at that cross section. As mentioned, this file design (Figures 2 and 7) features an offset rectilinear cross section. As can be seen from this figure, only two cutting angles engage the walls of the root canal at any one time. This offset rectilinear cross section not only contributes to the innate flexibility of the file, but also

CLINICAL

Figure 4: Postoperative radiograph of an upper first bicuspid with three canals. The mesial canals were prepared with files X1 and X2 only. The palatal canal was prepared with X1, X2, and X3. The canals were obturated using Schilder or warm gutta-percha technique (M. Scianamblo, San Rafael, California)

permits intermittent cutting, which mitigates cyclic fatigue (Perrez-Higueras, et al., 2014; Nyguen, et al., 2014, and Elnaghy, et al., 2014). In addition, the offset cross section provides larger clearance angles for hauling, which can further enhancing the cutting efficiency and performance, and mitigate the opportunity for apical extrusion of debris (Capar, et al., 2014 and Kocak 2015). Lastly, the helical architecture of the file would imply that the instruments are compressible. Although these studies are not complete, it has been demonstrated that these instruments impart less internal stress and can minimizing crack formation (Capar, et al., 2014; Arias, et al., 2014; and Berutti, 2014), in addition to cutting more efficiently (Burkelin, et al., 2014, and Pasqualini, et al., 2014). In light of this current research and reports of clinical success, this offset feature has been incorporated into the next generation of reciprocating files recently introduced as WaveOne® Gold. Continued research will be required to elaborate other advantages of ProTaper Next and similar designs.

Figure 5: A postoperative radiograph of an upper second molar with severely dilacerated canals. The mesial canals were prepared with files X1 and X2 only. The palatal canal was prepared with X1, X2, and X3. The mesial canals were obturated with Thermofil®, and the palatal canal was obturated using an X-3 gutta-percha cone (G. Barboni, Bologna, Italy)

Figure 6: A schematic of the cutting envelope of ProTaper Next. Note that each node or arc traces out a wave of amplitude X. The total distance traveled by any point on the arc, then equals 2X, which defines the cut diameter. Thus, the cutting envelope associated with any node along the instrument’s profile is potentially twice as wide as the instrument itself at that cross section

Sequence and method of use Again referring to Figure 3 and as stated previously, the instruments create larger cutting envelopes utilizing smaller cross sections. Thus, canals can be prepared safely with only two or three instruments. The clinical guidelines for use of ProTaper Next instruments was discussed previously by Van der Vyver and Scianamblo (2013 and 2014). In summary, a torque-controlled handpiece should be set at 300 rpms and 2NCm. Use up to 4 NCm may be considered as experience dictates. 28 Endodontic practice

Figure 7: A schematic of offset rectilinear cross section of ProTaper Next. As can be seen from this figure, only two cutting angles engage the walls of the root canal at any one time. This offset rectilinear cross section not only contributes to the innate flexibility of the file, but also permits intermittent cutting, which mitigates cyclic fatigue. The large clearance angle opposite the cutting flutes facilitate hauling and elimination of debris Volume 9 Number 2

a shift up in performance PROTAPER NEXT features the same variable tapered performance as the original PROTAPER, but is refined with: • Unique rotary motion that further enhances PROTAPER canal-shaping efficiency • Proven M-Wire® NiTi alloy for increased flexibility and resistance to cyclic fatigue • Rectangular cross-section design for greater strength

www.DENTSPLY.com

Performance Refined © DENTSPLY International, Inc. ADPTN2 Rev. 2 06/16

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CLINICAL

Figure 8: Postoperative radiograph of an upper second molar with four separate canals. The mesial canals were prepared with files X1 and X2 to the apex using X3 and X4 in the upper two-thirds of the canals in a back-stepping modality. The palatal canal was prepared with X1, X2, and X3 to the apex using the X4 and X5 in the upper two-thirds of the canals in a back-stepping modality. The canals were obturated using Schilder technique (R. Rishwain, San Rafael, California)

The X-file sequence is preceded by creation of a glide path with a No. 10 file, followed by the use of the PathFiles, or similar glide path files, e.g., ProGlider or a number 15-K file. Further enlargement of the upper portion of the canal and removal of restrictive dentin can also be accomplished using the XA orifice opener or use of the X1 in the coronal portion of the canal only. Once the glide path has been established, the X-File sequence using X-1 and X-2 is carried to the working length using a pull-pull motion allowing the instrument to work without forcible pressure in a continuous push-pull movement. Brushing may also be used to remove restrictive dentin due to the precessional cutting feature of these files. The instruments should be used in the presence of NaOCL and, as with all rotary nickel-titanium instruments, irrigation and recapitulation should follow the use of each instrument. The narrowest canals can usually be prepared with only the X1 (17/04) and X2 (25/06). Larger canals can be prepared by adding the X3 (30/07). The X4 (40/06) and X5 (50/06) can be used for much larger canals or enlargement vehicles in the upper portion of the canal, if a greater taper is desired. Finally, gauging should be accomplished using the hand file that corresponds to the tip size of each X-file. EP REFERENCES 1. Ahlquist M, Henningsson O, Hultenby K, and Ohlin J. The effectiveness of manual and rotary techniques in the cleaning of root canals: a scanning electron microscopy study. Int Endod J. 2001;34(7):533-537. 2. Arias A, Singh R, and Peters OA. Torque and force Induced by ProTaper Universal and ProTaper Next during shaping of large and small root canals in extracted teeth. J Endod. 2014;40(7): 973–976. 3. Berutti, E, Alovisi, M, Pastorelli, MA, Chiandussi, G, Scotti,

30 Endodontic practice

Figure 9: A postoperative radiograph of an upper second bicuspid with severely dilacerated canals and a complex bend. The mesial canal was prepared with files X1 and X2 only. The palatal canal was prepared with X1, X2, and X3. The canals were obturated using Schilder technique (X. Brant, Belo Horizonte, Brazil)

N and Pasqualini, D. Energy consumption of ProTaper Next X1 after glide path with PathFiles and ProGlider. J Endod. 2014; 40(12): 2015-2018. 4. Blum JY, Machtou, P, Esber S, Micallef, JP. Analysis of forces developed during root canal preparation with the balanced force technique. Int Endod J. 1997;30(6):386-396. 5. Bürklein S, Mathey D, Schäfer E. Shaping ability of ProTaper NEXT and BT-RaCe nickel-titanium instruments in severely curved root canals. Int Endod J. 2015;48(8): 774-781. 6. Berutti E, Alovisi M, Pastorelli MA, Chiandussi G, Scotti N, Pasqualini D. Energy consumption of ProTaper Next X1 after glide path with PathFiles and ProGlider. J Endod. 2014; 40(12):2015–2018. 7. Calberson FL, Deroose CA, Hommez GM, Raes H, De Moor RJ. Shaping ability of GT Rotary Files in simulated resin root canals. Int J Endod. 2002;35(7):607-614. 8. Capar ID, Arslan H, Akcay M and Uysal B: Effects of ProTaper Universal, ProTaper Next, and HyFlex instruments on crack formation in dentin. J Endod. 2014;40(9):1482–1484. 9. Capar ID, Arslan H, Akcay M, Ertas H. An in vitro comparison of apically extruded debris and instrumentation times with ProTaper Universal, ProTaper Next, Twisted File Adaptive, and HyFlex instruments. J Endod. 2014;40(10):1638–1641. 10. Cheung GS, Peng B, Bian Z, Shen Y, Darvell BW. Defects in ProTaper S1 instruments after clinical use: fractographic examination. Int Endod J. 2005;38(11):802-809. 11. Chow DY, Stover SE, Bahcall JK, Jaunberzins A, Toth JM. An in vitro comparison of the rake angles between K3 and ProFile endodontic file systems. J Endod. 2005;31(3):180-182. 12. Coffae KP, Brilliant JD. The effect of serial preparation versus nonserial preparation on tissue removal in the root canals of extracted mandibular human molars. J Endod. 1975;1(6):211-214. 13. Elnaghy AM and Elsaka, SE: Assessment of the mechanical properties of ProTaper Next nickel-titanium rotary files J Endod. 2014; 40:1830–183. 14. Elnaghy AM, Elsaka SE. Evaluation of root canal transportation, centering ratio, and remaining dentin thickness associated with ProTaper Next instruments with and without glide path. J Endod. 2014;40(12):2053–2056. 15. Esposito, PT, Cunningham, CJ. A comparison of canal preparation with nickel-titanium and stainless steel instruments. J Endod. 1995;21(4):173-176. 16. Glosson CR, Haller RH, Dove SB, Del Rio CE. A comparison of root canal preparations using N-Ti hand, Ni-Ti enginedriven and K-flex endodontic instruments. J Endod. 21(3):146-151. 17. Koçak MM, Çiçek E, Koçak S, Sağlam BC, Yılmaz N. Apical extrusion of debris using ProTaper Universal and ProTaper Next rotary systems. Int Endod J. 2015;48(3):283-286. 18. Kum KY, Spängberg L, Cha BY, Il-Young J, Msd, SeungJong L, Chan-Young L. Shaping ability of three ProFile rotary instrumentation techniques in simulated resin root canals. J Endod. 2000;26(12):719-723. 19. Maillefer, PL, Aeby, F, inventors; Maillefer Instruments, S.A. Instrument for boring dental radicular canals. US Patent 5,746,597. May 5, 1998.

20. Pérez-Higueras JJ, Arias A, de la Macorra JC, Peters OA. Differences in cyclic fatigue resistance between ProTaper Next and ProTaper Universal instruments at different levels. J Endod. 2014;40(9):1477–1481. 21. Nguyen HH, Fong H, Paranjpe A, Flake NM, Johnson JD, Peters OA. Evaluation of the resistance to cyclic fatigue among ProTaper Next, ProTaper Universal, and Vortex Blue rotary instruments. J Endod. 2014;40(8):1190–1193. 22. Pasqualini D, Alovisi M, Cemenasco A, Mancini L, Paolino DS, Bianchi CC, Roggia A, Scotti N, Berutti E. Micro– computed tomography evaluation of Protaper Next and BioRace shaping outcomes in maxillary first molar curved canals. J Endod. 2015; 41(10):1706-1710. 23. Peters OA, Schönenberger K, Laib A. Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro computed tomography. Int Endo J. 2001;34(3):221-230. 24. Roane JB, Sabala CL, Duncanson MG Jr. The “balanced force” concept for instrumentation of curved canals. J Endod. 1985;11(5):203-211. 25. Scianamblo, MJ. A contemporary approach to cleaning and shaping the root canal system emphasizing “early coronal enlargement.” In: Castellucci A. Endodontics. Chapter 16. Florence, Italy: Il Tridente. 2005:470-501. 26. Scianamblo, MJ, inventor. Critical path endodontic instruments for preparing endodontic cavity spaces. US Patent 6,942,484. Sept 13, 2005. 27. Scianamblo, MJ, inventor. Bending endodontic instruments. EP Patent 1,709,934 B1. March 30, 2011. 28. Scianamblo, MJ, inventor. Endodontic instruments for preparing endodontic cavity spaces. US Patent 7,955,078. June 7, 2011. 29. Scianamblo, MJ, inventor. Swaggering Endodontic Instruments. US Patent 8,454,361. June 4, 2013. 30. Scianamblo, MJ, inventor. Swaggering Endodontic instruments. US Patent 20150173853. June 25, 2015. 31. Spanaki-Voreadi AP, Kerezoudis NP, Zinelis S. Failure mechanism of ProTaper Ni-Ti rotary instruments during clinical use: fractographic analysis. Int Endod J. 2006; 39(3):171-178. 32. Schäfer, E. Relationship between design features of endodontic instruments and their properties. Part 2. Instrumentation of curved canals. J Endod. 1999; 25(1):56-59. 33. Schäfer E, Florek H. Efficiency of rotary nickel-titanium K3 instruments compared with stainless steel hand K-Flexofile. Part 1. Shaping ability in simulated curved canals. Int Endo J. 2003; 36(3):199-207. 34. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2):269-296. 35. Walia HM, Brantley WA, Gerstein H. An initial investigation of the bending and torsional properties of Nitinol root canal files. J Endod. 1988;14(7):346-351. 36. Weine FS, Kelly RF, Lio PJ. The effect of preparation procedures on original canal shape and on apical formation shape. J Endod. 1975;1(8):255-262. 37. Yao JH, Schwartz SA, Beeson TJ. Cyclic fatigue of three types of rotary nickel-titanium files in a dynamic model. J Endod. 2006;32(1):55–57.

Volume 9 Number 2

Achieving A Predictable Seal

Comes Naturally ProRoot® ES provides a natural seal by sealing the root canal biologically. • Biocompatible with periradicular tissues • Not cytotoxic in the mixed or hardened state • Bioinductive for cementum to support tissue regeneration

CALL TO ORDER TODAY! 1-800-662-1202 Made from an enhanced formula of its counterpart ProRoot® MTA root repair material, ProRoot ES contains the same healing properties clinicians have come to trust from the ProRoot name. Its non-toxicity ensures it does not stimulate an inflammatory or root-resorptive response so you can be confident the infection stops with the ProRoot ES seal.

©DENTSPLY International, Inc.

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ADPRES Rev.0 02/16

CONTINUING EDUCATION

Successful anesthesia in acutely inflamed pulps Dr. John Lordan examines how to achieve profound pulpal anesthesia in teeth with irreversible pulpitis

uccessful anesthesia in mandibular molar teeth is challenging under normal pulpal conditions but particularly so when the patient presents with a symptomatic acutely inflamed pulp. This will not surprise any operating dentist who faces the challenge of trying to operate on a patient who cannot tolerate the procedures due to lack of profound anesthesia. It is important to realize that the inferior alveolar nerve block (IANB) has deficiencies in providing the desired level of pulpal anesthesia in normal pulps and could be considered not fit for purpose in acutely inflamed pulp situation (Vreeland, et al., 1989; Wali, et al., 1988). It is well established that complete pulpal anesthesia is not achieved 100% of the time in normal pulps, and that lip numbness does not confirm pulpal anesthesia. In fact, confirmed 100% lip numbness after IANB in inflamed pulps reported only 55% successful pulpal anesthesia. There are multiple theories on the reasons for failure, and the reality is that a combination of factors are involved (Nusstein, et al., 1998; Cohen, et al., 1993). There are many theories on what causes anesthetic failure in acutely inflamed pulps, such as increased blood flow in inflamed tissues and lowered pH locally interfering with LA solution activity (Hargreaves, Keiser, 2002). Accessory innervation from mylohyoid nerve has also been mentioned (Vandermeulen, 2000). The presence of inflammatory mediators such as substance P and calcitonin neuropeptides also reduces the effect of local anesthetic (Rood, et al., 1981). Nerve sprouting also occurs in inflamed tissues, increasing the volume of nerve tissue to be anesthetized (Hargreaves, 2001). The central core theory (de Jong, 1997; Strichartz, 1976) states that the outer nerves of the inferior alveolar bundle supply

John Lordan, BDS, MSD Endo, completed his endodontic residency in Boston University in 1994 with the renowned mentor Dr. Herbert Schilder — considered by many to be the pioneer of modern endodontics. Dr. Lordan returned to Dublin in 1994 and established Northbrook Endodontics where he provides endodontic support to the dental profession. He is a regular presenter to the dental fraternity promoting confidence and predictability in all aspects of endodontics.

