Endodontic Practice - Autumn 2016 Vol 9 No 3

clinical articles • management advice • practice profiles • technology reviews Fall 2016 – Vol 9 No 3

Dr. John West

Tactile-controlled activation (TCA) technique with controlled-memory files Dr. Antonis Chaniotis

Endodontic irrigation involving the NaOCl component Dr. Jeffrey Krupp

ENDODONTICS

http://www.zeiss.com/us/DentalMicroscopes

The three Fs of predictable endodontics: “finding, following, and finishing”

IN

ZEISS Microscope Visualization

EXCELLENCE

See it all in stunning detail.

PROMOTING

Practice profile Dr. Edward Sebok

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION

CREDITS PER YEAR!

16

Additional 50% magnification.

Image courtesy of Dr. Bijan Vahedi, Augsburg, Germany

We will never be “good enough.”

Average. Adequate. Good enough. For too long, standard root canal treatment has left bacteria, biofilm and smear layer behind. And for too long, treatment failure has been considered unfortunate, but unavoidable. That’s why Sonendo has developed breakthrough Multisonic Ultracleaning™ technology, giving you the power to deliver a level of cleaning that’s anything but “good enough.”

The GentleWave® Treatment Instrument provides disinfection that leads to fast healing1 with minimal instrumentation.

Talk to Sonendo® about the GentleWave® System today—and go beyond good enough.

Visit sonendo.com/better.

1 Sigurdsson A et al. J Endod. 2016; 42:1040-48 © 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 01

Fall 2016 - Volume 9 Number 3 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 3

M

ost of the world recently witnessed the 2016 Rio Olympics, and greatness was on display in many areas. It’s fascinating to watch these elite athletes who have trained and prepared for years to be at the peak of performance in their given sport. Their preparation not only involves extensive physical training, but also attention to detail in their diet, sleep habits, studying techniques in their given sport, and even mental preparation to be at their peak when it counts. Although most of us won’t be competing for a gold medal in the Olympics, there are many lessons each of us can learn from these athletes that will help us achieve excellence in our own practices.

In order for you and your team to achieve greatness in the field of endodontics, I offer the following four recommendations: Commit to elevating your game. The most important step in improving anything is to first commit to making the improvement. Kaizen is a Japanese word meaning constant and never-ending improvement, and any athlete or healthcare professional should continually seek for ways to add Kaizen in his/her practice. As soon as an athlete stops learning, training, competing, and improving, they enter a slippery slope that leads to mediocrity, diminished performance, and ultimately failure. The same thing happens to healthcare professionals when they and their teams stop learning and striving for continual improvement. Are there areas where you and your team can make improvements in the quality, safety, and efficiency of endodontic treatment you provide? Do you continually look for ways you can add more value to your patients and referring offices and provide a better experience interacting with your practice? Do you schedule regular training sessions with your team to improve their communication skills, customer service level, and practice systems? If not, commit to immediately implementing ways you and your team can elevate their game in these areas.

Measure what matters. Just as it would be unacceptable to hold a track meet without a timer, it’s unacceptable to not measure data critical to the success of your practice. A business strategist named Keith Cunningham wisely says, “What gets measured and reported improves exponentially.” If you want to make improvements, begin measuring and tracking data critical to the growth, efficiency, and quality of your practice.

Utilize technology for superior results. We truly are in an amazing time to be alive and practice endodontics! I can’t imagine practicing endodontics without my ZEISS surgical microscope, Carestream 8100 3D CBCT, DEXIS™ digital sensors, and all the other advancements we have in instrumentation and materials that improve the quality and efficiency of diagnosing and treating our patients. Top level athletes and their teams look for the best equipment and gear available to improve performance. We should also strive to educate ourselves and incorporate tested, proven technology that will improve our practices.

Find the best coaches. Just as world-class athletes like Michael Phelps, Usain Bolt, and Gabby Douglas use top level coaches to continue making improvements, so should we continue to find coaches and mentors to improve our practices. Our team and I have worked with and have been guided by several coaches, consultants, and mentors throughout my career. Some have been more influential than others, but all of them have provided useful ideas, training, systems, and support that helped our practice move to the next level. I feel receiving quality training and coaching is critical to having breakthroughs and continued improvement in a practice, which is why I still seek great mentors today.

The late Coach John Wooden, who was both a tremendous basketball player and alltime great coach famously said, “I may play against another player that is more gifted than me, but I will never play against another player that is more prepared than me.” May each of us do the necessary preparation to take our practices to the next level and find the joy, rewards, and satisfaction that come from continuous improvement.

Garth W. Hatch, DDS, PLLC, currently maintains a private practice with three full-time endodontists in Kennewick, Washington. He is also the President and Founder of Dental Specialist Institute, LLC, a dental consulting company dedicated to assisting specialists and their staffs obtain more referrals, profits, and personal freedom. Through Dental Specialist Institute, LLC, he has lectured and trained teams throughout the country, including their signature Rock Star Team Training Program that helps dental teams gain a sense of ownership for the success of the practice and utilize systems to find leverage, efficiency, and productivity within the practice.

In 2003, Dr. Hatch received his dental degree from Indiana University School of Dentistry and then joined the U.S. Army Dental Corps, where he completed an AEGD-1 year program at Fort Jackson, South Carolina. In 2007, he received his Certificate in Endodontics from the U.S. Army, Fort Gordon Endodontic Residency Program. After completing his military obligation, he moved to Kennewick, Washington, in 2010 where he purchased a private practice and was able to grow the practice by 60% in the first year with continued growth every year since. When he isn’t practicing or consulting, Dr. Hatch enjoys exercising and spending time with his wife, Alissa, and their five children. He is a member of the American Association of Endodontists, the American Dental Association, and the Washington State Dental Association. He can be contacted at garth@dentalspecialisti.com.

Endodontic practice 1

INTRODUCTION

Is your office going for the gold?

TABLE OF CONTENTS

Financial focus

Practice profile Edward Sebok, DMD

6

A focus on precision

Is your retirement plan strategy due for an annual checkup?

Tom Zgainer discusses the benefits of reviewing your 401(k) plan on a regular basis.................................... 12

Case study Management of a tooth with a large radiolucency: part 3 For part 3 of his series, Dr. Nishan Odabashian discusses treatment of teeth with failing previous root canal treatment exhibiting large radiolucencies................................. 16

Case study Nonsurgical root canal therapy on a tooth with dens invaginatus Dr. Garth Hatch discusses how CBCT helped diagnose a case of dens invaginatus

14

Endodontic insight The three Fs of predictable endodontics: “finding, following, and finishing�

Dr. John West navigates the roadmap to endodontic success....................20

ON THE COVER Inset X-ray image courtesy of Drs. John West and Jason West. See article on page 20.

2 Endodontic practice

Volume 9 Number 3

TM

WHERE SAFETY MEETS EFFICIENCY Together, the Genius motor, contra-angle, and files give you both reciprocation and rotary movement with just the touch of a button.

EFFICIENCY

SAFETY

360˚

OR

RECIPROCATION

ROTARY

THE SAFETY OF RECIPROCATION WITH CLOCKWISE AND COUNTER-CLOCKWISE MOVEMENT

THE EFFICIENCY TO REMOVE DEBRIS WITH ROTATIONAL MOVEMENT

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

800.552.5512 | ultradent.com © 2016 Ultradent Products, Inc. All Rights Reserved.

TABLE OF CONTENTS

Continuing education Tactile-controlled activation (TCA) technique with controlled-memory files Dr. Antonis Chaniotis discusses the tactile-controlled activation technique using controlled-memory files for severely curved and challenging canals .......................................................31

Practice management Is your website really working?

Ian McNickle, MBA, discusses how to convert website visitors into new patients...........................................38

Continuing education

26

Endodontic irrigation involving the NaOCl component Dr. Jeffrey Krupp discusses different irrigation components in conjunction with the use of NaOCl

Product spotlight EndoSync™ Endodontic Handpiece System

by Brasseler USA® A new era in endodontic instrumentation................................39

Abstracts The latest in endodontic research Dr. Kishor Gulabivala presents to latest literature, keeping you up-to-date with the most relevant research...............40

Product profile The Finishing File by Engineered Endodontics® The most cost-effective and simplest way to clean a canal....................... 42

Product profile MTA Repair HP New bioceramic material..................44

Endospective Big money for big cleaning?

Dr. Rich Mounce gets to the root of cleaning systems.............................46

Small talk Truth and fact Dr. Joel C. Small discusses the need to develop critical thinking as a means to defining and creating our preferred future................................................47

Product profile EndoUltra™

Materials & equipment......................... 43 4 Endodontic practice

New cordless ultrasonic activator significantly improves disinfection ........................................................48

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com GENERAL MANAGER | Alan Lobock Email: alobock@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 | Donna Aly Email: daly@medmarkaz.com MANAGER – CLIENT SERVICES | 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 E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.endopracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (4 issues) $99 | 3 years (12 issues) $219

Volume 9 Number 3

Improve the view in comfort.

ZEISS OPMI Microscopes

// VISUALIZATION MADE BY ZEISS

ZEISS OPMI® pico and OPMI PROergo® microscopes combine state-of-the-art optics and effortless maneuverability for maximum visualization and optimal comfort. Work ergonomically even at extreme treatment approach angles and view otherwise difficult-to-see regions in greater detail during delicate and complex procedures.

For more information, please contact us at 800-442-4020. http://www.zeiss.com/us/DentalMicroscopes

SUR.8040 ©2016 Carl Zeiss Meditec, Inc. All copyrights reserved.

PRACTICE PROFILE

Edward Sebok, DMD A focus on precision

Practice details Operatory number 1

What can you tell us about your background?

I was born in Westchester County, New York. My father was Hungarian and worked as a technical glass blower. My mother is German and spoke very little Hungarian. As a result, I was brought up speaking English, German, and Hungarian fluently. To maintain my ability to speak all three languages, I attended a Hungarian boarding school in Germany. I then went to the Semmelweis University Faculty of Dentistry and became a dentist in Hungary before I decided to move back to the United States. To become an accredited dentist in the U.S., I had to obtain U.S. licensure, which entailed 2 additional years of dental school. I completed these years at the University of Pennsylvania 6 Endodontic practice

School of Dental Medicine. At that point, I decided to pursue a career in endodontics and completed my specialty training at Penn.