32 Endodontic practice

Educational aims and objectives

This clinical article aims to investigate achieving profound pulpal anesthesia.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize that intraligamental and intraosseous techniques are very successful in achieving profound pulpal anesthesia. • Recognize that these techniques should be considered as part of the routine approach. • Identify a specific mandibular anesthesia protocol.

Figure 1: Mandibular anesthesia protocol

Figure 2: Nerve course

Figure 3: Location of nerves

Figure 4: Anesthetic

the molar teeth, whereas the nerves for the anterior teeth lie more deeply, making it more difficult for the anesthetic to diffuse through and provide an adequate block. Central nervous system sensitization can also occur where inflammatory conditions have existed for some time, as in slow onset pulpitis. It is safe to say that some of the reasons for failure are often related to physiological factors and not just anatomy with

decreased excitability thresholds on nerves compounded by an increased anxiety in those patients in pain (Cohen, et al., 1993; Hargreaves, et al., 2002). This can result in an innocuous stimulus presenting as painful in a patient who has been subject to central sensitization due to long-term exposure to discomfort. Patients presenting with irreversible pulpitis are often aware of symptoms for Volume 9 Number 2

Mandibular anesthesia protocol Inferior alveolar dental block is administered; wait for at least 15 minutes. Then once lip “numbness” is established and confirmed, follow up with buccal infiltration and lingual infiltration on attached gingiva (Figure 5). Evaluate anesthesia through electric pulp test (EPT) or cold test and advise the patient that you have facility for further anesthetic procedures at your disposal. And be prepared for this part of your routine preparation when supplementary anesthesia is indicated (Dreven, et al., 1987). Changing the anesthetic type or the block injection technique (Gow-Gates, Akinosi) does not improve the chances of success, and giving another inferior alveolar dental block (ID) will help only if the initial block has failed. Increasing the volume of the local anesthetic will not improve the pulpal anesthetic effect. It may, in fact, have the opposite effect due to tachyphylaxis where the anesthetic reaction becomes increasingly weaker due to “ion trapping” of the anesthetic in inflammation-induced acidic tissue (Gow-Gates, 1973; Claffey, et al., 2004; Mikesell, et al., 2005; Nusstein, et al., 2002; Goldberg, et al., 2008). Volume 9 Number 2

Maxillary molars

Intraligamentary injections

Patients presenting with acute pulpitic maxillary molars respond well to buccal and palatal infiltration, and profound anesthesia is readily achieved successfully. This confirms that, if you can place the anesthetic in close proximity to the root apex, the outcome is positive and anesthesia will be successful.

Periodontal ligament injection has been shown to be successful in achieving anesthesia in 75% of cases in an initial application and up to 96% success in a second injection. Periodontal ligament injection is essentially a route into the cancellous spaces, so it is, in effect, an intraosseous injection. Different kits are available, but the needle should be placed in the gingival crevice with the bevel facing the root surface and the injection under pressure for 10 seconds at each corner of tooth. The rate of onset is fast, but the duration is low; application can be problematic and uncomfortable for patients as well as stressful for the operator (Cohen, et al., 1993; Walton, Abbott, 1981; Smith, et al., 1983).

Anesthetic choice The anesthetic of choice is Lignospan® 2% 1:000.000 for IANB injections. There are studies supporting the use of articaine with 1:100000 adrenaline administered by buccal infiltration as an alternative to inferior alveolar nerve block in normal pulps; however, in symptomatic teeth, there was no advantage in using articaine, and there are some dangers of paresthesia (>20 times) in its uses as IANB technique (Claffey, et al., 2004; Kanaa, et al., 2009). The lingual nerve is more frequently damaged than the inferior alveolar in these cases due to its location (Figure 3). Thankfully, 90% of cases fully recover within 2 months, but this is an avoidable risk.

Intraosseous injection Intraosseous injections (Figures 6 and 7) deliver an anesthetic solution directly into the cancellous bone distal to the affected tooth. Stabident (Figure 8) and X-Tip™ (Dentsply) (Figure 9) systems are well established

Achieving profound pulpal anesthesia is the cornerstone of successful endodontics, and this poses challenges in teeth with irreversible pulpitis, particularly mandibular molars.

Figure 5: Buccal and lingual infiltration on attached gingiva

Figure 6: Periodontal ligament injection

Figure 7: Intraligamental injection

Figure 8: Stabident system Endodontic practice 33

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some time (weeks or months before) and may relate the discomfort to a restorative procedure such as composite filling placement or crown placement. Symptoms gradually become more severe with longer-lasting painful episodes occurring spontaneously and usually acute response to heat application relieved by cold and paroxysmal in nature. Patients may have had difficulty sleeping and are usually fractious and fragile. Dental confidence is low, and so every effort must be explored to reassure patients that we are aware and understanding of their situation and that we have the experience and techniques to deal with their symptoms comfortably. Naturally, when IANB is successful — i.e., lip numbness established but pulpal anesthesia still not achieved — we need to take positive action rather than trying to proceed with treatment on a very anxious patient. Preoperative oral administration of a non-steroidal analgesic, 800 mg ibuprofen, for example, can help improve the efficacy of local anesthetic in some cases (Ianiro, et al., 2007). Some patients may also benefit from oral diazepam — typically 10 mg15 mg taken the night before appointment and 1 hour before treatment.

CONTINUING EDUCATION intraosseous systems that deliver anesthetic solutions directly into the cancellous bone via a predrilled pathway. The Stabident system provides a perforation bur with a separate needle that works well, providing the access hole is readily located, which is not always the case, necessitating a second perforation with associated increased anxiety. The X-Tip system solves this issue by leaving a guide sleeve in situ to guide the needle access (Figures 9 and 10), but this is a bulky system that requires practice to perfect. Difficulty separating the drill from the guide sleeve can be an issue, and the large diameter guide sleeve can generate higher temperatures during perforation of thicker, denser cortical bone, resulting in postoperative discomfort (Parente, et al., 1998; Parente, et al., 1998; Nusstein, et al., 1998).

Figure 9: X-Tip system

Figure 10: X-Tip guide sleeve in situ to guide the needle access

QuickSleeper 4 The QuickSleeper 4 (Dental Hi Tec) (Figures 11-15) is a motorized needle system that can perforate the cortical plate and administer the local anesthetic through that perforation in a single procedure, which greatly reduces the margin for errors experienced with Stabident and X-Tip systems. Nusstein (1998) and Rood (1981) found that intraosseous injections of lignocaine 1.100000 adrenaline were successful more than 90% of the time and after achieving complete pulpal anesthesia once a successful IANB injection is confirmed. Onset is almost immediate, and duration has been reported to last approximately 45 minutes, which is more than adequate to access the pulpal space and complete biomechanical preparation. The big advantage of the QuickSleeper system is the single action of penetration, injection, and withdrawal; the efficiency and success of this procedure is invaluable in these cases.

Figure 11: QuickSleeper 4 (Dental Hi Tec)

Figure 12: QuickSleeper 4 (Dental Hi Tec)

Figure 13: QuickSleeper 4 perforates cortical plate

Intraosseous ligamental pathway via PDL My preference is a combination of intraligamental and intraosseous techniques facilitated by the QuickSleeper S4 (Dental Hi Tec) handpiece with the 16 mm motorized needle via the periodontal ligament in one continuous step. The needle is placed in the gingival crevice, and the anesthetic is pumped slowly before activating the motor to rotate the needle in 5 second intervals, passing through the periodontal ligament into the cancellous bone around the apices where the anesthetic is deposited to where it is most needed. This 34 Endodontic practice

Figure 14: QuickSleeper 4 in use

Figure 15: QuickSleeper activity field Volume 9 Number 2

Intrapulpal injection Despite the apparent success of the IANB supplemented by periodontal ligament or intraosseous injection (more than 90% complete pulpal anesthesia), it is not uncommon for patients with acute long-standing pulpitis to experience some discomfort as pulp fibers can still spark, despite apparent total anesthesia present. In these cases, smooth turbine bur action can usually be tolerated until pulp chamber access is established. Anesthetic can then be injected under pressure, allowing further access. In these cases, a fine gauge needle can be inserted into the canal orifice and anesthetic again injected under pressure before instrumenting the individual canals. It is a dynamic situation and requires constant monitoring and communication. A pinhead pulpal exposure can then be created and injected under pressure. Be committed and maintain constant communication, reassuring the patient that all is being done to get the desired result Volume 9 Number 2

and facilitating biomechanical preparation (Birchfield, Rosenberg, 1975; VanGheluwe, Walton, 1997).

Summary Achieving profound pulpal anesthesia is the cornerstone of successful endodontics, and this poses challenges in teeth with irreversible pulpitis, particularly mandibular molars. Failure has been attributed to poor technique or aberrant anatomy, while the reality is that the IANB is not fit for purpose in these situations, and supplemental techniques are required.

Intraligamental and intraosseous techniques are very successful in achieving profound pulpal anesthesia and should be considered as part of the routine approach. Stabident and X-Tip have been around for some time and are well proven. However, the QuickSleeper 4 motorized needle system, applied through the ligamental pathway, is a game changer, benefiting both the patient and operator through predictability and simplicity of use. It is an invaluable tool that should be a part of routine anesthetic protocol in acutely inflamed mandibular situations. EP

REFERENCES 1. Birchfield J, Rosenberg P. Role of the anesthetic solution in intrapulpal anesthesia. J Endod. 1975;1(1): 26-27. 2. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod. 2004;30(8):568-571. 3. Cohen HP, Cha B,Y Spangberg LS. Endodontic anesthesia in mandibular molars: a clinical study. J Endod. 1993;19(7):370-373. 4. de Jong RH. Neural blockade by local anesthetics. JAMA. 1977;238(13):1383-1385. 5. Dreven LJ, Reader A, Beck M, Meyers WJ, Weaver J. An evaluation of an electric pulp tester as a measure of analgesia in human vital teeth. J Endod. 1987;13(5):233-238. 6. Goldberg S, Reader A, Drum M, Nusstein J, Beck M. Comparison of the anesthetic efficacy of the conventional inferior alveolar, Gow-Gates, and Vazirani-Akinosi techniques. J Endod. 2008;34(11):1306-1311. 7. Gow-Gates GA. Mandibular conduction anesthesia: a new technique using extraoral landmarks. Oral Surg Oral Med Oral Pathol. 1973;36(3):321-328. 8. Hargreaves KM, Keiser K. Local anesthetic failure in endodontics: Mechanisms and Management. Endod Topics. 2002;1(1):26-39. 9. Hargreaves KM. Neurochemical Factors in Injury and Inflammation in Orofacial Tissues. In: Lavigne GJ, Lund JP, Sessle BJ, Dubner R. eds. Orofacial Pain: From Basic Science to Clinical Management. Chicago: Quintessence Publications; 2001. 10. Ianiro SR, Jeansonne BG, McNeal SF, Eleazer PD. The effect of preoperative acetaminophen or a combination of acetaminophen and ibuprofen on the success of inferior alveolar nerve block for teeth with irreversible pulpitis. J Endod. 2007;33(1):11-14. 11. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endod J. 2009;42(3):238-246. 12. Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. J Endod. 2005;31(4):265-270. 13. Nusstein J, Reader A, Beck FM. Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocks. Gen Dent. 2002;50(4):372-375; quiz 376-377. 14. Nusstein J, Claffey E, Reader A, Beck M, Weaver J. Anesthetic effectiveness of the supplemental intraligamentary injection, administered with a computer controlled local anesthetic delivery system, in patients with irreversible pulpitis. J Endod. 2005;31(5):354-358. 15. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod. 1998;24(7):487-491. 16. Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN (1998) Anesthetic efficacy of the supplemental intraosseous injection for teeth with irreversible pulpitis. J Endod. 1998;24(12):826-828. 17. Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN. Anesthetic efficacy of the supplemental intraosseous injection for teeth with irreversible pulpitis. J Endod. 1998;24(12):826-828. 18. Reader A, Nusstein J. Local anesthesia for endodontic pain. Endod Topics. 2002;(3):14-30. 19. Rood JP, Pateromichelakis S. Inflammation and peripheral nerve sensitisation. Br J Oral Surg. 1981;19(1): 67-72. 20. Smith GN, Walton RE, Abbott BJ. Clinical evaluation of periodontal ligament anesthesia using a pressure syringe. J Am Dent Assoc. 1983;107(6):953-956. 21. Stabile P, Reader A, Gallatin E, Beck M, Weaver J (2000) Anesthetic efficacy and heart rate effects of the intraosseous injection of 1.5% etidocaine (1:200,000 epinephrine) after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(4):407-411. 22. Strichartz GR. Molecular mechanisms of nerve block by local anesthesics. Anesthesiology. 1976;45(4):421-441. 23. Vandermeulen E (2000) Pain perception, mechanisms of action of local anesthetics and possible causes of failure. Rev Belge Med Dent. 1984;55(1):29-40. 24. VanGheluwe J, Walton R. Intrapulpal injection: Factors related to effectiveness. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83(1):38-40. 25. Vreeland DL, Reader A, Beck M, Meyers W, Weaver J. An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve block. J Endod. 1989;15(1):6-12. 26. Wali M, Reader A, Beck M, Meyers W. Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocks. J Endod. 1988;14(4):193 27. Walton RE, Abbott B. Periodontal ligament injection: a clinical evaluation. J Am Dent Assoc. 1981;103(4): 571-575.

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route follows a natural pathway, offering the least resistance to penetrating the cancellous bone through the PDL and avoids the problems posed by root anatomy, root proximity, and cortical bone density. The injection site can be adapted to the mesial, distal, furcation, or lingual aspects, depending on the most advantageous straightline approach for the needle determined by the tooth anatomy and position in the arch (Figure 14). This is administered routinely in acutely pulpitic mandibular cases in my practice, giving close to 100% results, enabling the endodontic procedure to be completed comfortably for both patient and operator. Onset of anesthesia is almost immediate, and this avoids the shortcomings and difficulties of Stabident, which include locating the perforation holes, the bulkiness of the X-Tip technique in limited space, difficulty perforating thick cortical bone in posterior mandibular teeth, and avoiding the root anatomy (Figure 15). The optimal injection site in lower molars is dependent on the root anatomy with distal or furcation approach covering most situations. Intraosseous injections with 2% lignocaine with 1:1000,000 adrenaline can result in a transient increase in heart rate in 70% of patients, and patients should be forewarned to expect this. They should also be reassured that this will pass and have the positive benefits highlighted to them to ensure acceptance and compliance (Stabile, et al., 2000).

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: EP V9.2 LORDAN

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Successful anesthesia in acutely inflamed pulps LORDAN

1. In fact, confirmed 100% lip numbness after IANB in inflamed pulps reported only ____ successful pulpal anesthesia. a. 24% b. 35% c. 55% d. 75% 2. There are many theories on what causes anesthetic failure in acutely inflamed pulps, such as ______________. a. increased blood flow in inflamed tissues b. lowered pH locally interfering with LA solution activity c. increased pH locally interfering with LA solution activity d. both a and b 3. ______________ states that the outer nerves of the inferior alveolar bundle supply the molar teeth, whereas the nerves for the anterior teeth lie more deeply, making it more difficult for the anesthetic to diffuse through and provide an adequate block. a. The central core theory b. The bundle molar theory c. The anesthetic diffusion theory d. The profound lip numbness theory 4. Preoperative oral administration of ___________,

36 Endodontic practice

for example, can help improve the efficacy of local anesthetic in some cases. a. cephalosporins, 500 mg cefaclor b. a non-steroidal analgesic, 800 mg ibuprofen c. aminoglycosides, 350 mg gentamicin d. corticosteroid, 20 mg cortef 5. Inferior alveolar dental block is administered; wait for at least ________. Then once lip â&#x20AC;&#x153;numbnessâ&#x20AC;? is established and confirmed, follow up with buccal infiltration and lingual infiltration on attached gingiva. a. 15 minutes b. 30 minutes c. 45 minutes d. 1 hour 6. Increasing the volume of local anesthetic will _____ the pulpal anesthetic effect. a. improve b. not improve c. increase d. double 7. (When using the intraosseous ligamental pathway via PDL) The injection site can be adapted to the _______ or lingual aspects, depending on the most advantageous straightline approach for the needle determined by the tooth anatomy and position in the arch.

a. mesial b. distal c. furcation d. all of the above 8. Intraosseous injections with 2% lignocaine with 1:100,000 adrenaline can result in a transient increase in heart rate in ____ of patients, and patients should be forewarned to expect this. a. 25% b. 45% c. 70% d. 90% 9. Achieving profound pulpal anesthesia is the cornerstone of successful endodontics, and this poses challenges in teeth with ________, particularly mandibular molars. a. irreversible pulpitis b. pulp necrosis c. periodontitis d. condensing osteitis 10. _________ techniques are very successful in achieving profound pulpal anesthesia and should be considered as part of the routine approach. a. cross innervation b. intraligamental c. intraosseous d. both b and c

Volume 9 Number 2

CE CREDITS

ENDODONTIC PRACTICE CE

Drs. Nicola Maria Grande, Gianluca Plotino, Hany Mohamed Aly Ahmed, Stephen Cohen, and Frédéric Bukiet provide a clinical perspective on the reciprocating movement in endodontics

haping the root canal facilitates cleaning the root canal system (RCS) and is probably the most important phase in endodontic treatment. It includes the removal of pulp tissue, microorganisms, infected dentin, and root canal filling materials (RCFMs) in nonsurgical retreatments (Hülsmann, Peter, Dummer, 2005). Shaping the canal enhances the efficiency of irrigants and medicaments, and optimizes subsequent filling procedures (Hülsmann, Peter, Dummer, 2005; Frank, 1967). In the last 2 decades, numerous advances in endodontic instrumentation have been developed to achieve proper enlargement of the main canal without procedural errors (Frank, 1967). Reciprocating motion (RM) had been extensively used with stainless steel (SS) files initially in the development of mechanical instrumentation in endodontics. RM applied to nickeltitanium files has many differences from the one used with SS (Grande, et al., 2015). RM has been a recent innovation employing nickel-titanium instrumentation systems that claim to better resist instrument separation, thus permitting easier treatment and thereby shortening the learning curve for nickel-titanium file systems.

Nicola Maria Grande, DDS, PHD, is assistant professor of endodontics at the Catholic University of the Sacred Heart. He works in private practice limited to endodontic and microsurgery in Rome, Italy. Gianluca Plotino, DDS, PHD, maintains a private practice in Rome, Italy limited to endodontics and restorative and esthetic dentistry. Hany Mohamed Aly Ahmed, BDS, HDD (ENDO) PHD, is a senior lecturer and endodontist at the School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia. Stephen Cohen, MA, DDS, FICD, FACD, is an adjunct clinical professor of endodontics at the Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, California. Frédéric Bukiet, DDS, MSC, PHD, is a senior lecturer, hospital practitioner, and associate researcher (Giboc, ISM, UMR CNRS 7287) at the University of Aix Marseille, Assistance Publique des Hôpitaux de Marseille, France. He maintains a clinical practice limited to endodontics.

Volume 9 Number 2

Educational aims and objectives

This clinical article aims to provide a clinical perspective on the reciprocating movement in endodontics.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 43 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the properties, effectiveness and clinical outcomes of the modern reciprocating files available in the market. • Realize the favorable results of reciprocating files, which indicate their potential application as viable alternatives to rotary file systems. • Realize some of the history and evolution of reciprocating motion. • Identify some modern uses of stainless steel files in reciprocation. • Recognize the potential in using greater taper nickel-titanium files in shaping the root canal.

Figure 1: The different types of reciprocating motion for endodontic instrumentation: (left) Complete reciprocation with horizontal rotational oscillations. (right) Partial reciprocation with rotational effect

Evolution of RM in endodontics — historical perspective The early era of mechanical instrumentation Automated instrumentation of the root canal space was an early objective of clinical endodontics, beginning in the 20th century, when pioneers were trying to develop mechanical instruments (Hülsmann, Peter, Dummer, 2005). Rotary SS root canal instruments, such as Gates Glidden burs and Peeso reamers, can be safely used in the coronal, and sometimes the middle third of relatively straight RCS, but their stiffness increases the risk of root perforation as the clinician approaches

the middle third of the canal (Laws, 1968; Jungmann, Uchin, Bucher, 1975; Martin, 1976). For this reason, a RM that has equal angles in both directions was successfully introduced. This type of symmetric reciprocation can be defined as complete oscillating reciprocation (Figure 1), resembling the classic watch-winding movement used with manual SS files. In the 1960s, different handpieces were manufactured initially and designed to reciprocate at 90º (Frank, 1967). The overall results regarding the shaping ability and its safety were generally similar (Frank, 1967; Luebke, Brantley, 1990; Lausten, Luebke, Brantley, 1993) or inferior (Dihn, 1972; Molven, 1970; Endodontic practice 37

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The reciprocating movement in endodontics

CONTINUING EDUCATION

The favorable results of RFs, especially their safety and low rate of fracture, indicate their potential as viable alternatives to rotary file systems.

O’Connell, Brayton, 1975; Klayman, Brilliant, 1974; Sargenti, 1974; Weine, Kelly, Lio, 1975; Weine, Kelly, Bray, 1976; Powell, Simon, Maze, 1986) to a classic approach using SS manual root canal preparation (RCP), with a higher frequency of iatrogenic errors, including a tendency for canal straightening (Abou-Rass, Ellis, 1996; Limongi, et al., 2004). In general, reducing the amplitude of the movement toward a smaller oscillation with a higher frequency decreased the incidence of iatrogenic errors but was still more of a problem than when using SS files manually to prepare canals (Turek, Langeland, 1982; Harty, Stock, 1974; Hülsmann, Gambal, Bahr, 1999; Bolanos, et al., 1988; Lehman, Gerstein, 1982; O’Conell, Brayton, 1975; Teodorovic, Ivanovic, 1998; Cheung, Chan, 1996; Nagy, et al., 1997; Smith, Edmunds, 1997; Hülsmann, Rummelin, Schäfers, 1997; Petschelt, et al., 1994). The other common observation after RCP with mechanical SS files was that increasing the size of the preparation risked a higher incidence of procedural errors (Hülsmann, Gambal, Bahr, 1999; Bolanos, et al., 1988; Lehman, Gerstein, 1982; O’Connell, Brayton, 1975; Teodorovic, Ivanovic, 1998; Cheung, Chan, 1996; Nagy, et al., 1997; Smith, Edmunds, 1997; Hülsmann, Rummelin, Schäfers, 1997; Petschelt, et al., 1994; Abou-Rass, Jastrab, 1982; Ianno, Weine, 1989). Other studies have also reported procedural errors linked to metal stiffness and restoring force of SS and worse results compared to nickel-titanium instrumentation systems (Hilaly Eid, Wanees, Amin, 2011; Ceyhanli, et al., 2014). The modern use of SS files in reciprocation Although there are many systems on the market, the tendency is to limit use to the scouting phase prior to shaping procedures to obtain a glide path. This would minimize the adverse effects of SS files, especially in larger more rigid sizes. Despite the widespread use of mechanical SS files, there is still a lack of scientific evidence on their efficacy (Limpngi, et al., 2004). 38 Endodontic practice

SS files used for glide path management should be used with equal 30° forward and backward movement in a reciprocating handpiece (M4 Safety™ Handpiece, SybronEndo/ Kerr). The primary observations regarding small SS files for glide path management seem to be promising, but studies are lacking on how they would fare in calcified, curved, and complex canals (Peters, Paque, 2010). The birth of modern reciprocation for nickeltitanium files of greater taper Studies have demonstrated the potential in using greater taper nickel-titanium files in shaping the root canal even in the most challenging of anatomical complexities (Hülsmann, Peters, Dummer, 2005; Parashos, Messer, 2006). However, fracture of nickel-titanium rotary instruments continues to be of concern (Best, et al., 2004) and appears to be a manifestation of continuous rotation. In 2004, one study investigated the endurance limit of nickel-titanium files (Best, et al., 2004); this is the level of stress or strain at which the file can be subjected to before separating (Lindeburg, 1999). This value is a specific deflection angle (DA), characteristic of each instrument; it depends on the size and design features of the instrument. Every time a rotating file cuts dentin in a constricted canal, torsional deformation develops on its axis. If the deformation is within the plastic limit of the metal, there are no structural changes. However, if repeated cyclic axial deformation accrues, the instrument will fracture due to torsional fatigue, and this is in addition to the flexural fatigue that develops within a curved canal (Pedulla, et al., 2015). Limiting the angle of rotation in the cutting direction under the endurance limit of the instrument led to the development of a movement that could be defined as partial or asymmetrical reciprocation (Figure 1), in which the angle of rotation in the cutting direction is higher than the angle of rotation in the opposite non-cutting direction. After a certain number of cutting cycles, the instrument would complete a full rotation. When first introduced (Yared, 2008),

an ATR Tecnika motor (ATR, Pistoia, Italy) was programmed for this asymmetrical motion, and the file used was a ProTaper® F2 (Dentsply Maillefer). The angles used were described as fourteenth of a circle (144°) in the clockwise (CW) cutting direction and two-tenths of a circle (72°) in the counterclockwise (CCW) non-cutting direction with a speed of 400 rpm. The technique showed promising results (Malentacca, Lalli, 2002). The overall speed of this kind of rotational reciprocation is much lower than the speed used for symmetric oscillating reciprocation. Consequently, the rotating effect given by the net difference between CW and CCW movements maintains an adequate cutting efficiency and an apical progression of the instrument while reducing torsional stress. It has been speculated that this kind of reciprocation is similar to the manual balanced force technique as described by Roane and colleagues in 1985. The dynamics enables the instrument to remain centered in the canal, as the cutting force is equal on the concave and convex side of the canal curvature (Figures 2, 3, and 4). Torsional stresses, which are developed on the shank of the file during the cutting action, are reduced as the rotation is under the ideal limit of the DA specific for the file. This novel asymmetrical movement led to the development of dedicated reciprocating single file (RSF) systems and a new technique where only one file is needed to fully shape a canal to length.

Figures 2A-2B: A. Three-dimensional reconstruction of a micro-computed tomographic scan of a mesial root of a mandibular first molar with three root canals before instrumentation (in yellow). B. Superimposition of pre- and post-instrumentation three-dimensional reconstructions (in pink postoperative) showing the centering ability of the reciprocating technique Volume 9 Number 2

Figures 3A-3D: A. Three-dimensional reconstruction of a micro-computed tomographic scan of a mesial root of a mandibular first molar with three root canals before instrumentation (in yellow). Superimposition of preoperative three-dimensional reconstruction and postoperative bi-dimensional sections at coronal. B-C. Superimposition of preoperative three-dimensional reconstruction and postoperative bi-dimensional sections at coronal middle and apical level. D. Showing the modification of root canal anatomy and geometry induced by reciprocating instrumentation Volume 9 Number 2

of 150°/30° (Reciproc with an average speed of 300 rpm and WaveOne with an average speed of 350 rpm) and that are within their characteristic endurance limit (Webber, 2015). Actual and set values of the asymmetrical reciprocating movement of different motors were assessed because variables, such as the delay between the two directions of movement and the acceleration to reach the desired speed, could play an important role in the efficacy of the different instruments (Fidler, 2014). Additional studies are needed to explore this variable. For commercial reasons, the flutes of reciprocating files are manufactured in a backward direction so that the CCW movement is greater than the CW movement; and after three cutting cycles, the instrument completes a full reverse rotation. All commercially available nickel-titanium files

rotate in a CW direction (Fidler, 2014). Both commercially available RFs are marketed as single file techniques after initial scouting of the canal to determine the correct file size to use to obtain the final shape. A single RSF produces a shape that traditionally would be obtained after a series of three or more rotary nickel-titanium files. The favorable results of reciprocating files indicate their potential as viable alternatives to rotary file systems. Occasionally, it might be necessary to use additional instruments to initially establish the glide path or clean the apical third and the fins of the RCS (Baugh, Wallace, 2005). An RSF is subjected to a certain amount of mechanical stress during use that otherwise would be distributed among a series of different rotary files. For this reason, manufacturers urge single-use for RSF techniques to prevent the increased risk

Figure 4A: Three-dimensional reconstruction of the crosssection at 1 mm from the apex of micro-CT scan of a root canal before instrumentation (in yellow)

Figure 4B: Three-dimensional reconstruction of micro-CT scan images of the same canal at the same cross section after instrumentation with a reciprocating file to an apical size of 40 (in pink)

Figure 4C: Superimposition of pre- and post-instrumentation images showing the centering ability of this type of instrumentation technique Endodontic practice 39