After obtaining all certifications, I moved to Portland, Maine and joined a group practice, which marked the beginning of my career as an endodontist. After 20 years of group practice, I decided to venture off on my own and have finally constructed the practice that I have always envisioned, Oak Hill Endodontics.

When did you become a specialist and why?

I graduated from my endodontic program at the University of Pennsylvania in 1998. I decided to become an endodontist because I enjoy the precision work and attention to

• Four assistants who are crosstrained and can perform all tasks within the office • One office manager • Three operatories, two of which are equipped with ZEISS surgical operating microscopes and one room dedicated to the CBCT • One dedicated sterilization room • One large lunchroom that doubles as a conference room • One doctor’s office • One office manager’s office • TDO Software used with DEXIS™ digital radiography • Relaxing waiting room with Wi-Fi, television, and a beverage center

Volume 9 Number 3

Is your practice limited solely to endodontics, or do you practice other types of dentistry?

Our practice is limited to conventional and surgical microscopic endodontics. We do not place implants.

Why did you decide to focus on endodontics?

I have always been a very detail-oriented person, so the precision of endodontics is right up my alley.

Do your patients come through referrals?

Yes, the vast majority of our patients are referred.

How long have you been practicing endodontics, and what systems do you use?

I have been practicing endodontics for 20 years. I perform all of my work under a

surgical operating microscope. I clean and shape with nickel-titanium files. I perform warm vertical obturation and use digital radiography. Finally, I adopted the CBCT scanner and use it on an ever-increasing percentage of my patients.

of my practice. I have also been fortunate enough to surround myself with a staff that I respect and treat like family, which has created a positive environment.

What training have you undertaken?

I graduated dental school for the first time in Budapest, Hungary, in 1990. When I moved back to the U.S., I completed another 2 years of dental school and 2 years of endodontic training at the University of Pennsylvania. My education was finally completed in 1998.

Who has inspired you?

I was mainly self-inspired; however, my father’s perfectionism was imbedded in my genes. This attention to detail has proven valuable in my career decision.

What is the most satisfying aspect of your practice?

I am now a solo practitioner, which has allowed me to dictate the pace and quality

From left: Erica, Katie, Dr. Sebok, Amanda, Sherri, and Brianna Volume 9 Number 3

Endodontic practice 7

PRACTICE PROFILE

detail. I also find the rapid technological advancements to be exciting.

PRACTICE PROFILE

Top 10 favorites 1. A first rate team!

2. My new office space 3. ZEISS OPMI® pico microscopes 4. Photography and video through the microscope 5. Gendex GXDP-700™ CBCT scanner 6. TDO endo software 7. DENTSPLY Tulsa Dental Specialties ProTaper Gold® 8. DEXIS™ Platinum digital sensors 9. Updated sterilization room 10. Living only 3 miles away from my office Waiting room

Professionally, what are you most proud of?

I am proud of the beautiful office that I have created and the positive feedback that we are receiving from patients, the community, and referring dentists.

What do you think is unique about your practice?

In fitting out our new office, the “Martha Stewart” really came out in me. I was able to create a calming environment to comfort our normally anxious patients.

What has been your biggest challenge?

After working in a group practice for 20 years, taking the step to go solo was daunting but has been very rewarding.

What would you have been if you didn’t become a dentist?

I would have been a professional athlete.

8 Endodontic practice

Operatory number 2 Volume 9 Number 3

Ad: Elements cartridges

An innovative twist to obturation.

Because no two canals look the same.

The specially designed, highly durable needle can be pre-bent to fit your patient’s canal anatomy. Bend, twist, and curve your cartridge needle into just the right shape.

Enough material to get the job done The state-of-the-art cartridge was re-engineered to eliminate waste and extrude more gutta percha than before. Each cartridge contains enough gutta percha to fill up to four canals.

A needle that goes where you need it The redesigned needle is 5mm longer, giving you greater ability to reach the working length of the canal.

Because warm vertical means “Warm” The unique copper and gold plating conducts heat more efficiently, reducing the risk of the gutta percha losing heat as it passes through the needle and into the canal chamber.

Elements Gutta Percha Cartridges ™

O B T U R AT I O N | I N N O VAT I O N

Visit KerrDental.com or call 800.KERR.123 for more information.

MKT-1999 ©2016 Kerr Corporation

Together, we’re more.™

PRACTICE PROFILE

Family trip to Budapest, Hungary

The key is to learn from each case, follow up, and not brush it under the carpet. It is very important to be humble and know your limitations. It is also important to treat your patients and staff the way that you would like to be treated — with respect and appreciation. Regardless of how many years of experience you have, there is always something new to learn.

Mister Handsome aka Pluto

What is the future of endodontics and dentistry?

With the improvement of technology (in the right hands), we will provide better quality care and diagnoses, which in turn will lead to better prognoses.

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

We all have cases that we would love to hide on the bottom of our portfolio. If you have not had any failures, you probably have not done many root canals in your career.

10 Endodontic practice

have competed in sports for practically my entire life. Biking is therapeutic for me on many levels and is a part of my daily routine.

With my European background, I travel overseas frequently to visit family and friends and to enjoy the culture. I also enjoy spending time with my wife, Amanda, and daughters, Gianna and Jasmin. EP

What advice would you give to budding endodontist?

Endodontics is a humbling practice.

Continue learning, challenge yourself, and focus on precision. I also feel that it is important to keep the needs of the general dentist in mind, with the focus on properly restoring the endodontically treated tooth. You are only as good as your last case.

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

Outside of my practice and family, my main hobby is cycling. I am an avid racer, both locally and internationally, and an active member of the U.S. Cycling Federation. I

Portsmouth Criterium Volume 9 Number 3

ENDOSYNC TEST DRIVE TM

CALL TO SCHEDULE AN IN-OFFICE DEMONSTRATION AND RECEIVE

$100 IN FREE BRASSELER SAMPLE PRODUCT

ENDOSYNC SIMPLE. SAFE. SMART.

TM

Endodontic Micromotor & Apex Locator

•

SIMPLE: When paired with the EndoSync A.I. Apex Locator, the “Apical Action” function automatically stops the file from spinning when it reaches the apex.

•

SAFE: The EndoSync’s OTR (Optimized Torque Reverse) technology intuitively disengages the file, reversing 90 when the userspecified torque level is met. This drastically reduces the likelihood of file separation.

•

SMART: The EndoSync monitors the torque load on the file up to sixteen times per second and communicates with the EndoSync A.I. Apex Locator to provide real-time depth readings.

Visit our website at BrasselerUSA.com To order call 800.841.4522 or fax 888.610.1937. In Canada call 800.363.3838

B-4641B-EP-7.16

FINANCIAL FOCUS

Is your retirement plan strategy due for an annual checkup?

Tom Zgainer discusses the benefits of reviewing your 401(k) plan on a regular basis

R

egular maintenance regarding our health, be it a twice a year teeth cleaning or an annual physical, allows the experts to determine if we are as fit as we think we are, or see if there might be some issues under the hood that need attention. Likewise, each April, we are reminded of whether our tax planning is sufficient or perhaps needs a tuneup. Similarly, your retirement plan strategy is worth reviewing with a pension plan expert as well.

Often the original plan and strategy you implemented get away from your intended individual and corporate goals. Your employee populace may experience turnover, the actual age demographics of your staff may take on a different makeup, and by the way, you are now a year closer to retirement. You can find these changes limit your personal contributions due to required employer contributions or, more positively, open up new opportunities to design a plan that accelerates your personal contributions.

Retirement plans — whether a 401(k), profit-sharing plan, a defined benefit, or

Tom Zgainer is CEO of America’s Best 401(k).

He has helped over 2,800 businesses obtain a new or improved retirement plan over the past 13 years with a focus on strategic plan design to help achieve individual and corporate objectives.

You can learn more at http://americasbest401k. com/fee-checker-medmark.

12 Endodontic practice

a cash balance plan — all require some give-and-take. For owners, principals, key associates, or partners to take advantage of the opportunity to maximize annual contributions, you’ll need to give a proportional amount that passes all the required compliance tests to eligible employees.

These employer contributions at first might not be palatable to you and your bottom line. However, utilizing a long vesting schedule — for example, up to 6 years — can help ensure an employee needs to stay and contribute to your practice that long to earn any 1 year’s contribution. Plus, you receive the tax deduction benefit of the full amount of employer contributions in the tax year of the contribution, up to 25% of gross payroll.

A great reason to go through an annual plan design checkup is to see if there is a better plan type option for you. As you get closer to retirement, generally over age 45, plan types, such as a new comparability profit-sharing plan, a cash balance or defined benefit plan, can be paired with a 401(k) to rapidly accelerate your personal contribution objectives.

For 2016, you can defer $18,000 into a 401(k) plan, with a $6,000 catch-up provision if over age 50. That’s generally the best first thing to try and accomplish. If your plan

demographics are suitable, meaning staff is younger than the owners, principals, or partners (HCEs), and you are over age 45, a new comparability profit-sharing plan can provide a maximum benefit for a select employee group, while providing the lowest possible contribution to non-key groups allowed by law. This plan design can help you add to your deferrals and get up to the $53,000/$59,000 maximum annual limits from combined employee and employer contributions.

To really accelerate your contributions, consider looking into adding a cash balance or defined benefit plan to the 401(k).

Maximum contributions for these plans range from $102,000 at age 45 to $237,000 at age 62. When added to the 401(k)/profit-sharing contributions, it’s like squeezing 20 years of retirement saving into 10, not to mention the significant reduction to your tax liability that you will enjoy.

Just as you might make an appointment with your physician or CPA, this is a great time of year to get a retirement plan checkup as well. It’s easy and painless, as a census with your current firm demographics will enable a experienced pension specialist or actuary help determine if there is a better way to proceed into the years ahead for your retirement planning. EP

Receive your retirement plan checkup here: http://americasbest401k.com/fee-checker-medmark/ Volume 9 Number 3

844.880.ENDO (3636)

CASE STUDY

Nonsurgical root canal therapy on a tooth with dens invaginatus Dr. Garth Hatch discusses how CBCT helped diagnose a case of dens invaginatus

A

13-year-old Caucasian female was referred to our clinic for an endodontic evaluation of tooth No. 9 following dental trauma. The patient had a history of trauma to the maxillary anterior region approximately 2 weeks prior from falling face first onto a cement floor. Spontaneous throbbing and tenderness to cold and hot were noted for the last 3 days in the maxillary anterior region. Lingering tenderness to cold, percussion, and palpation were noted with tooth No. 9 during the intraoral examination.