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Initial canal negotiation with small (0.08 mm, 0.10 mm tip diameter) SS scouting files allows the clinician to determine the size of the RSF, which will shape the canal (De-Deus, et al., 2010a, 2010b). This approach can be risky for files used in complete rotation because if the file exhibits “taper lock” in the canal, immediate fracture could occur (Yared, 2008). This modified CW/CCW movement led to nickel-titanium files specifically designed for the use in partial reciprocation, such as WaveOne® (Dentsply Maillefer) and Reciproc® (Dentsply VDW). The files are used with different angles in the cutting and non-cutting direction

CONTINUING EDUCATION of file separation in case of multiple usages (Yared, 2008). Recently, WaveOne has been upgraded to WaveOne Gold. The kinematic of this system is unchanged, but the cross section, size, and geometry of the files have been modified to make the file more flexible and efficient. Gold heat treatment is a proprietary Dentsply post-manufacturing heat treatment process unlike M-Wire, which is a premanufactured heat treatment process. The Gold heat treatment process improves flexibility (Shen, et al., 2013) and allows the instrument to be pre-curved, an advantage when placing the file into canals in more difficult-to-reach posterior regions (Figure 5). Reciproc (Dentsply VDW) is marketed as a file that can prepare the coronal and middle thirds of the root canal without the establishment of an initial glide path (Yared, Ramil, 2013). This procedure has been shown to be clinically successful and safe even in complex canals (De-Deus, et al., 2013) when the clinician follows the manufacturer’s directions for use (Plotino, Grande, Porciani, 2015). TF™ Adaptive files and the dedicated Elements™ Motor (SybronEndo) have recently been launched. The motor changes its kinematics from a rotating movement (600° CW horizontal rotational motion and 0° CCW) to partial reciprocation (370° in a CW cutting direction and 50° in the non-cutting direction). The change to reciprocation is dependent

on the torque to which the file is subjected. The average speed of the RM is not declared by the manufacturer. This type of movement could be defined as a hybrid reciprocation. Recently, Morita (Japan) has introduced the Root ZX® II OTR Module, a low-speed handpiece where the torque is automatically measured during file rotation. The manufacturer claims that if the torque is less than the set value, the file rotation continues; but if the torque has reached the set value, the file reverses rotation by 90° and then continues in the cutting direction once again. This type of movement could be also defined as a hybrid reciprocation. The clinician has the advantage of continuous rotation when needed, and reciprocating movement in a reverse direction activated by the torque measurement. If too much force is applied, the handpiece will continue reading a torque limit over the set value, and the reciprocating movement will continue. More recently, several motors have come to market with the functionality to adjust both forward and backward angle of reciprocation, as well as the speed of movement. Theoretically, any instrument on the market could be used in an asymmetrical reciprocation with these motors, but studies are still lacking on how they would perform in terms of safety and quality of the preparation. Due to the increased popularity of RM and reciprocating files usage, numerous

studies have been conducted mainly investigating the mechanical properties, shaping ability, preservation of the root canal anatomy, shaping time, cleaning effectiveness, microcrack formation, bacterial reduction, extrusion of debris, and removal of root canal filling materials. The conclusions from the literature can be summarized as follows (Plotino, et al., 2015): • Reciprocation extends the lifespan of all types of files tested. • The amplitude of reciprocation has a significant influence on the cyclic fatigue life of the files tested. • Reciprocation does not reduce the cutting efficiency of the files tested. • Reciprocating and rotary motion have similar cutting efficiency. • Reciprocating files shape canals well and preserve the original canal anatomy. • The cleaning effectiveness of reciprocating files is comparable to full rotary file sequence systems. Further studies should be conducted to understand the respective influence of the kinematics, the file design, and the number of instruments needed to fully shape canals. • Reciprocating single file usage reduces the shaping time compared to a full sequence rotary system.

Figure 5: (left) Previous WaveOne Primary file made in M-Wire alloy and features of the coronal, middle, and apical part of the instrument. (right) The new WaveOne Gold Primary file and features of the coronal, middle, and apical part of the instrument. The heat treatment of the files has been changed from M-Wire to gold alloy treatment. Note the ability to pre-bend the file 40 Endodontic practice

Volume 9 Number 2

Figure 6B: Working length. Note the sharp apical curvature of the distal root

Conclusion

Figures 6C and 6D: One-year control radiograph. Note conservative access only removed the old filling. Maximum maintenance of the dental structure of the distal area makes it compatible to proper cleaning, shaping, and filling procedures

Figure 7A: Preoperative periodical radiograph of the upper left second molar with apical periodontitis

RM, defined as a repeated backward and forward (clockwise/counter-clockwise) movement, has been extensively used in endodontics for many years and can be applied to many endodontic files. There are many variations of RM, including: • Complete reciprocation (oscillation) • Partial reciprocation (rotational effect) • Hybrid reciprocation (combined movements) Hybrid reciprocation can be fixed or flexible — i.e., it can shift from one type of reciprocation to the other in the canal based on mechanical resistance and torque. It must be borne in mind, however, that no file system is able to completely clean the canal, totally eliminate sessile and planktonic microorganisms, or remove the filling material completely from the root canal system. However, the favorable results of RFs, especially their safety and low rate of fracture, indicate their potential as viable alternatives to rotary file systems (Figures 6 and 7). EP

Figures 7B and 7C: Periapical radiograph of working length with manual stainless steel files. In MB2, it was impossible to negotiate the root canal with manual files Volume 9 Number 2

Endodontic practice 41

CONTINUING EDUCATION

Figure 6A: Preoperative radiograph of a lower left second molar tooth

• Dentin microcracks occur independently of the type of file and its kinematics. • The results of published studies show that the use of reciprocating files would lead to fewer or an equivalent amount of dentin microcracks compared with full sequence rotary systems. • RFs can promote significant bacterial reduction, but like rotary full sequence systems, they are not able to completely disinfect the RCS. • The ability of RFs to extrude less debris than rotary files remains a matter of debate. • Reciprocating files are effective in removing root canal filling material in less time as compared to rotary files, yet no system is able to remove the filling material completely from the RCS.

CONTINUING EDUCATION

Figures 7D and 7E: Periapical radiographs at different horizontal angulation of the final obturation. The scouting and negotiation of the MB2 was made possible with the mechanical reciprocation scouting approach using R25

REFERENCES 1.

presence of apical deviation with employment of automated handpieces with continuous and alternate motion for root canal preparation. J Appl Oral Sci. 2004;12(3):195-199.

Abou-Rass M, Ellis MA. A comparison of three methods of hand and automated instrumentation using the CFS and M4 for preparations of curved and narrow simulated root canals. Braz Endod J. 1996;1:25-33

26. Lindeburg MR. Civil Engineering Reference Manual for the PE Exam. 7th ed. Belmont, California: Professional Publications Inc.; 1999.

2. Abou-Rass M, Jastrab RJ. The use of rotary instruments as auxiliary aids to root canal preparation of molars. J Endod. 1982;8(2):78-82.

27. Luebke NH, Brantley WA. Physical dimensions and torsional properties of rotary endodontic instruments. 1. Gates Glidden drills. J Endod. 1990;16(9):438-441.

3. Baugh D, Wallace J.The role of apical instrumentation in root canal treatment: a review of the literature. J Endod. 2005;31(5):333-340.

28. Klayman SM, Brilliant JD. A comparison of the efficacy of serial preparation versus Giromatic preparation. J Endod. 1975;1(10):334-337.

4. Best S, Watson P, Pilliar R, Kulkarni GG, Yared G. Torsional fatigue and endurance limit of a size 30.06 ProFile rotary instrument. Int Endod J. 2004;37(6):370-373.

29. Malentacca A, Lalli F. Use of nickel titanium instruments with reciprocating movement. Italian Journal of Endodontics. 2002;6:79-84

5. Ceyhanli KT, Erdilek N, Tatar I, Cetintav B. Comparative micro-computed tomography evaluation of apical root canal transportation with the use of ProTaper, RaCe and Safesider systems in human teeth. Aust Endod J. 2014;40(1):12-16.

30. Martin H. Ultrasonic disinfection of the root canal. Oral Surg Oral Med Oral Pathol. 1976;42(1):92-99.

6. Cheung GS, Chan AW. An in vitro comparison of the Excalibur handpiece and hand instrumentation in curved root canals. J Endod. 1996;22(3):131-134. 7. De-Deus G, Moreira EJ, Lopes HP, Elias CN. Extended cyclic fatigue life of F2 ProTaper instruments used in reciprocating movement. Int Endod J. 2010a;43(12):1063-1068. 8. De-Deus G, Brandão MC, Barino B, Di Giorgi K, Fidel RA, Luna AS. Assessment of apically extruded debris produced by the single-file ProTaper F2 technique under reciprocating movement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010b;10(3):390-394. 9. De-Deus G, Arruda TE, Souza EM, Neves A, Magalhães K, Thuanne E, Fidel RA. The ability of the Reciproc R25 instrument to reach the full root canal working length without a glide path. Int Endod J. 2013; 46(10):993-998. 10. Dihn Q. An in-vitro evaluation of the Giromatic instrument in the mechanical preparation of root canals. [Thesis]. Minnesota: Univ. of Minnesota;1972. 11. Fidler A. Kinematics of 2 reciprocating endodontic motors: the difference between actual and set values. J Endod. 2014;40(7):990-994. 12. Frank AL. An evaluation of the Giromatic endodontic handpiece. Oral Surg Oral Med Oral Pathol. 1967;24(3):419-421. 13. Grande NM, Ahmed HM, Cohen S, Bukiet F, Plotino G. Current Assessment of Reciprocation in Endodontic Preparation: A Comprehensive Review-Part I: Historic Perspectives and Current Applications. J Endod. 2015;41(11): 1778-1783. 14. Harty FJ, Stock CJ. The Giromatic system compared with hand instrumentation in endodontics. Br Dent J. 1974;137(6):239-244. 15. Hilaly Eid GE, Wanees Amin SA. Changes in diameter, cross-sectional area, and extent of canal-wall touching on using 3 instrumentation techniques in long-oval canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(5):688-695.

31. Molven O. A comparison of the dentin-removing ability of five root canal instruments. Scand J Dent Res. 1970;78(6):500-511. 32. Nagy CD, Bartha K, Bernath M, Verdes E, Szabo J. A comparative study of seven instruments in shaping the root canal in vitro. Int Endod J. 1997;30(2):124-132. 33. O’Connell DT, Brayton SM. Evaluation of root canal preparation with two automated endodontic handpieces. Oral Surg Oral Med Oral Pathol. 1975;39(2): 298-303. 34. Parashos P, Messer HH. Rotary NiTi instrument fracture and its consequences. J Endod. 2006;2(11):1031-1043. 35. Pedullà E, Lo Savio F, Boninelli S, Plotino G, Grande NM, Rapisarda E, La Rosa G. Influence of cyclic torsional preloading on cyclic fatigue resistance of nickel-titanium instruments. Int Endod J. 2015;48(11):1043-1050. 36. Peters OA, Paque F. Current developments in rotary root canal instrument technology and clinical use: a review. Quintessence Int. 2010;41(6):479-488. 37. Petschelt A, Krämer N, Reinelt C, Ebert J. Apically extruded material after manual and mechanical root canal instrumentation. J Dent Res. 1994;73:216. 38. Powell SE, Simon JH, Maze BB. A comparison of the effect of modified and nonmodified instrument tips on apical canal configuration. J Endod. 1986;12(7): 293-300. 39. Plotino G, Grande NM, Porciani PF. Deformation and fracture incidence of Reciproc instruments: a clinical evaluation. Int Endod J. 2015;48(2):199-205. 40. Plotino G, Ahmed HM, Grande NM, Cohen S, Bukiet F. Current Assessment of Reciprocation in Endodontic Preparation: A Comprehensive Review-Part II: Properties and Effectiveness. J Endod. 2015;41(12):1939-1950. 41. Roane JB, Sabala CL, Duncanson MG Jr. The “balanced force” concept for instrumentation of curved canals. J Endod. 1985;11(5):203-211.

16. Hülsmann M, Gambal A, Bahr R. An evaluation of root canal preparation with the automated Excalibur endodontic handpiece. Clin Oral Investig. 1999;3(2):70-78.

42. Sargenti A. Engine powered canal preparation. Addendum to Endodontics. Locarno (Switzerland):AGSA Publication Scientifiques;1974.

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

43. Shen Y, Zhou HM, Zheng YF, Peng B, Haapasalo M. Current challenges and concepts of the thermomechanical treatment of nickel-titanium instruments. J Endod. 2013;39(2):163-172.

18. Hülsmann M, Peters OA, Dummer PM. Mechanical preparation of root canals: shaping goals, techniques and means. Endod Top. 2005;10:30-76. 19. Ianno NR, Weine FS. Canal preparation using two mechanical handpieces: distortions, ledging, and potential solutions. Compendium. 1989;10(2):100-102,104-105. 20. Kim HC, Kwak SW, Cheung GS, Ko DH, Chung SM, Lee W. Cyclic fatigue and torsional resistance of two new nickel-titanium instruments used in reciprocation motion: Reciproc versus WaveOne. J Endod. 2012;38(4):541-544.

44. Smith RB, Edmunds DH. Comparison of two endodontic handpieces during the preparation of simulated root canals. Int Endod J. 1997;30(6):369-380. 45. Teodorovic N, Ivanovic V. Effect of hand, ultrasonic and Excalibur instruments on root canal shaping. Int Endod J. 1998;31:216-217. 46. Turek T, Langeland K. A light microscopic study of the efficacy of the telescopic and the Giromatic preparation of root canals. J Endod. 1982;8(10):437-443. 47. Webber J. Shaping canals with confidence: WaveOne GOLD single-file reciprocating system. Roots. 2015;1:34-40

21. Jungmann CL, Uchin RA, Bucher JF. Effect of instrumentation on the shape of the root canal. J Endod. 1975;1(2):66-69.

48. Weine FS, Kelly RF, Lio PJ. The effect of preparation procedures on original canal shape and on apical foramen shape. J Endod. 1975;1(8):255-262.

22. Lausten LL, Luebke NH, Brantley WA. Bending and metallurgical properties of rotary endodontic instruments. IV. Gates Glidden and Peeso drills. J Endod. 1993;19(9):440-447.

49. Weine FS, Kelly RF, Bray KE. Effect of preparation with endodontic handpieces on original canal shape. J Endod. 1976;2(10):298-303.

23. Laws AJ. Preparation of root canals: an evaluation of mechanical aids. NZ Dent J. 1968;64:156.

50. Yared G, Ramli GA. Single file reciprocation: a literature review. Endo (Lond Engl). 2013;7(3): 171-178.

24. Lehman JW 3rd, Gerstein H. An evaluation of a new mechanized endodontic device: the Endolift. Oral Surg Oral Med Oral Pathol. 1982;53(4):417-424. 25. Limongi O, Klymus AO, Baratto Filho F, Vanni JR, Travassos R. In vitro evaluation of the

42 Endodontic practice

51. Yared G. Canal preparation using only one Ni-Ti rotary instrument: preliminary observations. Int Endod J. 2008;41(4):339-344.

Volume 9 Number 2

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

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The reciprocating movement in endodontics GRANDE, ET AL.

1. In general, reducing the amplitude of the movement toward a smaller oscillation with a higher frequency decreased the incidence of iatrogenic errors but was still more of a problem than when using _______ manually to prepare canals. a. SS files b. NiTi files c. reciprocating files d. tapered files 2. The other common observation after RCP with mechanical SS files was that increasing the size of the preparation ________ procedural errors. a. achieved a lower incidence of b. risked a higher incidence of c. had no effect on d. markedly reduced 3. SS files used for glide path management should be used with equal _____ forward and backward movement in a reciprocating handpiece. a. 10° b. 20° c. 30° d. 40° 4. Studies have demonstrated the potential in using _______ nickel-titanium files in shaping the root canal even in the most challenging of anatomical complexities.

Volume 9 Number 2

a. lesser taper b. greater taper c. non-tapered d. asymmetrical 5. Every time a rotating file cuts dentin in a constricted canal, _______ develops on its axis. a. metal stiffness b. flexural constriction c. torsional deformation d. shank constriction 6. Limiting the angle of rotation in the cutting direction under the endurance limit of the instrument led to the development of a movement that could be defined as ________, in which the angle of rotation in the cutting direction is higher than the angle of rotation in the opposite non-cutting direction. a. partial reciprocation b. asymmetrical reciprocation c. torsional deformation d. both a and b 7. For commercial reasons, the flutes of reciprocating files are manufactured in a backward direction so that the CCW movement is greater than the CW movement; and after ________ cutting cycles, the instrument completes a full reverse rotation.

a. two b. three c. four d. five 8. _____ produces a shape that traditionally would be obtained after a series of three or more rotary nickel-titanium files. a. An SS b. A single RSF c. A single NTF d. A Peeso reamer 9. The conclusions from the literature can be summarized as follows: • The amplitude of reciprocation has _________ the cyclic fatigue life of the files tested. a. no influence on b. a significant influence on c. a minimal effect on d. none of the above 10. The results of published studies show that the use of reciprocating files would lead to _____ of dentin microcracks compared with full sequence rotary systems. a. fewer b. an equivalent amount c. more d. both a and b

Endodontic practice 43

CE CREDITS

ENDODONTIC PRACTICE CE

FOCUS ON FILES

Efficient, flexible, universal, or flared? Assessing hand file options Dr. Rich Mounce discusses clinical relevance and uses for four hand file classes

and files are to an endodontist what brushes are to a painter. Different brushes have different characteristics providing the artist with functional options. Similarly, the file’s metal and geometry provide its functional characteristics. This clinical product feature will highlight four hand file classes to discuss their clinical relevance and uses. I have extensive experience with each of the hand files described; hence, Mani® products will be referenced. Specifically, Mani K (universal), RT (efficient cutting), Flexile (K Flex® type “flexible” hand file), and Flare (.05 tapered hand files manufactured in stainless steel and nickel titanium) will be briefly described. Mani K files (6-140) are a “universal” staple of the endodontic clinician’s armamentarium. They are relatively sharp at their tips due to the acute cutting angle formed at the transition of the tip and the flutes. K files are intermediate in stiffness between Flexile files (discussed below) designed for flexibility and cutting effectiveness and that of Mani D Finders which are manufactured purely for stiffness to gain patency in curved and calcified canals. Mani K files are square in cross section from sizes Nos. 6-40 and triangular from sizes Nos. 45-140. Mani K files are used with a quarter turn and vertical pull (Figure 1). Mani K files are also available in “medium” sizes (12, 17, 22, 27, 32, and 37) and available in a “safe-ended” variety, which does not possess the acute cutting angle mentioned above (Mani SEC O K files). Mani RT files are designed for efficient cutting by clinicians who want to shape

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

44 Endodontic practice

Figure 1: Mani K file

canals by hand. They have approximately 1.5 times the cutting force of standard Mani K files and yet are also somewhat flexible. The file has two cutting edges provided by a modified rectangular shape in cross section (Figures 2A-2B). RT files are available from sizes 15-80 and used with a quarter turn and vertical pull. These instruments are very popular in countries where hand filing predominates due to the cost of nickeltitanium instruments. Mani Flexile files (15-40) are triangular in cross section making them approximately 2 times more flexible than K files. Flexile files are not intended for use with any significant degree of vertical pressure. Rather, in curved anatomy, especially for the creation of deep body shape at the juncture of the middle and apical third, they enlarge canals using the same quarter turn and pull of the files above. Use of Flexile files is a matter of personal preference relative to RT files. Triangular files below a size No.15 are not stiff enough to be clinically useful; hence, the first Flexile file size is a No.15. Mani K files, RT files, and Flexile files are all .02 tapered and made of stainless steel (Figure 3). By contrast, Mani Flare files (15-60) are .05 tapered and come in a stainless steel and

Figures 2A-2B: Mani RT file

Figure 3: Mani Flexile file Volume 9 Number 2

FOCUS ON FILES

Figure 4: Mani Flare file (stainless steel)

nickel-titanium (NiTi) version. In addition, the stainless steel version of the Mani Flare files is available in medium sizes (12-37). Flare files, due to their larger taper, are triangular in cross section to provide optimal flexibility. Used with a quarter turn and vertical pull (as described earlier), these instruments are designed to create larger canal taper using a hand instrument. Mani NiTi files (15-40) provide shape memory and greater flexibility than their stainless steel counterparts (Figure 4). Clinically, there are an infinite number of ways these files can be used separately and in combination. While the trends in endodontics are to use fewer files, it is axiomatic that the more complex the anatomy to be treated, the more instruments realistically will be required. One illustrative clinical scenario would be the use of the Complex pack configuration of Mani Silkâ&#x201E;˘ (.08/25, .04/25, .04/20) (or a similar nickel-titanium system) in combination with the files as described, in a severe three-dimensional apical curvature. After achieving straight-line access, the .08/25 Mani Silk orifice opener shapes the canal to the point of first curvature. After gaining patency and preparing a glide path created using Nos. 6, 8, 10, 12, and 15 hand K files, the Mani Silk .04/20 is inserted followed by the .04/25. If for any reason neither of these files will track the canal easily to its terminus, a No. 15 Flexile file or RT file can be used initially followed by either a No.17 medium Flexile file or No. 20 RT file as appropriate. The canal can be sequentially enlarged by hand using Flexile or RT files until the Mani Silk (or other rotary file) will advance effortlessly down the canal. In essence, in Volume 9 Number 2

Figure 5: Clinical case treated using Mani Silk with the techniques described

Clinically, there are an infinite number of ways these files can be used separately and in combination. While the trends in endodontics are to use fewer files, it is axiomatic that the more complex the anatomy to be treated, the more instruments realistically will be required.

this scenario, the Flexile and/or RT file is used a bridge where needed to gain shape around the problematic area of curvature without ledging and, by doing so, reduce any NiTi fracture risk. After adequate shape is acquired by hand filing as described, the canal is finished via any standard shaping protocol. For doctors who are hand filing, using Mani Gates Glidden drills in the coronal and middle half of the canal to the point of first curvature is followed by hand filing potentially by all four Mani file types, if desired, or whatever combination is most efficient. For example, the apical third can be negotiated

with K files or D Finders, shaped with Flexile files and RT files, and finished to the appropriate final taper with Flare files (in either the stainless steel or nickel-titanium variety). A brief overview of Mani K, RT, Flare, and Flexile files has been presented. Emphasis has been placed on using the appropriate file for the given clinical indication. While there is some overlap between the functionality of various files, these file types represent a universal (K files), efficient cutting with flexibility (RT files), primarily flexible (Flexile), and tapered files that cut dentin effectively (Flare files in stainless steel or nickel titanium). EP Endodontic practice 45

ENDODONTIC INSIGHT

MTAFlow™ — overcoming the boundaries of MTA clinical applications Dr. Carlos Spironelli Ramos discusses a beneficial advancement in endodontics

linicians who use endodontic materials face several challenges.1 Optimally, the materials should be easy to use, visible in radiographs, biocompatible, bioactive, antimicrobial, and resorbable in tissues but should resist resorption within tooth structures. They should also be nonstaining to tooth structures, strengthen the tooth, be dimensionally stable, and provide a permanent, high-quality seal with dental hard tissues yet be easy to replace. They should also have the mechanical strength that is optimal for the site and task for which they are used.2 One of the truly beneficial advancements in dentistry has been the introduction of mineral trioxide aggregate (MTA) repair cements into endodontic treatment. The development of bioceramic-based materials has greatly improved pulp cappings, pulpotomies, the treatment of open apices, apicoectomies (retrograde fillings), accidental perforation, and resorption repairs. Several authors have published studies about the properties of MTA as a repair material in comparison with other materials,3,4 showing very good results concerning the biological and physical aspects of the material. Even though MTA has proven to be an excellent repair material, the biggest weakness of both white and gray MTA cement is that they are not easy to use. Material additives were included in the original powder/ liquid formulation of the first MTA cements, which enhanced some of the material’s properties and improved its mixing, delivering, and functional abilities.5 However, the multipurpose use of MTA necessitated the development of improved formulations that allowed for easier mixing and delivery, as well

Figure 1: MTAFlow™ from Ultradent Products, Inc.

One of the truly beneficial advancements in dentistry has been the introduction of mineral trioxide aggregate (MTA) repair cements into endodontic treatment. as a shorter setting time and better washout resistance. The delivery of MTA to different sites inside the tooth has emerged as a major challenge. The handling of MTA based on powder/pure water mixtures resembles the handling of wet sand in some aspects. The cement loses consistency in the presence of excess liquid, even at the proportions recommended by the manufacturer. MTA is not easy to mix and even harder to

Carlos Spironelli Ramos, DDS, MS, PhD, graduated in dentistry in 1987 in Brazil, then soon after received a scholarship to study in Japan. He finished his residency in endodontics in Brazil in 1990. From 1991 to 1993, he attended the master’s program in endodontics, receiving a Master of Science degree. He then began the PhD program in endodontics, completing it in 1997, the same year he published his first book. From 1995 to 2012, he worked as a professor of endodontics at the State University of Londrina, where he coordinated the endodontics sector. During this same time, he published three books and wrote more than a dozen chapters for various endodontics books. Professor Ramos is currently the R&D Endodontics Manager at Ultradent Products in South Jordan, Utah. He performs many lectures, hands-on workshops, and conferences worldwide each year and has visited over 40 countries.

46 Endodontic practice

Figure 2: Different textures can be achieved with MTAFlow repair cement by varying the ratio of the fine powder and water-based gel during or right after mixing. A thin consistency can be delivered through a delivery tip for different applications that demand more accuracy and control, such as apexification, apical plug, or perforations

deliver to the right spot without making a mess, as it can stick to metal instruments better than it attaches to the cavity walls or to itself. A variety of different tools and guns have appeared on the market to facilitate the placement of MTA without presenting the proposed easy and accurate delivery. A new MTA repair cement, MTAFlow™ from Ultradent Products, Inc., (Figure 1) avoids many of these issues. It presents Volume 9 Number 2

systems. Even for very difficult procedures involving MTA application, like apexification or apical plugs (Figure 3), the clinician can quickly and accurately deliver the material with a syringe and NaviTip® 29 ga tip. EP

REFERENCES 1. Ørstavik D. Endodontic materials. Adv Dent Res. 1988;2(1):12–24. 2. Haapasalo M, Parhar M, Huang X, Wei X, Lin J, Shen Y. Clinical use of bioceramic materials. Endodontic Topics. 2015;32(1):97–117. 3. Nakata TT, Bae KS, Baumgartner JC. Perforation repair comparing mineral trioxide aggregate and amalgam using an anaerobic bacterial leakage model. J Endod. 1998;24(3):184–186. 4. Sluyk SR, Moon PC, Hartwell GR. Evaluation of setting properties and retention characteristics of mineral trioxide aggregate when used as a furcation perforation repair material. J Endod. 1998;24(11):768–771. 5. Shen Y. Evolution of bioceramic cements in endodontics. Endodontic Topics. 2015;32(1):1–2.

Figure 3: MTAFlow repair cement mixed in a thin consistency being delivered using a NaviTip 29 ga tip to create the apical plug

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6. Neelakantan P, Grotra D, Sharma S. Retreatability of 2 mineral trioxide aggregate-based root canal sealers: a cone-beam computed tomography analysis. J Endod. 2013;39(7):893–896.

THE FUTURE HAS RETURNED.

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Endodontic practice 47

ENDODONTIC INSIGHT

finer particle sizes of tricalcium silicate material and a proprietary salt-free polymer gel mixing liquid for easy handling. The consistency can be varied for different uses, from pulp capping to retrograde filling material. By using the gel and varying the powderto-gel ratio, different textures and physicalrheological properties can be obtained. The gel has been formulated to confer washout resistance with better results compared to other products mixed with water, and it avoids the rough “sandy” viscosity of other MTA repair cements (Figure 2).6 It is important to emphasize that MTAFlow repair cement powder and gel ratios can be modified during or right after mixing, giving flexibility regarding the desired final mixture texture. Depending on the given consistency, a syringe/tip delivery system can be used to dispense the desired amount of MTAFlow cement to the site, avoiding the need for other delivery instruments or

TECHNOLOGY

GentleWave® System by Sonendo® Clean and disinfect even complex root canal anatomies with Sound Science® — and a revolutionary mechanism of action

s endodontists, we are specialists in saving teeth, and as specialists, we are people of science. We are driven by an innate curiosity, a need to see results firsthand, and a hunger to understand exactly how things work. It’s a curiosity that naturally extends into the realm of technology. Maybe you’re a techie — the first kid on the block to have the latest gadget. Maybe you’re more conservative and likely to wait until one or more of your colleagues shares results that indicate a new technology delivers on its promises. Either way, you’re probably eager to know which new innovations can directly benefit your practice. Interestingly, technological innovations in the field of endodontics have been for the most part, shall we say, incremental. Whatever advancements we’ve seen in recent years, we are often still relying on the same approach: shaping, cleaning, and disinfecting in the first treatment session, then obturating in a second session. And all too often, these conventional endodontic protocols can be the root cause of the very issues that lead to treatment failure. At Sonendo, we have recognized the need to rethink the fundamentals of conventional root canal therapies. And it starts by challenging the status quo and leveraging advancements in technology that result in a new mechanism of action — Multisonic

Pre GentleWave® treatment (image courtesy of Tyler F. Baker, DDS, MS) 48 Endodontic practice

Ultracleaning™ technology, available with Sonendo’s groundbreaking GentleWave System. The GentleWave System’s mechanism of action begins in the operating system, located in the system’s console. The treatment fluids — sodium hypochlorite, EDTA, and distilled water — are stored here, where the automated fluid management system prepares and delivers the desired concentration. The system also reduces the gas content of the treatment fluids. Any gas that enters into the root canal system can significantly reduce efficacy. The gases found in even the most microscopic bubbles can prevent treatment fluids from reaching canal walls and into dentin tubules and other complex anatomy. In addition, these bubbles can result in apical vapor lock, in which the flow of fluids is restricted in the apical onethird of the canal. Apical vapor lock has been shown to have a detrimental impact on the efficacy of debridement — GentleWave technology’s ability to extract all gases and optimize the treatment fluids, before they enter the canal, helps prevent apical vapor lock from occurring. The carefully calibrated fluids then pass through the GentleWave System’s Treatment Instrument, and this is where things get revolutionary. Because it’s here in the Treatment Instrument where patented Multisonic Ultracleaning technology enters into the equation.