Teeth Nos. 6, 7, 8, 10, and 11 responded within normal limits to cold, percussion, and palpation. The diagnosis for tooth No. 9 was symptomatic irreversible pulpitis with symptomatic apical periodontitis related to recent dental trauma of the maxillary anterior region.

The initial periapical radiograph taken revealed an unusual mesial root anatomy of tooth No. 10 with two separate pulp canals noted. A large periapical radiolucency (PARL) was also noted on the coronal two-thirds of the mesial root of tooth No. 10 apical to the accessory root. A 3D cone beam image of the maxillary anterior region was also taken Garth W. Hatch, DDS, PLLC, currently maintains a private practice with three full-time endodontists in Kennewick, Washington. He is also the President and Founder of Dental Specialist Institute, LLC, a dental consulting company dedicated to assisting specialists and their staffs obtain more referrals, profits, and personal freedom. Through Dental Specialist Institute, LLC, he has lectured and trained teams throughout the country, including their signature Rock Star Team Training Program that helps dental teams gain a sense of ownership for the success of the practice and utilize systems to find leverage, efficiency, and productivity within the practice.

In 2003, he received his dental degree from Indiana University School of Dentistry and then joined the U.S. Army Dental Corps, where he completed an AEGD-1 year program at Fort Jackson, South Carolina. In 2007, he received his Certificate in Endodontics from the U.S. Army, Fort Gordon Endodontic Residency Program.

After completing his military obligation, he moved to Kennewick, Washington, in 2010 where he purchased a private practice and was able to grow the practice by 60% in the first year with continued growth every year since. When he isn’t practicing or consulting, Dr. Hatch enjoys exercising and spending time with his wife, Alissa, and their five children. He is a member of the American Association of Endodontists, the American Dental Association, and the Washington State Dental Association. He can be contacted at garth@dentalspecialisti.com.

14 Endodontic practice

The invagination in tooth No. 10 is clearly evident on the CBCT separating the main root and pulp chamber with the mesial lateral canal. Note the large PARL extending into the coronal two-thirds of the root apical to the lateral root. The sectional view reveals the main root and pulp chamber with the mesial accessory root and mesial PARL

with a Carestream CS 8100 3D CBCT. The CBCT image revealed a mesial accessory root with a pulp chamber separated from the main pulp chamber of tooth No. 10. A root invagination also presented, separating the two canals consistent with dens invaginatus.

Classification of dens invaginatus Several dental classifications exist to describe dens invaginatus, including ones developed by Hallett in 1953. The most widely used classification system for dens invaginatus was developed by Oehlers in 1957 and revisited with Alani and others. Oehlers categorizes invaginations into three classes as determined by how far the extension is radiographically from the crown into the root.

Type I The invagination is minimal and enamel lined; it is confined within the crown of the tooth and does not extend beyond the level of the external amelo-cemental junction.

Type II The invagination is enamel lined and extends into the pulp chamber but remains within the root canal with no communication with the periodontal ligament.

Type IIIA The invagination extends through the root and communicates laterally with the periodontal ligament space through a pseudoforamen. There is usually no communication Volume 9 Number 3

Type IIIB The invagination extends through the root and communicates with the periodontal ligament at the apical foramen. There is usually no communication with the pulp.

Treatment

Figure 1: An intraoral radiograph of the maxillary anterior region revealing two separate pulp chambers of tooth No. 10 with Oehlers’ Type IIIA dens invaginatus. Note the accessory root with an adjacent invagination opening into the periodontal ligament creating an apical radiolucency

Figure 2: Completed root canal therapy of tooth No. 9. Treatment performed by Chad Dawson, DDS

Treatment options were discussed, and the patient and her mother consented to nonsurgical root canal therapy of tooth No. 9 and to monitor tooth No. 10. The patient and parent were advised on the questionable long-term prognosis of tooth No. 10 due to dens invaginatus (Oehlers’ Type IIIA) with a significant PARL. The patient will monitor tooth No. 10 and treat as needed, ideally once the patient has fully matured in case extraction is indicated. EP

REFERENCES 1. Hallett GE. The incidence, nature, and clinical significance of palatal invaginations in the maxillary incisor teeth. Proc R Soc Med. 1953;46(7):491-499.

2. Oehlers FA. Dens invaginatus. I. Variation of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol. 1957;10:1204-1218.

3. Alani A, Bishop K. Dens invaginatus. Part 1: classification, prevalence, and aetiology. Int Endod J. 2008;41(12):1123-1136.

Bio-Innovation™

BIOROOT™ RCS ROOT CANAL SEALER

A new WAVE of root canal sealing!

Active Biosilicate Technology allows BioRoot RCS to give you a tight seal with single cone obturatioN

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 3

Endodontic practice 15

CASE STUDY

with the pulp, which lies compressed within the root.

CASE STUDY

Management of a tooth with a large radiolucency: part 3 For part 3 of his series, Dr. Nishan Odabashian discusses treatment of teeth with failing previous root canal treatment exhibiting large radiolucencies Introduction A healthy 30-year-old female presented to our office on December 13, 2012, after her mother, a previous patient, insisted that she obtain a second opinion prior to having her tooth in the left mandibular molar area extracted as she was advised by her general dentist. She was referred to an oral surgeon for an extraction, bone graft, and implant with an implant-supported crown as the final restoration.

Clinical findings and dental history The patient had a crown on tooth No. 19, which according to the patient, was placed 5 years prior. She had composite and amalgam restorations on her remaining maxillary and mandibular premolar and molar teeth in the quadrant. The patient did not have any intraoral swelling but had been experiencing dull pain on the tooth for some time. However, she had been too busy to have the problem evaluated earlier. Both teeth No. 18 and No. 20 responded normally to cold sensitivity testing. Probing depths were within normal limits, measuring 2 mm-3 mm as probed at eight different sites around the tooth, using the “walking-the-probe technique.”

in the mesial apex and mesial aspect of the distal root.

Medical history Medical history was non-contributory.

Diagnosis • Pulpal: Pulpless — Previously treated root canal • Periapical: Symptomatic periradicular periodontitis

Treatment plan options • Initiate retreatment, and based on short-term response, determine proximate course of action — i.e., continue retreatment protocol or send for extraction/implant.

• Refer for extraction.

Treatment

Differential diagnosis • Lesion of endodontic origin • PA cyst • PA granuloma • Other

The patient wanted to think about her treatment options and advise us of her decision. Six weeks after the initial consultation, the patient finally decided that she would give retreatment a try.

Retreatment was initiated by isolating with a rubber dam and accessing the crown, removing the core and the screw post from

Figure 1: 12-13-2012 — Pre-op PA radiograph

Figure 2: 12-13-2012 — Pre-op BW radiograph

Figure 3: 2-4-2013 — Pre-op clinical photograph

Figure 4: 2-4-2013 — Access into chamber

Radiographic findings Periapical and bitewing radiographs pointed to a large “unilocular” lucency in the furcation area of tooth No. 19. The lucency extended almost the entire length of the roots from the furcal aspect. Tooth No. 19 had a previous root canal treatment that the patient noted had taken place approximately 10 years prior. The tooth had a screw-type post in the distal root, a core, and a PFM crown, with the apical resorption apparent

Dr. Nishan Odabashian is a graduate of Tufts University School of Dental Medicine. After 8 years of practicing restorative dentistry, he pursued his specialty training in endodontics at Loma Linda University School of Dentistry (LLUSD), Department of Graduate Endodontics. He is part-time faculty at LLUSD, and practices microscope-aided restorative endodontics in Glendale, California.

16 Endodontic practice

Volume 9 Number 3

CASE STUDY

Figure 5: 2-4-2013 — Screw post removal

the distal canal, as well as removing gutta percha from all canals. It could be seen that there was a viscous material resembling pus in close contact to the apical gutta percha.

The canals and pulp chamber were flushed with copious amounts of sodium hypochlorite. During drying of the canals, dark material adhered to the paper points. The canals were then irrigated, dried, and dressed with calcium hydroxide. The tooth was temporized with Cavit™. The patient was seen again during the 2 following weeks to continue cleaning the canals of their contents, again remedicated with calcium hydroxide for 10 weeks, and again 6 weeks later.

The patient presented for her next appointment almost 4 months after initiation of retreatment; there was a slight improvement of the furcal lucency. However, it was less than what was expected. At this appointment, after further cleaning, MTA was placed in the distal canal to seal the perforation on the mesial aspect of the distal root. The patient was seen at 6 weeks and 3 months after to monitor the healing and osseous repair.

We were able to notice clear ossous regeneration in the furcation area at the next visit, which was 8 months after the initiation of the retreatment process. Calcium hydroxide was again placed in the mesial canals for 3 more months, and completion of the treatment was planned for the next visit.

It was now 1 year since the initiation of the retreatment. The healing of the furcal bone was phenomenal. Both the operator and the patient were very pleased with the results. The mesial roots were obturated with gutta percha, and an amalgam core buildup was placed.

One year after the initiation of the retreatment, the patient presented for the obturation Volume 9 Number 3

Figure 6: 2-4-2013 — Paper point showing canal “filth”

Figure 7: 2-4-2013 — Canal cleaning and shaping

Figure 8: 2-4-2013 — Calcium hydroxide (clinical)

Figure 9: 2-4-2013 — Calcium hydroxide (radiographic)

Figure 10: 3-29-2013 — Calcium hydroxide (radiographic)

Figure 11: 5-6-2013 — MTA repair (radiographic)

Figure 12: MTA repair (clinical) Endodontic practice 17

CASE STUDY appointment. The healing and regeneration of the furcal bone were phenomenal. Both operator and patient were very pleased with the results.

Follow-up Follow-ups continued every 3 months for the first year, and for 6 months during the second year after the completion of the procedure. At the 2-year follow-up, one can see an almost complete resolution of the furcation lucency. This was accomplished without any surgery and without any grafts.

The patient is completely asymptomatic and is able to use the tooth in full function.

Discussion This case presentation is a third in a series of teeth exhibiting large periradicular lucencies associated with failing root canal treatments. (The first two articles were published in Endodontic Practice US in May/June 2014, Vol. 7 No. 3 and January/ February 2015, Vol. 8 No. 1.) As mentioned in the two previous reports, treatment of teeth with large lucencies requires more than the garden-variety retreatment or surgery.