As the system is activated, treatment solution flows through the treatment tip of the instrument into the tooth. The stream of the treatment fluid interacts with the stationary fluid inside the pulp chamber creating a strong shear force, which causes hydrodynamic cavitation in the form of a cavitation cloud. The continuous formation and implosion of thousands of micro-bubbles inside the cavitation cloud generates an acoustic field with broadband frequency spectrum that travels through the fluid into the entire root canal system. The treatment tip of the instrument is designed to deflect the stream of treatment fluid in such a way to generate a flow over the orifices of the root canals. This flow induces gentle vortical flow as well as a slight negative pressure within the root canal system. The

Post GentleWave® treatment (image courtesy of Tyler F. Baker, DDS, MS)

By allowing you to perform root canal therapies with minimal instrumentation, the GentleWave® System actually reveals complex anatomies that may have otherwise been missed. The result is a reduced risk of reinfection

The GentleWave® System’s unique mechanism of action

Volume 9 Number 2

to 30/.06 or 50/.06, GentleWave technology enables you to instrument to as small as a 15/.04 in every canal! By using smaller instruments, endodontists are able to shape and work into the main areas of the canal, and in the process, locate more of the complex anatomies where bacteria can be left behind. Because minimal instrumentation gives GentleWave System users the ability to preserve canal structure, they are consequently able to save more of their patients’ teeth. As we bring a variety of technologies together in one mechanism of action, Sonendo has developed a truly revolutionary system for cleaning and disinfecting even complex root canal anatomies. The GentleWave System’s three-dimensional Multisonic Ultracleaning™ technology brings optimized treatment fluids throughout the entire canal system — from the crown to the apex — allowing for simultaneous canal disinfection and debris removal with minimal instrumentation. In addition, because this mechanism

of action is able to work so effectively and efficiently, most root canal therapies are able to be performed in just one treatment session. As a result, GentleWave practices find that they are able to schedule more billable visits throughout the day and take on even more referrals. As endodontists, we are optimists who specialize in saving teeth, but as people of science, we are often skeptical by nature. That’s why Sonendo invites you to visit its website www.sonendo.com to learn more about the GentleWave System’s mechanism of action, as well as peruse the latest case reports, peer-reviewed clinical outcomes, and in vitro research. After seeing the many benefits of Multisonic Ultracleaning™ technology, we hope you will schedule a handson experience with a Sonendo representative and learn more about how Sound Science® can improve outcomes for your patients and your practice. EP This information was provided by Sonendo.

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TECHNOLOGY

treatment fluid is degassed to minimize the energy loss and also to ensure energized treatment fluid is delivered throughout the root canal system. The result is highly effective cleaning and disinfection from the crown to the apex, with minimal instrumentation. How minimal is instrumentation with the GentleWave System? We have found that overinstrumentation within the canal can pack debris into canal eccentricities such as fins, lateral canals, and ramifications and remove important tooth structure. As you might expect, this renders irrigation far less effective. Overinstrumentation can lead to more bacteria and tissue remaining in the canal, which in turn, leads to an increased risk of reinfection, as well as a weakening of the tooth. The benefits to minimal instrumentation are profound. According to Tyler Baker, DDS, MS, it’s often the case that the more we instrument, the less of the actual anatomy we see. Where you once would have cleaned and shaped a canal using instrumentation

TECHNOLOGY

t’s a fact that endodontists have consistently embraced new technology faster than general practitioners. As specialists, it’s only natural that they should require specialized technology. Today, cone beam computed tomography (CBCT) systems give endodontists greater diagnostic capabilities and provide enhanced care to patients. There’s compelling evidence that you should be using this technology in your practice; however, “going 3D” is an even bigger paradigm shift than moving from film to digital. A CBCT system is a worthy investment, but admittedly a big one. And with more than 50 different CBCT solutions on the market, taking it all in can be overwhelming. If you’re considering a CBCT system for your practice, there are some key questions to ask to ensure your new technology works to your advantage.

The must-haves 1. Does it feature a focused field of view (FOV)? In 2015, the AAE and American Academy of Oral and Maxillofacial Radiology (AAOMR) released a more comprehensive update to the original joint position statement released 5 years prior regarding CBCT. Of the 12 recommendations for when limited FOV CBCT “should be considered the imaging modality of choice,” 10 recommend the use of CBCT over intraoral radiography. Therefore, it’s essential that any CBCT system you choose provide a focused FOV, such as 5 cm x 5 cm. Ideally, a system should include endodontic-specific modes that combine a Jordan Reiss is the national sales director of 3D imaging for Carestream Dental and assists practitioners in the transition to various digital technologies. He has spoken at numerous events on different facets of 3D imaging, conducted hands-on events for more than 1,000 clinicians, and has extensive knowledge on the vast landscape of 3D systems available in the market. He holds an MBA from Vanderbilt University.

50 Endodontic practice

Carestream Dental CS 8100 3D 75-micron maxilla posterior region with finding of apical lesion on patient with multiple crowns adjacent to region of interest

focused FOV with high resolution at a low dose. Many studies have shown that high resolution scans greatly assist with diagnosis. Per an AAE Communiqué (January 2014), “numerous authors have illustrated the usefulness and importance of CBCT in the diagnosis and management of dentoalveolar trauma, especially root fractures” to most effectively diagnose disruptions to the space. 2. Can I view clinical images taken with this unit to determine image quality? One of the greatest benefits of a CBCT system is its ability to remove overlying structures — superimpositions — when viewing a scan. But the patient’s own anatomy isn’t the only thing that can block your diagnostic efficacy when trying to treatment plan a region of interest. When looking at a CBCT system, be sure to request scans of complex cases

involving metal, silver points, gutta percha, or implants — clinical cases where there are a lot of foreign materials. Slick marketing for CBCT systems focus on catchy terms like metal artifact reduction (MAR) or scatter reduction technology (SRT), but looking at real cases in the software that comes with the system will provide clarity. High-quality scans are what will help you make the best diagnosis in a clinical setting, not idealized marketing images. 3. How intuitive is it for the clinician and the staff to use? Easy-to-use 3D imaging software makes using your system more intuitive. We’ve seen how much CBCT software has progressed in the past few years. With all of these changes, supportive educational resources for using the software and consistent, reliable updates are key. Also, consider a system that makes it Volume 9 Number 2

education include access to an online video library of tips and tricks and how-tos or free webinars, both recorded and live, for your staff to participate in. The most advanced system on the market doesn’t benefit you or your patients if not used properly, and training ensures you’re using the system to your best advantage.

the importance of referrals. In fact, you may find that a “side effect” of CBCT is a better relationship with other doctors. It’s important that you can share the full version of your 3D software (including implant planning) with referrals, so they can better understand your diagnosis and eliminate the chance of miscommunication.

The nice-to-haves

The splurges

4. Does the company you’re looking to purchase from offer ongoing training? Every CBCT system on the market comes with an upfront training session, but I cannot overemphasize the value of good training, education, and support on an ongoing basis. You’re about to make a big investment, and you’ll want to ensure you’re getting the most out of your system. Look to partner with a company that wants you to succeed as a clinician by offering live hands-on courses to better understand your imaging software. Other examples of ongoing

5. How easy is it to share files? All systems are DICOM-compatible, but does the system you’re considering acquire images natively in DICOM, or do you need to convert the file? A DICOM-ready file eliminates extra steps, reduces overall storage, and easily imports into third-party systems that allow for surgical guides, implant planning, and many other procedures.

7. Are there any add-ons or upgrades I could consider in the future? Look for a system that can grow as your practice does. If you plan to collaborate with implantologists or are hoping to someday add another specialist to your practice, consider a CBCT system that allows you to add FOVs to meet future needs. Other add-ons include extraoral imaging filters, object acquisition, and cephalometric arms.

6. Will this system help or hinder my relationship with referrals? The ease of sharing images brings me to

Today, cone beam computed tomography (CBCT) systems give endodontists greater diagnostic capabilities and provide enhanced care to patients.

Carestream Dental CS 9000 3D, 200-micron scan of mandibular anterior region demonstrating ability to view behind metal plate Volume 9 Number 2

8. Will this system help me with advanced treatments and techniques? Having a system with a deeper gray scale (or bit depth) allows you to do more, such as create STL files (digital models and impressions) that can be used for surgical guides and implant planning. These features are already popular with implantology, but will likely grow into endodontics in the next few years. What you should take away from these questions is that, as a specialist, your technology must adapt to your unique needs — not the other way around. Invest in a solution that provides endo-specific features for more precise diagnosis, increased patient case acceptance, and improved relationships with referrals. Like the microscope before it, a CBCT system is the new standard of practice for endodontists. If you’re in doubt, consider the words of Dr. John Khademi of Four Corners Endodontics in Durango, Colorado.: “Unlike the microscope — which I think is necessary for practicing at a high level — I do think that it’s possible to practice high-level endodontics without CBCT.” “However, I think it is impossible to practice at the highest level.” When you’re ready to practice at the highest level, asking the preceding questions can help you navigate the selection of CBCT systems on the market and ultimately help you find the one that will improve your diagnostic capabilities, treatment planning, patient care, and colleague collaboration. EP Endodontic practice 51

TECHNOLOGY

easy for your staff to acquire images — some examples of this include laser-free positioning and face-to-face positioning. Don’t forget about how the new system will integrate with your existing dental practice management software (DPMS). Seamless integration not only shortens the learning curve, but also creates the staff perception that the new unit is simply an additional module to the DPMS they’re already familiar with using.

TECHNOLOGY

MoraVision™ 3D: A paradigm shift in the ergonomics of dental imaging Dr. L. Stephen Buchanan offers his view of an innovative imaging technology

seldom addressed issue is the postural challenge of using operating microscopes in practice. This is probably because the advent of dental microscopes so dramatically improved dentists’ posture from the days of loupe magnification because they required dentists to sit more upright and to angle their patients’ heads instead of their own as they visualized the operative field. Better that patients have a neck ache for a couple of days after visiting the dentist, than the dentist becoming disabled by doing the same thing every day for years. Despite this improvement, the ergonomic stress delivered to dentists using microscopes is still quite significant, as this limited range of position requires them to sit in static positions for hours, every day of practice. Microscopes used in dental practice have an inherently limited range of positioning due to the requirement that wherever the microscope is positioned over the patient’s face, the dentist must be able to look into the binocular eyepieces — a requirement that limits the microscope’s range of angulation to about 15°. The muscle fatigue attendant to static positioning during practice is no different than that delivered to our patients who constantly hold or press their teeth together all day and all night long — the result is myofascial pain emanating from dentists’ backs and necks. I know this from personal experience, having had three spinal procedures

Figure 1: MoraVision camera over patient’s torso, aiming up at the maxillary arch, and allowing maxillary molar access cavity preparation without a mirror. Note the relaxed posture-independent view line of the operator

to alleviate pinched sciatic nerves. After a day of intense practice with a microscope, I felt like my back and neck belonged to a 1,000-year-old endodontist. The MoraVision™ 3D camera system — invented by Dr. Assad Mora, a prosthodontist in my home town of Santa Barbara — has changed all of that because with his imaging device, my view line is no longer posturedependent. Now that I use his 3D camera system instead of a microscope, I can move at any and all times during procedures, and

L. Stephen Buchanan, DDS, FICD, FACD, currently serves as an assistant clinical professor at the University of Southern California School of Dentistry and the University of California at Los Angeles School of Dentistry. He also maintains a private practice limited to endodontics and implant surgery in Santa Barbara, California. He began pursuing three-dimensional anatomy research early in his career. In 1986, he became the first person in dentistry to use microcomputed tomography technology to show the intricacies of root structure. In 1989, he established Dental Education Laboratories and subsequently built a state-of-the-art teaching laboratory devoted to hands-on endodontic instruction where he continues to teach. Through Dental Education Laboratories, he has lectured, conducted participation courses around the world, published numerous articles, and produced the award-winning video series The Art of Endodontics. In addition to his activities as an educator and practicing clinician, he holds a number of patents for dental instruments and techniques. Most notably, he was the first to introduce variable-tapered instruments for use in endodontic therapy and pioneered a system-based approach to treating root canals. In 1978, he received his dental degree, was valedictorian of his class at the University of the Pacific Arthur A. Dugoni School of Dentistry, and completed the endodontic graduate program at Temple University in Philadelphia, Pennsylvania in 1980. He is a Diplomate of the American Board of Endodontics and a Fellow of the International and American College of Dentists.

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my back and neck feel as fresh at 6:30 p.m. as they did at 8:30 a.m. Clinicians can now sit in any position, or better yet, in many positions during procedures because they only need to have a sight line to the 3D monitor on the wall of their operatories, eliminating the stress of static positioning. Not only does this imaging system help the operator, it also allows assistants to see the field exactly the same, an accomplishment that previously required them to also hold static positions at assistant’s scopes attached to the dentist’s scope. No longer will the image of a dentist and assistant huddled up to the binoculars of a microscope be the sine qua non of topflight dental practices. MoraVision™ takes vision ergonomics from a fixed, extremely limited line of sight that is totally dependent on the postural limitations of the operator, to a highly variable and posture-independent line of sight. Because this magnification device has been divorced from the operator’s face and the binocular eyepieces, the range of position is now a 180° hemisphere over the patient’s Volume 9 Number 2

Maxillar y access wit hout a mir ror.