It requires time, patience, proper follow-up, sound restorative treatment, proper diagnosis and, when needed, involvement of other specialists.

In this case, the 30-year-old female patient was slated to go through an extraction

and extensive bone and soft tissue grafting surgery with the loss of her tooth. And although neither the general dentist nor the oral surgeon can be faulted for the treatment that was about to be rendered, publication of these types of treatment results allow for the consideration of the possibility of retaining these teeth with long-term endodontic treatment.

The titrated-type of treatment which was rendered allowed us to “throw in the towel” if the signs and symptoms had not improved. At such time, the option of extraction, grafting, and implant placement would be performed. By attempting to treat the lucency and save the tooth, the implant option is never taken “off the table.”

This case also shows the capacity of the body to heal if and when the offending insults are removed. It shows the result of patience and taking the time to perform the

Figure 13: 10-1-2013 — Calcium hydroxide in mesials; MTA in distal

most conservative dental treatment possible.

It would have been easier (for the endodontist) to “just extract” and after surgery and grafting, to place an implant and implantsupported crown. It was definitely more timeconsuming for this clinician, but also much more rewarding. The treatment rendered was much less invasive, much less expensive, and was associated with less morbidity for the patient.

Summary This case shows what is possible with endodontic treatment/retreatment as far as osseous healing of large periradicular lucencies. This case also shows the benefit of multi-visit endodontic retreatment. Titrated treatment is very useful in these types of cases. It allows for re-evaluation of the results (or lack thereof) during the course of treatment. EP

Figure 14: 1-7-2013 — Gutta percha in mesial canals

Treatment of teeth with large lucencies requires more than the garden-variety retreatment or surgery.

Figure 15: 1-7-2013 — Amalgam buildup

Figure 17: 3-month recall 18 Endodontic practice

Figure 18: 15-month recall

Figure 16: 1-7-2013 — Post-op PA radiograph

Figure 19: 3-year recall from the initiation of the retreatment Volume 9 Number 3

Pure Peace of Mind.

Pure Maillefer.

READY•STEEL

Maillefer READY•STEEL available in:

Maillefer READY•STEEL™ files come pre-sterilized and packaged for single-patient use

•

– so they’re ready when you are. You get the Maillefer stainless steel quality you trust,

•

without the hassle of autoclaving or the risk of cross-contamination.

•

™

Call your distributor representative to order yours today.

maillefer.com © DENTSPLY International, Inc., DENTSPLY Maillefer ADMAIRS3 Rev. 0 2/16

• • •

C+ Files K Files FlexoFiles® Senseus® FlexoFiles® K Reamers Hedstroms

ENDODONTIC INSIGHT

The three Fs of predictable endodontics: “finding, following, and finishing” Dr. John West navigates the roadmap to endodontic success

T

he classic “Endodontic Triad” is founded on the 3 pillar principles of cleaning, shaping, and packing. More specifically, the historical triad was described as debridement, sterilization, and obturation.

However, the best mental and technical process for actually achieving cleaning, shaping, and packing is best understood from the perspective of the proper 3 F technical sequence. The 3 Fs of finding, following, and finishing canals focus on the biologic and mechanical objectives required in treating every endodontic canal. Once this simple thought process is recognized, the 3 Fs guidelines become the watchwords for what to do when in endodontic treatment.

The 3 Fs also coach dentists on how to focus on the outcome they want, how to measure the milestones along the way, and what to do differently if they are not getting the desired result. In other words, dentists know where they want to go in endodontic mechanics, how to get there, and what, why, and how to do things differently if they are not getting there.

endodontic canals, while not always easy, can indeed make their location easier and even enjoyable.

I have listed 12 practical techniques to improve a dentist’s ability for successfully finding endodontic canals: 1. Microscope and 3D CBCT — As clinicians, if we can see it, we can treat it.1 The operating microscope allows dentists to see at an unprecedented level of accuracy (Figure 1A). In daily dentistry and certainly endodontics, the endodontic microscope brings us closer to reality. In order to remain competitive and be at the top of his or her game, the dentist of the future will need to see with more precision. The microscope does just that; not just for the dentist but also the patient and the dental assistant. It is not a question of if the microscope will be part of every dental practitioner’s future, but when. To be ahead of the curve of excellence, dentists must be able to see and do dentistry as well as educate their patients, create perceived value, and reveal A.

real value. If a picture is worth a thousand words, a live video feed of the patient’s very own dental procedure is worth 10,000 words. Predictable dental mastery is in the details, and the microscope provides the simultaneous magnification and illumination to achieve a “what you see is what you get” experience for the dental team and the patient.

Digital imagery, especially in endodontics, much like the microscope, brings the clinician closer to the reality of diagnosis, treatment options, and treatment mechanics.

The simple act of making images dozens of times larger on a monitor allows the dentist to identify root canal system anatomy and obstacles. CBCT digital imaging provides a 3D blueprint of the same 2D root canal system anatomy and can often give the information needed for the dentist to make the endodontic diagnosis and lead toward the proper treatment plan and sequence where a 2D image may be insufficient or even misleading (Figure 1B).

B.

C.

Finding For the restorative dentist performing endodontics, Finding canals is one of the biggest technical problems that must be overcome in order to treat the patient’s endodontically diseased tooth. By understanding dentinal color maps, the typical location of orifices, and virtual rehearsing with the ToothAtlas (toothatlas.com), finding John West, DDS, MSD, is founder and director of the Center for Endodontics in Tacoma, Wash. He graduated from the University of Washington Dental School and received his MS degree and endodontic certificate at Boston University, where he has been awarded the Alumni of the Year Award. He is an educator and clinician, and his focus is interdisciplinary endodontics. He has authored several textbook chapters and is an editorial board member for the Journal of Esthetic and Restorative Dentistry, Practical Procedures in Aesthetic Dentistry, and the Journal of Microscope Enhanced Dentistry. He can be reached at (800) 900-7668, johnwest@ centerforendodontics.com, or visit centerforendodontics.com.

Disclosure: Dr. West is the co-inventor of ProTaper, WaveOne, and Calamus instruments.

20 Endodontic practice

D.

E.

Figure 1. Finding. (A) Zeiss and Global Surgical microscopes with magnification and simultaneous illumination bring the dentist closer to reality. When dentists can see it, they can do it. (B) CBCT 3D instruments such as the CS 9300 (Carestream Dental) bring the dentist even closer to reality. This 3D imaging has the ability to literally see inside teeth. (C) The JW 17 Microexplorer (CliniMed) enables the dentist to pierce the endodontic orifice without blocking it with collagen or dentin mud, which larger explorers tend to do. (D) Microexplorers (lower image) are narrower than the classic DG 16 explorer (upper image). (E) Illustration shows the difference between sliding through orifice dentin mud or collagen versus collecting the mud or collagen and blocking the canal orifice Volume 9 Number 3

E.

I.

B.

F.

C.

G.

J.

ENDODONTIC INSIGHT

A.

D.

H.

K.

L.

Figure 2. Finding and Following. (A) Cohen text reference of average number of canals characteristic for every tooth. (B) ToothAtlas is a useful virtual roadmap rehearsal before actually treating a specific endodontic tooth. (C) Mueller burs have the advantage of penetrating and then identifying the canal orifice entrance by leaving a “white dot” that is filled with hydroxyapatite and identifies the entrance to the canal itself. (D) Illustration of typical maxillary anterior root canal system. (E) Canals calcify crown-down in response to aging, but more specifically due to carious and restorative trauma. (F) Pretreatment image of mandibular left first molar revealing apparent calcified pulp chamber. (G) When locating the narrow roof of a calcified pulp chamber, a treatment film is valuable to prevent perforation of the chamber floor versus the roof. If the image is not perfectly positioned at a right angle to the rubber dam clip, the access depth cannot be seen. (H) Image is still foreshortened. (I) Parallel image allows the clinician to see that the current access depth is far short of the chamber floor and can safely penetrate a couple of millimeters deeper until the dentin roadmap allows discovery of the canal orifices. (J) Modified bite-wing of mandibular right first molar. Note calcified chamber. (K) Arrows outline dentin roadmap for location of MB canal orifice. Mueller bur penetration in brown color map (surrounded by red arrows) is where the MB orifice is waiting to be found! (Figures 2J and 2K courtesy of Dr. Jordan West, Tacoma, Wash). (L) Q-Mix (DENTSPLY Tulsa Dental Specialties), agitation with the EndoActivator (DENTSPLY Tulsa Dental Specialties), makes identification of small seemingly blocked orifices possible

2. Access Cavity — Successful shaping and cleaning begin with the ideal access cavity.2 The balance between the size and design of an access versus unimpeded and unfettered access cavities is a renewed conversation in the endodontic literature.

Like many controversies, the pendulum swings back and forth often due to emerging structural and biologic determinants coupled with new technologies. These changes may disrupt traditional mechanics while still producing the needed biologic requirements for either healing or preventing lesions of endodontic origin. As structural technologies improve, such as new breakthroughs in bonding, the need for miniscule access designs is actually less and less important.

In fact, the standard and proper endodontic access cavity has less importance than the restorative preparation in so far as structural integrity. The so-called notion of “minimally invasive endodontics” should take into consideration what Nature herself considers minimally invasive. Modern endodontic access cavities and appropriately shaped Volume 9 Number 3

canals for facilitating shaping, cleaning, and predictable 3D obturation do, in fact, perfectly mimic the natural root canal system both in access cavity (simply de-roofing the chamber) and radicular shaping. The only tooth structure that is removed in ideal endodontic accesses is the roof of the chamber and the dentinal triangles, neither of which “weaken” the tooth. Ideal radicular preparations also mimic Nature’s shapes by reproducing 7% to 10% tapers that travel from the minimal apical constriction to Nature’s coronal radicular width of between one fifth and one third the diameter of the coronal portion of the canal. No transformation of paradigm shift is needed here. No new articles about minimally invasive endodontics should be wasted on attempts to make endodontic preparations smaller than the ones that have genetically evolved for more than 900 human generations. Nature knew and still knows what she is doing. The term maximally appropriate endodontics is actually the desired “appropriate” term and goal. Until one of the parts of the endodontic triad (cleaning, shaping,

or obturation) experiences a radical change in technology such as sterilization without shaping, the current concepts of “maximally appropriate” cleaning, shaping, and obturation comprise the fundamental philosophy and methodology of today’s best practices.