TECHNOLOGY

Figures 2A-2B: Side and front views of 4" cube camera head

face, remarkably allowing access cavities and tooth preparations to be cut without a mirror when the camera is placed over the patient’s torso aimed up at their maxillary arch. During the use of hand-held or rotary files on mandibular teeth, rather than dealing with the severe parallax errors that typically occur when sitting in a 12 o’clock position, the MV camera can be placed to either side of the mandibular tooth so the sight line is exactly orthogonal to the file, and the clinician sees the stop dead-on as it meets the reference point. Surprisingly, with this device, my handeye coordination remains intact even when the camera is aimed from these unusual angles. There have been other camera systems that displayed a dental operating field image to a monitor, such as Karl Storz’s EXOscope, and while they have delivered a greater depth of field than microscopes, the resulting 2D image typically requires months of practice to accommodate — similar to the time needed for endoscopic medical surgeons to train up to working without the third Z-plane dimension in their minimally-invasive procedures. The third dimension delivered by MoraVision’s stereoscopic twin cameras means that the learning curve in using this device is short and very intuitive — much less than I needed to become adept with microscopes. For most clinicians, the first time they view a patient’s mouth with this 3D system and enter the operative field with hands and instruments, it is a very obvious and natural thing to place them exactly where they need to be. The three-dimensionality of this device is the game changer; it makes all the difference. Why now and not before? Basically, like all disruptive technology, many different advancements must arrive and work together for its potential to be unleashed. Until 3D monitors were made to display the split-second representation needed by 54 Endodontic practice

Dentists finally have light and magnification they need elegantly presented in a manner that makes its use simple and intuitive. gamers, also a requirement for 3D dentistry, the small lag time between hand movement and depiction on the screen required some time to master and made it awkward to use. On the value proposition side of the equation, the price of 1080p camera systems finally came to a price point that delivers a good value for clinicians, when comparing the $38,500 cost of MoraVision to the $70,000 price of a ProErgo Zeiss microscope. I have used this system for nearly a year during my live demonstrations for courses at my training center, Dental Education Laboratories, and the response has been amazement and fascination. Instead of a mirror view of the upper first molar I am treating, they get a straight-on, full view of the procedure. Beyond the obvious advantages of 3D presentation for live demos — one of which I did for last year’s ADA Session in Washington, DC — is the recording capabilities of the device. It ports directly into my TDO Chart where I can save still images or video in 2D and/or 3D format. It’s a mind bender, but I am predicting that 3D will take implant surgery and general dentistry in a way microscopes never did because of these significant advantages: 1. Depth of field 2. Width of field 3. Foot-controlled zoom and focus 4. Its 180° hemisphere of positioning

Figure 3: Course attendees watching the procedure with 3D glasses during a live patient demonstration. Current 3D monitors allow angle-independent viewing without eye fatigue

5. Its posture-independence and the improved ergonomics that it delivers 6. Its ridiculously small size compared to microscopes 7. Its ease of installation (Lift the edge of your chair; slide the pole support underneath; you are installed) 8. Cost 9. Simplicity and ease of clinical documentation 10. Last but not least — its freakish cool factor Dentists who have gone through the challenge of learning to use microscopes may be skeptical about this new inflection point in dental visualization. Dentists, specifically those who found microscopes to be unwieldy in general dentistry and implant surgery, finally have the light and magnification they need, elegantly presented in a manner that makes its use simple and intuitive when working in a wider field than an access cavity or retrograde surgical field. What would it be like to have perfect light and magnification with a depth of field that extends from third molars to incisors, installable in 20 minutes — all in a 5” cube? I’ve been using them since I sold my ProErgo scopes and, as usual, the view up front is the best. Visit dentalcadre.com for information. EP Volume 9 Number 2

ENDO TIPS

Problem-solving endodontics Dr. John Rhodes looks at locating canal orifices

odern preparation techniques provide a very efficient means of rapidly tapering the primary root canals prior to disinfection, but in practice, the first hurdle is often being able to actually find the orifices. An infected, missed canal could result in a persistent inflammatory response and failure of treatment. This article describes how to decode the pulp floor map in order to locate difficult to find canal orifices.

Decoding the pulp floor map The maxillary first molar in Figure 1 proved difficult to root treat as the sclerosed canals could not be located. The following steps demonstrate how to make the process more achievable. Good access The access cavity must be located correctly and provide sufficient space to allow adequate visualization of the pulp floor. This means removing tooth substance conservatively, but not compromising the ability to work efficiently during mechanical preparation. By removing the entire restoration in this case, orientation and visualization of the pulp floor was maximized. The same is true if the operator has created an oversized access in a previous attempt at root treatment; this can be used to advantage without affecting the integrity of the tooth. Magnification and illumination Magnification and illumination are essential. A microscope provides the best operating field, and this is why endodontists routinely use them. Being able to see where you are working is a massive advantage, and many of the instruments require direct vision in order to be used safely.

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

Volume 9 Number 2

An infected, missed canal could result in a persistent inflammatory response and failure of treatment.

The pulp floor The pulp floor tends to be darker than the walls of the access cavity, but when irritation dentin is present in the pulp chamber, this can be difficult to interpret. Calcified material needs to be removed with either ultrasonic instruments or a bur such as the Tungsten carbide LN bur (Dentsply). To prevent perforation of the pulp floor, an estimation of safe depth can be made from the preoperative radiograph, and direct vision with magnification and illumination will allow instruments to be used safely while refining the access and pulp floor. The canal orifices tend to be located at the extremities of the darker pulp floor and may appear as a small white dot if packed with dentin chips. Use a micro-opener (Dentsply) to gauge for signs of an orifice. In a maxillary molar such as the one in this article, the palatal canal is likely to be most readily located and, once confirmed, working along the border of the pulp floor map makes location of the main buccal canals easier. In this case, an attempt had already been made to locate the canals; the divots and iatrogenic irregularities created by burs can

Figure 1: Maxillary first molar proved difficult to treat as the sclerosed canals could not be located

be disorientating, so great care is required to establish and confirm the true pulp floor map to allow identification of the canal orifices. In the maxillary first molar, there is often a lip of dentin covering the second mesiobuccal canal that needs to be removed in order to locate the orifice. Once the primary mesiobuccal canal has been located, look for signs of an isthmus — following this in the direction of the palatal canal will often lead you to the second canal. Ultrasonics There are many ultrasonic instruments available for working deep in the access cavity to remove calcifications and trough between canals; some are diamond coated while others have machined tips. In this case, a No. 3 Start-X™ (Dentsply) instrument was used, vibrated at medium power in a Piezo ultrasonic unit (Satelec, Acteon). The tip can be used dry or with water spray, but it is important to be able to see where the tip is cutting to avoid perforation. Dentin chips and smear can be washed away with sodium hypochlorite, EDTA, or citric acid to clear the operative field. Gaining access The tip of a fine file, DG16 endodontic probe, or micro-opener (Dentsply) will catch in the orifice of the canal once located. This can be teased open with the micro-opener before confirming patency in the coronal aspect with a flexible hand file and continuing with preparation. EP

Watch the video To see how these steps are applied, visit https://youtu.be/BL2MKxF4vK0 or search YouTube for “Endo Practice — Decoding the pulp floor map.” The author is happy to answer questions directly via YouTube or Twitter @johnrhodesendo.

Endodontic practice 55

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT New vise bracket eliminates risk of dropping tabletop dental instruments ASI has introduced a new vise bracket that allows tabletop dental instruments to be securely mounted within reach of the operator for convenient access during procedures. Dental instruments include common brands of apex locators, obturation wands, and other cordless dental devices. The vise bracket can be mounted onto new and existing ASI dental delivery systems via the instrument holder bar or directly to the chassis. Easy-to-turn thumbscrews establish a precise, custom fit. Silicone rings provide added grip strength, ensuring the dental instrument will not slip or fall to the floor. Removal and replacement of the dental instrument are simple and convenient with no special tools required. The unique ball-and-socket feature provides dental professionals the ability to personally position the dental instrument for optimum visibility. A cord wrap located on the side of the bracket platform lends additional convenience and organization. Precisionmachined anodized aluminum construction gives the vise bracket a sleek finish with added strength and durability. For more information, visit www.asimedical.net.

Healing properties of ProRoot MTA available as a sealer Dentsply Sirona Endodontics has added another innovative product to its ProRoot® MTA family of endodontic advanced treatment options. ProRoot® ES endodontic root canal sealer is made from an enhanced formula of its counterpart ProRoot MTA root repair material, which has been trusted in over four million canals. Now, the same healing properties that clinicians have come to know and trust from ProRoot MTA are available in a biocompatible sealer. The unique formula of ProRoot ES provides a natural seal by sealing the root canal biologically. It is bioinductive for cementum and thereby supports tissue regeneration. The sealer has proven to be dimensionally stable and stimulates a hard-tissue covering over the apical foramen, while enabling the repair of the periradicular tissues. ProRoot ES uses a polymer-enhanced, powder and gel system that is not cytotoxic in a freshly mixed or hardened state, so it does not stimulate an inflammatory or root resorptive response. The water-based, easy-to-mix formula creates a smooth stringy consistency for excellent handling and also provides a flexible working time, setting quickly, even in the presence of moisture. The sealer initially sets within 65 minutes providing sufficient working time. Esthetically, the tooth-colored advanced sealer is highly radiopaque, offering a greater visual for placement of the sealer. For more information on ProRoot ES, visit www.DENTSPLY.com.

Vista Dental’s SmearOFF™ — one product, multiple benefits Nano Gutta Percha™ Points offer a simple, reliable way of filling root canal systems Nano Gutta Percha Points are precision machine-made for ideal cone fitting and have a lower working temperature and a longer working time. A newly developed precision manufacturing process shapes the points to precisely correspond to the exact apical size and taper of almost any file system used to shape canals. This ensures that each gutta percha point precisely fits into the most apical portion of the canal, promoting predictability and confidence in filling root canal systems. This proprietary formulation significantly improves heat conductivity and the ability to work at a much lower working temperature. The latex-free Nano Gutta Percha Points are completely synthetic and are formulated with a dense material that is less prone to volumetric change during heating and cooling cycles, thus reducing the risk of fracturing a root. The higher-density material also helps prevent trapping internal voids and helps reduce material oxidation. To learn more, call 800-344-1321, or visit www.obtura.com.

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SmearOFF™ by Vista Dental Products effectively replaces two commonly used solutions: EDTA and CHX. SmearOFF™ is an EDTA-based formula enhanced with chlorhexidine. SmearOFF™ not only effectively removes the smear layer, but also kills bacteria in one easy step. SmearOFF™ removes significantly more canal debris compared to standard 17% EDTA and leaves the root canal surface cleaner by opening a greater percentage of dentin tubules. Additionally, SmearOFF™ provides the added benefit of killing root canal bacteria. Unlike other 2-in-1 mixes, SmearOFF™ is compatible with sodium hypochlorite and will not form a precipitate, eliminating steps and saving time with each procedure. To find out more, visit vista-dental.com or call 877-418-4782.

Volume 9 Number 2

In 2016, the most prestigious award for dental industry companies will transition sponsorship from the Pride Institute to the newly launched Cellerant Consulting Group, founded by Lou Shuman, DMD, CAGS. The Cellerant “Best of Class” Technology Award, formerly known as The Pride “Best of Class” Technology Award, recognizes innovative game-changing technology offerings, services, and devices. Since the inaugural presentation in 2009, the “Best of Class” Technology Awards have grown to occupy a unique space in dentistry by creating awareness in the community of manufacturers that are driving the discussion as to how practices will operate now and in the future. Prior to founding Cellerant Consulting Group, Dr. Shuman served as the President of Pride Institute where he created and developed the “Best of Class” Technology Awards. In just 8 years, the “Best of Class” designation has become a trusted criterion for dental professionals to make educated, informed product and technology investment decisions for their practices and their patients.

Volume 9 Number 2

Sonendo’s GentleWave® System finalist in the 2016 Medical Design Excellence Awards Sonendo®, Inc., the developer of a disruptive technology for the endodontic marketplace, announced that the GentleWave® System has been chosen as a finalist in this year’s Medical Design Excellence Awards (MDEA) for its compelling and innovative design. MDEA are the premier awards for the medical technology industry that honor the highest caliber medical devices on the market today. Disruptive innovation for the endodontic market is at the center of Sonendo’s product development efforts as evidenced by the GentleWave® System, which leverages minimally-invasive, proprietary technology to clean the entire root canal system. As opposed to conventional endodontic files that only touch 50%-65% of the canal surface, the GentleWave System reaches deep into dentin tubules and other complex anatomies that cannot be accessed with conventional techniques.* To learn more about Sonendo and the GentleWave System, please visit www.sonendo.com. References on file with Sonendo®.

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INDUSTRY NEWS

Transition year for “Best of Class” Award recognizing game-changing dental technologies

PRODUCT PROFILE

EvoFill Duo™ by DiaDent® Sealing root canals to help ensure treatment success

he purpose of obturating a root canal is to fill the space three-dimensionally to eliminate any gateways through which bacteria might enter. Thanks to DiaDent®, doctors can now have a bulletproof way to seal root canals that will help ensure treatment success. Studies indicate that using the warm compaction technique increases the chances that no voids will be left behind in the obturation process. Introducing EvoFill Duo™ Obturation System — this new piece of technology consists of an EvoFill Backfill Obturation Device and an EvoPack Warm Vertical Compaction Device. While countless methods and techniques are available for root canal, perhaps none is as easy, intuitive, and timesaving as DiaDent’s complete obturation system. With an innovative electric motor that prevents hand fatigue, EvoFill Duo offers fast heating and controlled guttapercha extrusion with precise 3D fills and reliable results. Both units can be fully charged within 90 minutes! EvoPack™ is a cordless, warm vertical compaction device. It effectively and tightly compacts and seals all canals, including lateral canals. After a canal has been shaped and cleaned, a master cone is selected for a snug fit and tug back. EvoPack is then used to cut, soften, downpack, and compact the root canal filling material. The new, innovative LED light-guided condenser enables users to have a clear view inside the oral cavity. Color-coded heating condensers are available in five different sizes, including XF, F, FM, M, and ML. Its quick-heating tip reaches its highest temperature of 250°C within 1 second to save treatment time. Three levels of temperature and two heating-time settings let users have full control of any procedure. EvoFill™ then follows. EvoFill is a motorized cordless obturation system that extrudes warm gutta percha to backfill the yet unfilled portion of the canal. The motorized mechanism prevents users from hand fatigue. EvoFill uses a hygienic one-time use gutta-percha cartridge to deliver fast, precise, and direct injection of softened gutta percha into the root canal. The tips can be bent to the desired shape and angle using the multipurpose wrench provided. 58 Endodontic practice

EvoFill Duo™ by DiaDent®

The clear GP window displays the amount of gutta percha available in the cartridge. With the new disposable fast-loading guttapercha cartridge, there is no more messy, tedious cleanup. EvoFill has three variable temperature settings to allow precise control of obturation flow. The pre-heating function

quickly softens the gutta percha when device temperature is low. Detailed instructional and introductory videos can be viewed on DiaDent’s website at www.diadent.com. Brochure and demo units can also be requested. Purchase EvoFill Duo from your trusted dental dealers such as Henry Schein®, Patterson Dental, Benco Dental, Ultimate Dental, and others. DiaDent will be exhibiting at the GNYDM in New York from November 27-30, 2016. For more product and company information, please call 877-342-3368. EP EvoFill and EvoPack are trademarks of DiaDent. This information was provided by DiaDent.

Volume 9 Number 2

Your light at the end of the tunnel.

Anniversary Celebration!

Promotions, brochures and samples are available upon request. Please contact our office directly at 604-451-8851 or diadent@diadent.com.

NEW

FEATURES

Nickel Titanium Rotary File

Superior Cutting Efficiency • Sharp and strong blade construction to help file move deep into the canal • Triangular cross section reduces contact with the canal wall • Designed to instrument calcified or severely curved canals • Superior ability to create glide path and remove debris

Shaping

Finishing

High Flexibility • Progressive taper design increases flexibility and efficiency • High corrosion resistance with coated surface • Enhanced stability minimizes the pressure applied to files • Premium nickel titanium material Highly Integrable • Designed to work interchangeably with your current technique and system • Depth markings and ISO color coding for fast identification • Perfect matching GP and PP points: Dia-ProTTM Compatibility Chart*

DiaDent Group International www.diadent.com | 1.877.342.3368 Follow us on FACEBOOK

DX: Access File (19mm) D1: ProTaper® S1 D2: ProTaper® S2 D3: ProTaper® F1 D4: ProTaper® F2 D5: ProTaper® F3

*ProTaper is a registered trademark of Dentsply International Inc.

PRODUCT PROFILE

NeoMTA Plus® and Grey MTA Plus® root and pulp treatment materials “MTA — Your way.” Predictable. Convenient. Affordable.

valon Biomed Inc. has a mission to save teeth with MTA-type products. Uniquely qualified, the company’s management team has 19 years of experience inventing and manufacturing MTA, including three patents for MTA. Understanding the chemistry, products, and clinicians’ needs, they developed premium MTA-type products with affordable pricing, to ensure the product’s use. A note about bioceramics from Company President and Materials Scientist, Carolyn Primus, PhD: MTA Plus root and pulp treatment materials (NeoMTA Plus® and Grey MTA Plus®) from Avalon Biomed are bioactive bioceramics, as are all MTA-type products (mineral trioxide aggregate). By definition, a bioceramic is any ceramic used in vivo. Bioceramics are often inert, but bioactive bioceramics induce the precipitation of hydroxyapatite in synthetic body fluids or in vivo.

NeoMTA and Grey MTA Plus powders (above) and mixing MTA Plus (right)

Table 1: Major phases, determined by X-ray diffraction Product brand name

Tri/dicalcium silicate

Radiopaque*

ProRoot® MTA (white)

Biodentine®

BioRoot™

MedCem MTA®

TheraCal

EndoSequence Sealer

EndoSequence® Root Repair

EndoSequence BP Root Repair

® ®

EndoSequence RRM

NeoMTA Plus®

Grey MTA Plus®

* Bismuth oxide, barium zirconate, zirconia, and/or tantalite

Figure 1: Bioactive bioceramics are a subset of all bioceramics

MTA chemical composition All MTA-type products are formulated with tri/dicalcium silicate and blended with various radiopaque powders (Table 1). Products in the marketplace vary in their amounts of radiopaque powder, particle size distributions, and minor phases. These variations in composition affect properties such as setting time and handling characteristics. All MTA-type products are hydrophilic. They require water for setting, and calcium 60 Endodontic practice

NeoMTA Plus® and Grey MTA Plus® root and pulp treatment materials

Stainproof Popular “white” MTA products may discolor over time because of their bismuth oxide content. Available since early 2015, NeoMTA Plus does not contain bismuth oxide and is stainproof. (Note: Grey MTA Plus is not stainproof.)

Product format The MTA Plus products from Avalon Biomed Inc. are available as NeoMTA Plus and Grey MTA Plus in powder format, which the clinician mixes with the proprietary waterbased MTA Plus gel.

Easy to mix and dispense The Avalon Biomed powders are not “sandy” and difficult to handle. The fine MTA Plus powders mix easily with MTA Plus gel to any desired consistency from PUTTY to SEALER.

hydroxide is a reaction product, embedded in the cement matrix, as shown in equation 1. 2Ca3SiO5 + 7H2O g 3CaO.2SiO2.4H2O + 3 Ca(OH)2 (1)

Volume 9 Number 2

Packaging is smart and convenient • Desiccant-lined bottle protects the fine powder from hydration • Bulk powder and gel packaging (in bottles) allow for dispensing as needed • Compact design minimizes packaging waste Multiple indications From vital pulp therapy to perforation healing, apexification, root-end filling, obturation, and sealing.

PRODUCT PROFILE

By mixing the fine powder with gel (instead of water), many advantages are achieved: • Washout resistant upon placement • Short setting time (15 minutes at PUTTY consistency) • Handling like IRM® or SuperEBA™; no special instruments for placement • Easy mixing without special equipment

Made in the USA The offices and manufacturing facility of Avalon Biomed Inc. are located in (sunny) Bradenton, Florida. Avalon Biomed is a small, woman-owned corporation, focused on providing premium bioactive products at an affordable price. They focus on providing clinical convenience and personalized support to existing and potential customers. Affordable Some MTA products are expensive, up to $30 per dose. MTA Plus is priced to be globally affordable, so all patients, including children, can receive the benefit of the bioactive formula. (Pricing can be obtained from Avalon Biomed Inc. or from one of its distributors.) All MTA-type products are bioactive bioceramics, but they vary in features, benefits, and costs. Since 2011, the experts at Avalon Biomed have designed and manufactured MTA Plus to meet the needs of clinicians around the world. EP This information was provided by Avalon Biomed Inc.

NeoMTA Plus

Grey MTA Plus

MTA — The way you’ve always wanted it. NeoMTA Plus® or Grey MTA Plus® Root & Pulp Treatment Material Bioactive Stainproof Easy to mix & dispense Multiple indications Made in the USA Affordable

Yes

o o o o o o

avalonbiomed.com 941-896-9948

Volume 9 Number 2

Endodontic practice 61

ENDOSPECTIVE

Making the office a sanctuary Dr. Rich Mounce offers advice for calming a stressful environment

ecently, a good friend and I were discussing patient behavior. He expressed concern about the accumulating negativity and frustration he was experiencing from the frequent complaints, bad behavior, and lack of cooperation from some people. He is slowly starting to burn out. My friend summarized his feelings and thoughts with one sentence, “Rich, I don’t want to end up hating people, and I feel like I am starting to.” Many of us can relate. We live in a strange era culturally. Some feel entitled to say or do whatever they want without filters and/or respect for those around them. In a world where some patients are texting during treatment, choosing not to listen, placing blame, or wanting to use the bathroom every 10 minutes (among a host of similar behaviors), we are being challenged emotionally as never before. How do we remain calm, confident, professional, and clinically excellent without letting the above issues weigh on us? Here are my thoughts for maintaining a healthy attitude when such issues arise: 1. We must first realize there will always be some level of conflict and friction in practice. People are people, and bringing people together means conflict, miscommunication, and challenges. Expecting calm seas all the time is unrealistic. The best we can do is to be positive, maintain perspective, and be calm in the face of histrionics. Making sure our own actions and words are appropriate and professional provides confidence that we do not own the problem, which makes it easier to let go of. 2. In baseball terms, it is important to see the anticipated curve of the pitch as it arrives. In essence, to ask oneself with every patient where the personal and case risks might be,

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

62 Endodontic practice

As much as possible, make your private office environment your sanctuary, a place that energizes, comforts, empowers, and buffers us from the stresses of the day.

and whether those risks are worth taking. Can you meet the patient’s expectations? We never need the fee enough to be “beat up” by a case or patient’s behavior. If we can’t meet the expectations or don’t want to perform the case, it has value to simply tell patients that you cannot meet their expectations and let them see someone else that can. In essence, we swing only at pitches we can hit. 3. Practice less; practice long. There are no medals at the end of a career for the endodontist who treated the most teeth, did the most surgeries, or made the most money. Living less large and practicing longer in a state of better health is a prescription for a happier life in and out of the office. 4. People regret what they said more than what they did not say. Our tongues, like the rudder of a ship, have an outsized influence on our actions and the reactions of others to us. When in doubt, be silent, and evaluate what is happening. Very few are the situations where we must immediately speak or act. Being able to step away from the situation in the heat of the moment gives us time to

gain our composure and respond ultimately. Losing one’s temper is never productive, ever. 5. Create a firewall between home and work. Leaving the office at the office and being fully present at home creates a safe space to recharge. Such a firewall potentiates a more well-rounded and positive conversation outside the office. As a part of our “out of office” health, the value of being physically fit and burning off stress through regular, programmed, and sustained exercise cannot be overstated. 6. As much as possible, make your private office environment your sanctuary, a place that energizes, comforts, empowers, and buffers us from the stresses of the day. Creating a sanctuary can take the form of artwork, smells, music, furnishings, colors, among many possible domestic elements. I listened to my friend and did not offer solutions to his problem. And perhaps that is the answer for our patients as well — to observe, empathize, listen, and help only where, when, and if we really can. Listening has great value to the one being heard. I welcome your feedback. EP Volume 9 Number 2

SMALL TALK

Blind spots and self-limiting beliefs Dr. Joel C. Small discusses ways to increase practice potential through awareness

lind spot: One’s prejudice, or an ignorance that is beyond his/her field of awareness. Self-limiting belief: A personal prevailing belief that prevents the development or expression of one’s self. “Most ailing organizations have developed a functional blindness to their own defects. They are not suffering because they cannot resolve their problems but because they cannot see their problems.” ~John Gardner Several years ago I developed the tagline “Line of Sight Leadership,” which referred to leaders’ ability to develop a clear and unobstructed vision of where they (and their organization) are now and where they want to be in the future. It is this high degree of clarity that allows leaders to identify and ultimately remove the barriers and/or obstructions that block the path to our predetermined goal. At the time, I saw these barriers as tangible items that acted as restraints to our progress and achievement. That has all changed since my introduction to professional coaching. I now believe with certainty that the most daunting barriers to achieving our predetermined goals are not tangible at all. In fact, they are blind spots and self-limiting beliefs that remain unrecognized and undermine our ability to pursue our aspirations. It goes without saying that no degree of knowledge, skill, or self-efficacy can remove a barrier that is unrecognized. So how can we overcome an unrecognized barrier? Furthermore, how can we know that we have a blind spot or self-limiting belief if it is not on our radar? I have found through my coaching that when someone is experiencing frustration from repeated unsuccessful attempts to achieving a goal that the underlying cause is often related

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 jsmall@ntendo.com.

64 Endodontic practice

to a barrier created by a blind spot or selflimiting belief. Take, for example, a clinician (my client) who believes that becoming the best manager possible is the secret to creating a successful clinical healthcare practice. Doctors work diligently in establishing systems within their practice and managing these systems. They even hire professional practice consultants to help them develop the best possible systems and teach them to become an exceptional systems manager. Years pass, and the doctors, in spite of their best intentions and efforts, become increasingly frustrated because they never are able to realize their aspirations. The doctors begin to find less joy in their practices as the burden of overseeing systems become more and more tedious and less enjoyable. They find that with each passing year, their staff becomes less engaged and shows an increasing lack of self-motivation. Their once clear line of sight is now becoming blurred as they find an increasing number of obstacles blocking the paths to their initial predetermined goal. Eventually, the doctors can no longer recognize their once cherished goal, and they are now experiencing an acute case of “burnout,” which is characterized by a state of depression brought on by disillusionment, a victim’s perspective, and an abundance of self-limiting beliefs and blind spots. How did these once noble aspirations deteriorate into this state of despair? The answer is that the doctor was doomed to fail due an initial unrecognized blind spot in the form of “an ignorance that is beyond our field of awareness.” Unfortunately, this doctor’s same ignorance is shared by the vast majority of healthcare professionals who have never been taught how to effectively run a business. This blind spot makes us vulnerable, and we are easily duped into believing that managing a business is our key to success when, in fact, managing, even when done properly, is only part of the success equation. The blind spot, or ignorance if you will, relates to leadership. As Warren Bennis, the professor emeritus of the USC School of Leadership and leadership icon, has stated, a great business must be led. If the disillusioned doctors knew that leadership was the missing link, they would have surely taken this path initially. Their leadership skills would have empowered and motivated their staff by creating a culture of commitment with shared values and purpose.

They would have provided their staff with the resources, knowledge, and skill to manage the business systems, so the doctors could concentrate on patient care. And most importantly, the doctors would have allowed the staff to make decisions and experience the critical motivational factor found in their staff’s sense of self-efficacy — the sense that they have the skill and ability to achieve their professional aspirations and play a significant part in the practice’s success. My client’s failure to recognize this blind spot had a significant life-altering effect. As the situation spiraled out of control, the doctor developed other barriers in the form of selflimiting beliefs. After numerous failed attempts to realize his goal, the doctor came to the conclusion that he was incapable of realizing his aspirations. He felt trapped in this joyless and unfulfilling environment and eventually developed a victim’s perspective to his situation, which spilled over and affected his personal life. Having recognized this blind spot early on could have resulted in the doctor taking a different path and realizing a significantly different result. The doctor would have been freed of the management burden by a very competent, self-motivated, and committed staff. The doctor would have used the energy wasted on managing systems for a better, much more meaningful, and purposeful cause — pursuing his vision and noble aspirations. This is just one example of how blind spots and self-limiting beliefs can negatively impact our lives. Perhaps the most significant and damaging self-limiting belief is that we have no self-limiting beliefs. Each of us possesses numerous unrecognized beliefs that limit our growth and development. It is important that we free ourselves of blind spot and self-limiting beliefs if we are to reach our full potential in our personal and professional lives. These insidious beliefs are best recognized through self-awareness that for some can be achieved internally. For others, however, an external source in the form of a mentor or professional coach is the surest way to gain this awareness that enables us to overcome blind spots and self-limiting beliefs. The cost of professional help is a small price to pay when the potential benefit is so significant. By the way, what self-limiting beliefs do you have that might be getting in your way? Or what if you asked your team to help you identify blind spots and help you create solutions? You might be surprised by what you discover. EP Volume 9 Number 2

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