3. Microexplorer —The classic DG 16 endodontic explorer is too large in diameter to identify and penetrate the entrance to endodontic canals that are undergoing calcific metamorphosis, calcific degeneration, or just plain shrinkage with time. The purpose of a narrower endodontic explorer is to pierce within the orifice of narrowing canal without simultaneously blocking it with collagen or “dentin mud” (Figures 1C to 1E).

4. Chairside Reference — Prudent clinicians laminate this chart from the author’s chapter in Michael Cohen’s 2008 Quintessence text, Interdisciplinary Treatment Planning: Principles, Design, Implementation, so that the reference is readily available during endodontic canal finding (Figure 2A).3 5. ToothAtlas — The best practice endodontic clinicians preview ToothAtlas Endodontic practice 21

ENDODONTIC INSIGHT images prior to treating any particular tooth number. Becoming accustomed to both the trends and variables of any particular tooth produces knowledge and confidence. It also alerts the dentist to any specific tooth local knowledge and/or booby traps. Imagine that you plan to endodontically treat a patient’s maxillary lateral incisor. You say to yourself: “Maxillary lateral incisor…piece of cake! One canal and I can see it right in front of the patient’s mouth.” However, when you peruse the ToothAtlas, a maxillary lateral incisor common characteristic jumps out at you. Most canals end with an abrupt turn to the distal and often the palatal! This apical “hook” is often blocked during endodontic mechanics, a shelf is formed, and the lateral incisor ends up with an under-filled root canal system. The answer of treating the entire root canal system starts with awareness, and there is no better path to awareness than the ToothAtlas (Figure 2B).

6. New Burs — New burs are a must, not a luxury, for efficient access preparations.

7. Mueller Burs and Ultrasonics — Like the ultrasonic tip, the Mueller bur allows the clinician to see and do simultaneously, which results in control (Figure 2C). By having a long shaft, the head of the handpiece does not block the view of the bur, and therefore the bur can be precisely positioned for accuracy. In addition, the bur cleanly cuts the dentin and reveals the canal entrance rather than smearing the dentin, concealing the canal orifice, as is the case with ultrasonics. The main value of ultrasonics in this endodontist’s experience is in endodontic disassembly, such as removing posts and broken instruments. Ultrasonics are excellent for removing dentinal triangles and refining the walls, as well as removing denticles and calcifications from the chamber and coronal orifice entrances.

8. Calcify Crown-Down — Pulps die and calcify crown-down.4 In other words, root canal system anatomy becomes wider when penetrating deeper (Figures 2D and 2E). Rather than thinking, “I can’t find the canal,” think, “The canal is not yet present at the current preparation depth. Go deeper.”

Nature never does its own root canal. It only looks like it sometimes. Before the dentist is uncomfortably deep, however, it is important to bring in an endodontist before accidental root perforation in order to keep in the patient’s best interest and well-being.

9. Dentin Roadmaps and Dentinal Triangles — Stay away from white dentin areas because a perforation is soon to follow!

A bite-wing radiograph is essential before the endodontic access of posterior teeth to 22 Endodontic practice

Becoming accustomed to both the trends and variables of any particular tooth produces knowledge and confidence.

determine the occlusal-gingival width of the chamber. Sometimes a crown may block this measurement. In access of these teeth, if the dentist seems deep enough to have prepped through the chamber roof in a full crown tooth but has not, pause to take a right angle radiograph to avoid inadvertent perforation through the chamber floor versus the chamber roof (Figures 2F to 2K).

In addition, each posterior tooth should have three well-placed horizontal images before the access cavity: mesial, perpendicular, and distal. Some endodontists also want a CBCT image, especially in retreatment situations in order to better unravel the diagnosis and improve predictability.5 10. Orifice Location and Root Shape — If the canal is in the center of the chamber of a mandibular molar, there is only one distal canal. However, if there is a canal in the DL or DB of the mandibular molar, 100 % of the time, there will be another orifice in the other corner of the access cavity. If you cannot find it, you simply cannot find it yet. It is there, waiting to be discovered.

Remember, canals calcify crown-down. You need to follow the dentin color maps with the Mueller bur and go deeper.

11. Q-Mix Trick for Narrow Orifice Location — If you follow a narrow or calcified canal orifice with the Mueller bur but cannot yet slide a small file into the canal, irrigate with Q-Mix (DENTSPLY Tulsa Dental Specialties), which has a surfactant in it with the EndoActivator (DENTSPLY Tulsa Dental Specialties), for 10 minutes (Figure 2L). This technique removes the mineralized dentin (collagen plus hydroxyapatite), which is densely crushed and packed by the Mueller bur into the previous narrow porous space of the calcified canal. The now dentin “plug,” which appears as a white dot, will usually be patent after Q-Mix agitation and will allow a narrow manual file such as the No. 6 to slip and slide down the canal.

12. Restraint — The previous 11 specific tips and hints focus on products and technique in canal finding. The twelfth tip and hint concentrates on principle. Finding canals takes restraint as well as a thoughtful strategy using patience and intention. The expected canal is almost always present,

and rather than “not being able to find the canal,” instead think that the canal is “simply not present at this access location.” Step back, take a deep breath, review and reorient yourself, look at cemento-enamel junction root anatomy for canal location clues and take a CBCT 3D image if you are completely lost. The key here is to slow down and step back. Sometimes we cannot see the forest for the trees. It is true in endodontic canal finding as well. The canal is still there and waiting to be discovered!

Following First, remove all access dentinal triangles (Figures 3A to 3C). Manual “instrumentation” or glidepath validation and creation are the lost art of endodontics. Following canals from their orifice to their terminus is also the missing link of mechanical endodontics and represents, in many ways, the most difficult part of endodontics if certain rules and principles are not followed. The dentist must be vigilant to the certain manual mechanical motions and understand the skill of restraint.

Our survival of the fittest has largely been just that: the strongest of our species has survived. While that trait may have been useful to fight off predators, lack of food and water, and challenging elements, “fight or flight” does not work in endodontics. In fact, it makes things worse because when the dentist pushes then blocks, ledges, and transportations result.

Glidepaths are lost and so is the 3D endodontic seal. When following canals with small manual files, restraint and yield are the best watchwords allowing the file to literally “slide” down the existing walls of the canal. If the file does not easily navigate the canal, there are four reasons for this: (1) the canal is blocked with dentin mud, collagen, or previous endodontic obturation material; (2) the angle of incidence and the angle of access are different — that is, the selected curve on the file does not easily mimic the curve of the canal and cannot easily follow; (3) the tip of the hand instrument is too wide for the canal; or (4) the shaft of the file is too wide for the canal, i.e., restrictive coronal dentin is preventing the instrument to travel deeper into the root canal system.

Volume 9 Number 3

B.

C.

E.

F.

G.

I.

J.

ENDODONTIC INSIGHT

A.

D.

H.

K.

Figure 3. Following and Finishing. (A) ProTaper Gold SX auxiliary NiTi file (DENTSPLY Tulsa Dental Specialties) allows for gentle and predictable removal of dentin triangles for unrestricted entrance into the root canal system. (B) First brushing and then following is an excellent technique for removing coronal interferences such as dentin triangles and coronal restrictive dentin due to crown-down calcification. (C) Brushing and Following with ProTaper Gold Shapers or any NiTi file pre-enlarges canal coronal section for easy finishing without removing unnecessary dentin. (Figures 3A to 3C original images are courtesy of Advanced Endodontics, Santa Barbara, Calif.) (D) Precurve every manual file before every entrance into the canal while preparing the glidepath. A curved file is a smart file and can randomly follow Nature’s canal configuration. (E) ProGlider (DENTSPLY Tulsa Dental Specialties) enables safe mechanical glidepath enlargement for all rotary and reciprocation endodontic shaping. (F) ProTaper Gold S1 placed into electric handpiece. (G) ProTaper Gold S1 curved gently against finger. (H) Curve partially remains and allows better access over access cavosurface as handpiece can approach more parallel to the curve of Spee versus perpendicular to it, requiring the patient to sometimes open to a difficult or impossible position. (I) Matching ProTaper Gold Finishing files and special machine made gutta-percha (DENTSPLY Tulsa Dental Specialties). (J) Pretreatment image of mandibular left second molar. (K) Finished result using all the principles and technique described in this article as well as ProTaper Gold Shaping and Cleaning technology. (Courtesy of Dr. Jason West, Tacoma, Wash.)

The dentist often thinks, “It is tight at the end of the canal” while, in fact it is tight at the coronal portion of the canal.

I have listed 3 practical techniques to improve dentist’s ability to follow canals from their orifice entrance to the radiographic terminus.

1. Curving Manual Files — Perhaps the number one trick in successful canal following besides restraint is to precurve the endodontic file in 1 or 2 planes before every entry into a canal with the intention of following to the radiographic terminus (Figure 3D).

2. Manual Glidepath Distinction of 4 Manual Motions — The 4 manual glidepath motions are follow, smooth, envelope, and balance.

Follow has to do with gliding down the canal until the radiographic terminus.

Following requires being gentle and patient.

You cannot go further until this essential step is complete, so take your time here, stay mistake-free, and enjoy being successful.

Volume 9 Number 3

Smooth has to do with vertical in and out strokes with increasing amplitude until the file can easily travel more than several millimeters of canal length. Remember, you are only wearing away or smoothing enough of the canal wall to guide NiTi shaping.

Envelope has to do with removing restrictive dentin with the hand file that does not easily progress to the radiographic terminus.

One common and often forgotten reason that a file does not easily progress down a canal is restrictive dentin against the coronal part of the file shaft. Envelope motion is performed by following a precurved file short of maximum resistance, and then simultaneously turning clockwise and removing the file in order to carve away the restrictive dentin.

Then follow this motion until either repeating the envelope short of maximum resistance or following to the radiographic terminus. The envelope is the only form of dentistry that occurs as the dentist is withdrawing from or leaving the tooth.

Balance is used when a smooth No. 10 hand file glidepath is established but the clinician desires an enlarged glidepath prior to rotary. A No. 15 file can be used in this case safely and predictably by turning the file clockwise at the point of resistance, then counterclockwise with slight apical pressure and proceeding to radiographic terminus as long as the file easily progresses. If not, remove the file in a clockwise direction, clean file flutes, and repeat to the radiographic terminus followed by smoothing motion and then NiTi rotary.6-8 3. Mechanical Glidepath — Many clinicians feel safer with an enlarged glidepath that is wider than the glidepath produced with a No. 10 loose file.9 Progressing to a size No. 15 runs the risk of blocking or ledging, since the No. 15 file is 50% wider at the tip than a No. 10 file. Some schools even teach the use of a No. 20 file at length or slightly short before rotary shaping. This, too, predisposes the dentist to blocking, ledging, or Endodontic practice 23

ENDODONTIC INSIGHT transporting since the No. 20 file is actually 33.3 wider at the tip than a No. 15 file! This is smooth glidepath sabotage in the making.

A safer, more predictable, and more efficient glidepath enlargement can be accomplished using a mechanical glidepath file such as ProGlider (DENTSPLY Tulsa Dental Specialties), which in essence is a baby ProTaper (DENTSPLY Tulsa Dental Specialties), meaning progressively increasing tapers. A single mechanical glidepath file makes all rotary and especially reciprocation easier and safer (Figure 3E).

Finishing Finishing is essential to endodontic predictability. Successful endodontic clinicians must finish as strong as when they start. The same time, energy, and concentration are needed during all 3 Fs. Finishing is divided into shaping, cleaning, conefit, and obturation.10 1. Shaping — Shapers and Finishers are 2 distinct NiTi file designs and are novel to the ProTaper Gold concept of incrementally preparing shapes in delicate dentin versus “drilling out” shapes with fixed tapered NiTi files. Endodontic clinicians have control when they progressively shape canals by first removing restrictive dentin with shapers (in other words, roughing out the canal) and then finish the shape using finishers to connect the dots between the minimal apical constriction and the appropriate one fifth to one third the root with at its coronal termination.

Shapers are used in a brush/follow motion and finishers are used in a follow/ brush motion. First, brush to the side of the canal, then let the shaper follow deeper, and then repeat to length. In other words, paint your way to the apex. Finishers are used with the same watchwords but in reverse order: follow/brush. So gently follow down the canal and then brush out. Then repeat to length.

A particularly useful technique with special heat treated, highly flexible NiTi rotary instruments is the precurving of the file before canal entry (Figures 3F to 3H).

This curving enables the dentist to sneak into the access over the access cavity cavosurface versus approaching straight down the canal. Therefore, the patient does not need to open as far, and canal entry is more graceful and easy. In addition, the precurving creates an immediate NiTi file envelope of motion, which encourages the file to shape and clean into the intricacies of the root canal system as well as creating 24 Endodontic practice

a shape slightly larger than the geometry of the file itself, which improves efficiency.

When is shaping completed? When the apical flutes are visibly loaded with dentin, the exact shape is finished, and the dentist can count on the corresponding gutta-percha cone to fit. The canal is then ready for vertical compaction of warm gutta-percha or carrierbased obturation.

When do you conefit? When the apical blades are loaded with dentin, the canal is ready for a predictable conefit.

2. Cleaning — Full-strength sodium hypochlorite is the ideal irrigant during following and glidepath preparation, as this solution digests detached collagen and removes dentin mud. If collagen is suspected apically, a viscous chelator such as ProLube (DENTSPLY Tulsa Dental Specialties) is useful in emulsifying the collagen. Ethylenediaminetetraacetic acid (EDTA) is useful during rotary as the indiscriminant chelator slightly softens glidepath walls for easier shaping and simultaneously removes smear layer.

EDTA, or better yet Q-Mix, which has the benefit of a penetrating surfactant, should be agitated with the EndoActivator to remove any remaining smear layer before drying and obturation.11 3. Conefit — Conefit is a lost art of endodontics. When I teach dentists endodontic techniques, conefit is one of the least understood aspects of treatment.

Conefit is a skill in and of itself. To assume the matching cone will fit the matching file is inaccurate. While cone sizing is improving (NanoFlow Gutta-Percha [DENTSPLY Tulsa Dental Specialties]), root canal anatomy is never perfectly round in all canals (Figure 3I). Therefore, knowing how to fit a custom master cone is essential in order to produce the least gutta-percha/dentin distance by distorting the apical gutta-percha and, consequently, relying less on sealer, which still remains the weakest link in endodontic obturation. Although reported improved sealers are being introduced into the endodontic literature, very few reports have been published on their suitability for warm gutta-percha compaction.

4. Packing — The author’s thinking is that the clinician’s obturation technique preference may become less significant as our ability to clean and sterilize root canal systems increases. Nonetheless, a standard measurement of the quality of endodontic treatment remains the efficacy and thoroughness of obturation based on final radiographic images. It is paramount to remember the rationale of endodontic success is simply

and profoundly still true: “If the root canal system is rendered inert through shaping, cleaning, and sealing the portals of exit, lesions of endodontic origin will be cured where they exist and prevented where they do not exist.” The final radiograph represents the metric of the clinician’s endodontic performance.

Obturation technique is a personal preference and may vary from single cone with sealer, lateral condensation, and vertical compaction of warm gutta-percha to carrierbased obturation. This author prefers the predictability and choices offered in the vertical compaction techniques (Figures 3J and 3K).

Closing comments Many dentists start endodontic procedures without a clear goal in mind. This article summarizes a thought process and guide for dentists to follow during endodontics.

The exact steps needed to perform predictable endodontics have been reviewed and explained. With a plan, the dentist can truly be in control.

The 3 Fs: Find, Follow, and Finish are presented as a roadmap to get where we need to go in endodontic success, mark the milestones along the way, and know what to do differently if we are not getting there.

This is what gives the clinician the freedom of knowing and the feeling of mastery. It is a place where the dentist experiences as newfound level of competence, consistency, and confidence.

Endodontic problems are for overcoming, which in turn creates freedom for proving. EP

REFERENCES 1. West JD. The role of the microscope in 21st century endodontics: visions of a new frontier. Dent Today.

2000;19:62-69.

2. West J, Chivian N, Arens DE, et al. Endodontics. In: Goldstein RE, Chu SJ, Lee EA, et al, eds. Esthetics in Dentistry.

3rd ed. 2016: Shelton, CT; People’s Medical Publishing House USA: chapter 24. In press.

3. West JD. Endodontic predictability—“Restore or remove: how do I choose?” In: Cohen M, ed. Interdisciplinary Treatment Planning: Principles, Design, Implementation. Chicago, IL: Quintessence Publishing Co; 2008: 123-164.

4. West JD. Ten myths about endodontics: “fact versus pulp fiction.” Dent Today. 2014;33:118-125.

5. West JD. The role of endodontics in interdisciplinary dentistry: Are you making the right decisions? Dent Today.

2014;33:80-85.

6. West JD. The endodontic Glidepath: “Secret to rotary safety.” Dent Today. 2010;29:86-93.

7. West JD. Manual versus mechanical endodontic Glidepath.

Dent Today. 2011;30:136-140.

8. West JD. Glidepath implementation: “Return to the beginning.” Dent Today. 2011;30:90-97.

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

10. West JD. Finishing: the essence of exceptional endodontics.

Dent Today. 2001;20:36-41.

11. Ruddle CJ. Hydrodynamic disinfection: tsunami endodontics. Dent Today.2007;26:110-117.

Reprinted by permission of Dentistry Today. ©2016 Dentistry Today

Volume 9 Number 3

Remove up to 36% less dentin with superior overall shaping*.

Aid disinfection by disrupting polymicrobial biofilms and significantly reducing bacteria*.* Contact up to 75% of walls along the entire canal*.

Create a predictable apical shape with up to 32% less transportation*.

Call to learn more or request a demo today.

Preserving What Matters.

The inner green area indicates the unprepared canal.

TRUShape 3D Conforming Files conform to natural canal anatomies for a more conservative shape (red area).

The file’s unique S-shape creates an innovative envelope of motion within the canal that conforms to unconstrained spaces while respecting constrained spaces.

Traditional ISO files make round shapes, and can unnecessarily remove tooth structure (white line).

Image courtesy of Ove A. Peters, DMD, MS, PhD.

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

© 2015 DENTSPLY International, Inc. ADTS Rev. 0 2/15

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

www.TulsaDentalSpecialties.com

CONTINUING EDUCATION

Endodontic irrigation involving the NaOCl component Dr. Jeffrey Krupp discusses different irrigation components in conjunction with the use of NaOCl

S

odium hypochlorite (NaOCl) is the most ubiquitous irrigating solution in endodontics. It has numerous favorable qualities and properties. NaOCl performs bactericidal cytotoxicity, benefits the dissolution of organic material, and enhances minor lubrication.1 Sodium hypochlorite by itself is not sufficient for total cleaning of the endodontic system.2 It has no measurable effect on the smear layer, and its high surface tension does not allow for cleaning and disinfection of the root canal system’s totality. For this reason, and according to individual clinical situations, we must use other irrigants in combination with sodium hypochlorite.

The basic biologic objective of root canal treatment, beyond removal of subjective symptomatology, relies on the complete removal of the pulpal tissue and the destruction of residual microorganisms, including yeasts, molds, and viruses often

Educational aims and objectives

This clinical article aims to discuss different irrigation components in conjunction with the use of NaOCl.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 30 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some of the favorable qualities and properties of sodium hypochlorite (NaOCl).

• Identify various components of endodontic irrigation.

• Recognize some basic biologic objectives of root canal treatment.

• Realize different irrigation components in conjunction with the use of NaOCl. • Recognize some ideal properties of an irrigant.

found in infected root canals. Therapeutic endodontic treatment also mandates an effective radicular seal in order to prevent recolonization of the root canal system with microorganisms.3 Dr. Herbert Schilder emphasized the importance of cleaning and shaping. We as clinicians respect that the proper shaping of

a canal develops a conduit, which can now be effectively irrigated and cleansed.4 The components of endodontic irrigation fall into a number of categories. Irrigation solutions, devices, protocols, advances, and clinical challenges all factor to some degree how the clinician approaches this foundational aspect of endodontic therapy.

The choice of irrigants will always vary from practitioner to practitioner. No irrigant to date provides 100% elimination of bacteria and cleansing of the root canal system.

This article will review in part different irrigation components in conjunction with the use of NaOCl, a prominent endodontic irrigant.

The amazing complexity of human dental morphology has been described and extensively studied. The astounding variation of root and canal morphology renders therapeutic endodontic treatments a constant challenge.5,6

Figure 1: Successinendodontics.com Jeffrey Krupp, DDS, MS, is a Board-Certified Diplomate of the American Board of Endodontics. Dr. Krupp has been in full-time endodontic private practice for 34 years in San Jose, California, and the Executive Producer/Author of the ADA - CERP, and AGD - PACE 14 CE unit-certified course “Success In Endodontics,” which is available at SuccessinEndodontics.com as a DVD/ Manual set or online at Dentaltown.com.

Figures 2A-2C: Images courtesy of Dr. Craig Barrington 26 Endodontic practice

Volume 9 Number 3

Ideal properties of an irrigant15 • • • • • • •

Tissue/debris solvent Low toxicity Low surface tension Lubricant Sterilization/disinfection Removal of smear layer Have a broad antimicrobial spectrum and high efficacy against anaerobic and facultative microorganisms organized within biofilms • Inactivate endotoxin Volume 9 Number 3

• Systemically nontoxic, non-caustic to periodontal tissues • Low cost, easy availability, shelf life Sodium hypochlorite when used as an endodontic irrigant becomes an effective antimicrobial with tissue-dissolving capabilities. It has low viscosity, allowing easy introduction into the canal, an acceptable shelf life, easy availability, and inexpensive. The antibacterial and tissue dissolution action of hypochlorite increases with its concentration, but this accompanies an increase in toxicity.

Concentrations ranging from 0.5% - 5.25% are widely used. Although less concentrated solutions have shown antimicrobial effectiveness, higher concentrations of NaOCI present faster and greater bactericidal effect. However, the higher the concentration of NaOCl, the greater its cytotoxic effect.16,17 Different contact times evaluated both at 1 minute and 5 minutes were found to be effective against growth of E. faecalis.

Retamozo, et al.,18 reported that long exposure time to NaOCl is needed for elimination of E. faecalis-contaminated dentin, such as 40 minutes. As clinicians we need to keep in mind the findings of Zhang, et al.,19 where it was reported that collagen degradation was significantly increased, and the flexural strength of mineralized dentin was significantly reduced after the use of 5.25% NaOCl as the initial irrigant for more than 1 hour.

My office employs “Fresh Scent” Clorox®, which has a concentration of 4.13% directly from the bottle.20 It is always advised to flush the root canals with NaOCl throughout the cleaning and shaping process as it helps to increase the working time available for the irrigant and improves cutting efficiency of the instrument.

Additionally, the axiom is never manipulate a file in a dry canal to avoid file separation due to binding of the file in the canal. Keeping irrigant in the canal decreases the potential for file separation as well as helps flush out debris as the file is moved in an apicalcoronal direction.

NaOCl neutralizes the amino acids forming water and salt. With the output of hydroxyl ions, a reduction in the pH occurs.

The hypochlorous acid, a substance present in the NaOCl solution, when in contact with organic tissue, acts as a solvent releasing chlorine, which combined with the amino group of proteins, forms chloramines.

Hypochlorous acid (HOCl) and hypochlorite ions (OCl-) lead to degradation of amino acids and hydrolysis, so the dissolution of organic necrotic tissue can be verified in

the saponification reaction when NaOCl degrades fatty acids and lipids, resulting in soap and glycerol and promoting a deodorant effect. Sodium hypochlorite exhibits a dynamic balance as shown by the following reaction:21

Saponification reaction Sodium hypochlorite acts on fatty acids, transforming them into fatty acid salts (soap) and glycerol (alcohol) that reduce the surface tension of the remaining solution.

Neutralization reaction NaOCl neutralizes amino acids and forms water and salt. With the exit of hydroxyl ions, there is a reduction of ph.

Chloramination reaction Hypochlorous acid, present in NaOCl solution, when in contact with organic tissue acts as a solvent, releases chlorine that, combined with the protein amino group, forms chloramines that interfere in cell metabolism, helping to render its antimicrobial affect

Endodontic practice 27

CONTINUING EDUCATION

The intricacy and anatomical complexity of the root canal system, presence of dentinal tubules comprising the root morphology, invasion of the tubules by microorganisms, formation of smear layer during instrumentation, and presence of dentin as a tissue are the major challenges in obtaining the therapeutic intention of complete cleaning and shaping of root canal systems.7 Besides sodium hypochlorite (NaOCl), other commonly used irrigants are chlorhexidine, ethylenediamine tetraaceticacid (EDTA), and a mixture of tetracycline, an acid, and a detergent (MTAD).

Sodium hypochlorite is an excellent nonspecific proteolytic and antimicrobial irrigation solution. It is effective against most bacteria typically found in the canal system, including Enterococcus faecalis but is concentration dependent.8 Although sodium hypochlorite appears to be the most prominent single endodontic irrigant, it displays no effect on the smear layer, and its high surface tension does not allow for cleaning and disinfection of the root canal system’s totality. Therefore, according to individual clinical situations, we must use other irrigants in combination with sodium hypochlorite.9,10 Chelating agents such as ethylenediamine tetraacetic acid (EDTA)11 and citric acid12 have therefore been recommended as adjuvants in root canal therapy. In addition to their cleaning ability, chelators may detach biofilms adhering to root canal walls.

Research has reported an increase in the antibacterial effect of 5.0% NaOCl when used alternately with 10% EDTA solution. This is related to the demineralizing action of EDTA, which prevents smear layer formation during instrumentation, resulting in an increased NaOCl penetration into the dentinal tubules.13 Citric acid has been reported to affect the removal of the smear layer similar to that obtained by EDTA. Citric acid is less cytotoxically irritable to tissue than EDTA.14

CONTINUING EDUCATION Hypochlorous acid (HOCl-) and hypochlorite ions (OCl-) lead to amino acid degradation and hydrolysis.

Chlorine (strong oxidant) presents antimicrobial action inhibiting bacterial enzymes leading to an irreversible oxidation of SH groups (sulfhydryl group) of essential bacterial enzymes.21 Sodium hypochlorite is a strong base (pH>11). Its antimicrobial mechanism of action can be observed verifying its physiochemical characteristics and its reaction with organic tissue.21 The high pH of sodium hypochlorite interferes in the cytoplasmic membrane integrity with an irreversible enzymatic inhibition, biosynthetic modification of cellular metabolism, and phospholipid degradation observed in lipidic peroxidation. The amino acid chloramination reaction forming chloramines disrupt cellular metabolism. Oxidation enhances irreversible bacterial enzymatic inhibition replacing hydrogen with chlorine.

This enzyme inactivation can be visualized with the reaction of chlorine among amino groups (NH2-) and an irreversible oxidation of sulfhydryl groups (SH) of bacterial enzymes (cysteine). Thus, sodium hypochlorite displays antimicrobial activity with action on bacterial essential enzymatic sites encouraging irreversible inactivation originated by hydroxyl ions and chloramination activity. Dissolution of organic tissue can be confirmed in the saponification reaction as sodium hypochlorite damages fatty acids and lipids resulting in soap and glycerol.21 The antimicrobial effectiveness of sodium hypochlorite, based in its high pH (hydroxyl ions action), is similar to the mechanism of action of calcium hydroxide.22 Mechanism of action of sodium hypochlorite is that the free chlorine in NaOCl dissolves vital and necrotic tissue by breaking down proteins into amino acids.23 Sodium hypochlorite has been demonstrated to be an effective agent against a broad spectrum of bacteria and to dissolve vital as well as necrotic tissue.24 Beside their wide-spectrum, nonspecific killing efficacy on all microbes, hypochlorite preparations are sporicidal and virucidal,25 and display enhanced tissue-dissolving effects on necrotic rather than on vital tissues.26 Decreasing the concentration of the NaOCl solution reduces its toxicity, antibacterial effect, and ability to dissolve tissues.

Increasing the temperature of a less concentrated solution helps in improving its effectiveness. Several studies revealed that warmed 28 Endodontic practice

Figure 3

No irrigant provides 100% elimination of bacteria and cleansing the root canal. Notwithstanding the complications, NaOCl is the benchmark irrigant used in normal clinical practice.

NaOCl solutions dissolved organic tissues better and exhibited greater antimicrobial efficacy compared to non-heated solutions.27-31 The ability of NaOCl to dissolve organic tissues is directly proportional to its concentration. According to Baumgartner and Cuenin, efficacy of the solvent and disinfectant action of NaOCl solutions at low concentrations can be increased by using higher volume of solution and frequent exchanges.32 Numerous endodontic protocols have recommended the alternate use of NaOCl and EDTA. The alternate or mixed use of EDTA during instrumentation with 2.5% sodium hypochlorite was the most effective form of irrigation for the removal of smear layer on the cervical and middle thirds. No form of irrigation was sufficiently effective to remove the smear layer in the apical third.33 Berutti, et al.,34 observed an increase in the antibacterial effect of 5.0% NaOCI when used alternately with 10% EDTA solution. This is related to the demineralizing action of EDTA, which prevents smear layer formation during instrumentation, resulting in an increased NaOCI penetration into the dentinal tubules.

Various irrigation techniques are available, but NaOCl is generally delivered to the

canal system using an irrigating syringe and tip. A safe-ended/side irrigation tip is recommended as this prevents accidental extrusion of the solution apically. The recommended tip should be passive in the canal and not be used to express it from the syringe as this will also prevent a potential NaOCl accident. Other methods include agitation with brushes and manual dynamic agitation with files or gutta-percha points. The previously mentioned methods are mechanical irrigation techniques. In today’s endodontic environment, rotary irrigation systems are also extensively used such as rotary brushes, continuous irrigation during instrumentation, sonic and ultrasonic vibrations, and application of negative pressure during irrigation of the root canal system.35 It is always advised to flush the root canals with NaOCl throughout the cleaning and shaping process as it helps to increase the working time available for the irrigant and improves cutting efficiency of the instrument.

The major disadvantages of NaOCl are its cytotoxicity when injected into periradicular tissues, unpleasant smell and taste, ability to bleach clothes, and ability to cause corrosion of metal objects.36 In addition, it Volume 9 Number 3

reactive molecule, it creates problems when used in a multiple-irrigant regimen. When sodium hypochlorite and chlorhexidine are mixed, an orange-brown precipitate known as para-chloroaniline is formed, which might be carcinogenic, although that has not been substantiated. Clinically, it’s seen as a difficult-to-remove, orange-brown film on tooth structure where the reaction occurs.

The major advantages of chlorhexidine over NaOCl are its lower cytotoxicity and lack of foul smell and bad taste.44-48 Endodontic success relies on the eradication of microorganisms, integrating

REFERENCES 1. Barnard D, Davies J, Figdor D. Susceptibility of Actinomyces israelii to antibiotics, sodium hypochlorite and calcium hydroxide. Int Endod J. 1996;29(5):320-326.

2. Ayhan H, Sultan N, Cirak M, Ruhi MZ, Bodur H. Antimicrobial effects of various endodontic irrigants on selected microorganisms. Int Endod J. 1999;32(2):99-102.

3. Garberoglio R, Becce C. Smear layer removal by root canal irrigants. A comparative scanning electron microscopic study. Oral Surg Oral Med Oral Pathol. 1994;78(3):359-367

removal of the smear layer during cleaning and shaping. Clinical success factors utilizing the NaOCl result in the irrigant’s full potential while treating endodontic cases.

The application of irrigants differs from practitioner to practitioner. No irrigant provides 100% elimination of bacteria and cleansing the root canal. Notwithstanding the complications, NaOCl is the benchmark irrigant used in normal clinical practice.

Appropriate administration of the preferred irrigant helps to achieve sufficient antimicrobial effect, thereby enhancing endodontic therapeutic success. EP

26. Austin JH, Taylor HD. Behavior of hypochlorite and of chloramine-T solutions in contact with necrotic and normal tissue in vivo. J Exp Med. 1918; 27(5):627–633 27. Sirtes G, Waltimo T, Schaetzle M, Zehnder M. The effects of temperature on sodium hypochlorite short-term stability, pulp dissolution capacity, and antimicrobial efficacy. J Endod. 2005; 31(9): 669-671.

28. Cunningham WT, Balekjian, AY. Effect of temperature on collagen dissolving ability of sodium hypochlorite endodontic irrigant. Oral Surg Oral Med Oral Pathol. 1980; 49(2):175-177.

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

29. Kamburis JJ, Barker TH, Barfield RD, Eleazer PD. Removal of organic debris from bovine dentine shavings. J Endod. 2003; 29(9):559-561.

5. Hess, W. The anatomy of the root canals of the teeth of the permanent dentition. In: E. Zurcher (Ed.) The anatomy of the root canals of the teeth of the deciduous dentition, and of the first permanent molars. London, John Bale, Sons & Danielson, Ltd; 1925.

30. Cunningham WT, Joseph SW. Effect of temperature on bactericidal action of sodium hypochlorite endodontic irrigant. Oral Surg Oral Med Oral Pathol. 1980; 50(6):569-571.

6. Barrett, M.T. The internal anatomy of the teeth with special reference to the pulp and its branches. Dent Cosmos. 1925; 67:581–592.

7. Torabinejad M, Handysides R, Khademi AA, Bakland LK. Clinical implications of the smear layer in endodontics: A review. Oral Surg Oral Med Oral Path Oral Radiol Endod. 2002;94(6):658-666.

8. Siqueira JF Jr, Rôças IN, Favieri A, Lima KC. Chemomechanical reduction of the bacterial population in the root canal after instrumentation and irrigation with 1%, 2.5%, and 5.25% sodium hypochlorite. J Endod. 2000;26(6):331-334 9. Barnard D, Davies J, Figdor D. Susceptibility of Actinomyces israelii to antibiotics, sodium hypochlorite and calcium hydroxide. Int Endod J. 1996;29(3):320-326.

10. Ayhan H, Sultan N, Cirak M, Ruhi MZ, Bodur H. Antimicrobial effects of various endodontic irrigants on selected microorganisms. Int Endo J. 1999;32(2):99-102.

11. Nygaard Östby B. Chelation in root canal therapy. Odontol Tidskr. 1957;65:311.

12. Loel DA. Use of acid cleanser in endodontic therapy. J Am Dent Assoc. 1975;90(1):148-151.

13. Berutti E, Marini R, Angeretti A. Penetration ability of different irrigants into dentinal tubules.

J Endod. 1997;23(12):725–727.

14. Machado-Silveiro Lf, González-Lopez S, González-Rodríguez MP. Decalcification of root canal dentin by citric acid, EDTA and sodium citrate. Int Endod J. 2004;37(6):365-369.

15. Schäfer E. Irrigation of the root canal. ENDO. 2007;1(1):11-27.

16. Shih M, Marshall FJ, Rosen S. The bactericidal efficiency of sodium hypochlorite as an endodontic irrigant. Oral Surg Oral Med Oral Pathol. 1970;29(4):613-619.

17. Marion JJC, Manhães FC, Bajo H, Duque TM. Efficiency of different concentrations of sodium hypochlorite during endodontic treatment. Literature review. Dental Press Endod.

2012;2(4):32-37.

31. Abou-Rass M, Oglesby SW. The effect of temperature, concentration, and tissue type on the solvent ability of sodium hypochlorite. J Endod. 1981; 7(8):376-377.

32. Baumgartner JC, Cuenin PR. Efficacy of several concentrations of sodium hypochlorite for root canal irrigation. J Endod. 1992;18(12):605-712.

33. Silveira LFN, Silveira CF, Martos J, Suita de Castro LA. Evaluation of the different irrigation regimens with sodium hypochlorite and EDTA in removing the smear layer during root canal preparation. JMAU. 2013; 1(1-2):51–56.

34. Berutti E, Marini R, Angeretti A. Penetration ability of different irrigants into dentinal tubules.

J Endod. 1997; 23(12):725–727.

35. Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR. Review of contemporary irrigant agitation techniques and devices. J Endod. 2009; 35(6):791-804.

36. Gomes BP, Ferraz CCR, Vianna ME, Berber VB, Teixeira FB, de Souza-Filho FJ. In vitro antimicrobial activity of several concentrations of sodium hypochlorite and chlorhexidine gluconate in the elimination of Enterococcus faecalis. Int Endod J. 2001; 34(6):424-428.

37. Siqueira JF Jr., Machado AG, Silveira RM, Lopes HP, de Uzeda M. Evaluation of the effectiveness of sodium hypochlorite used with three irrigation methods in the elimination of Enterococcus faecalis from the root canal, in vitro. Int Endod J. 1997; 30(4):279-82.

38. Sjogren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J. 1997; 30(5):297-306.

39. Shuping GB, Ørstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickeltitanium rotary instrumentation and various medications. J Endod. 2000; 26(12):751-5.

40. Shabahang S, Torabinejad M. Effect of MTAD on Enterococcus faecalis-contaminated root canals of extracted human teeth. J Endod. 2003; 29(9):576-9.

41. McCome D, Smith DC. A preliminary scanning electron microscopic study of root canals after endodontic procedures. J Endod. 1975; 1(7):238-42.

18. Retamozo B, Shabahang S, Johnson N, Aprecio RM, Torabinejad M. Minimum contact time and concentration of sodium hypochlorite required to eliminate Enterococcus faecalis. J Endod.

2010;36(3):520-523.

42. Sim TP, Knowles JC, Ng YL, Shelton J, Gulabivala K. Effect of sodium hypochlorite on mechanical properties of dentine and tooth surface strain. Int Endod J. 2001; 34(2):120-32.

19. Zhang K, Kim YK, Cadenaro M, Bryan TE, Sidow SJ, Loushine RJ, et al. Effects of different exposure times and concentrations of sodium hypochlorite /ethylenediaminetetraacetic acid on the structural integrity of mineralized dentin. J Endod. 2010;36(1):105-109.

43. Grigoratos D, Knowles J, Ng YL, Gulabivala K. Effect of exposing dentine to sodium hypochlorite and calcium hydroxide on its flexural strength and elastic modulus. Int Endod J. 2001;34(2):113-115.

20. Clorox Company, 1221 Broadway, Oakland, California, Oral communication, date.

44. Carter D. Endodontic Irrigants. Dentaltown.com. http://www.dentaltown.com/Images/dentaltown/magimages/0211/DTFeb11pg80.pdf. Published February 2011. Accessed June 13, 2016.

21. Estrela C, Estrela CR, Barbin EL, Spanó JC, Marchesan MA, Pécora JD. Mechanism of action of sodium hypochlorite. Braz Dent J. 2002;13(2):113-117.

22. Estrela C, Sydney GB, Bammann LL, Felippe Júnior O. Mechanism of action of calcium and hydroxyl ions of calcium hydroxide on tissue and bacteria. Braz Dent J. 1995; 6(2):85-90.

45. Naenni N, Thoma K, Zehnder M. Soft tissue dissolution capacity of currently used and potential endodontic irrigants. J Endod. 2004; 30(11):785–7.

23. Johnson WT, Noblett WC. Cleaning and Shaping In: 4th ed. Saunders. Endodontics: Principles and Practice. Philadelphia, PA, 2009.

46. Davies GE, Francis J, Martin AR, Rose FL, Swain G. 1:6-Di-4-chlorophenyldiguanidohexane (hibitane); laboratory investigation of a new antibacterial agent of high potency. Br J Pharmacol Chemother. 1954; 9(2):192– 196.

24. Senia ES, Marraro RV, Mitchell JL. Rapid sterilization of gutta-percha cones with 5.25% sodium hypochlorite. J Endod. 1975;1(4):136-140.

47. Hennessey TS. Some antibacterial properties of chlorhexidine. J Periodontal Res Suppl. 1973; 12:61–67.

25. McDonnell G, Russell AD. Antiseptics and disinfectants: activity, action, and resistance. Clin Microbiol Rev. 1999; 12(1):147–179.

48. Emilson CG. Susceptibility of various microorganisms to chlorhexidine. Scand J Dent Res. 1977; 85(4):255–265.

Volume 9 Number 3

Endodontic practice 29

CONTINUING EDUCATION

neither kills all bacteria,37-40 nor removes the entire smear layer.41 It also alters the properties of dentin.42,43 Most of the hypochlorite accidents are due to incorrect determination of endodontic working length, iatrogenic widening of the apical foramen, lateral perforation, or wedging of the irrigating needle. Clearly, precautions must be undertaken to prevent such mishaps.

Chlorhexidine has also been recommended used in conjunction with NaOCl as an irrigant as it raises effectiveness of the irrigation protocol. However, being a highly

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 V9.3 KRUPP REF: EP V9.3 CHANIOTIS

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

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

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkaz.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise, and judgment of a trained healthcare professional.

EMAIL

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Endodontic irrigation involving the NaOCl component

Tactile-controlled activation (TCA) technique with controlled-memory files

KRUPP

CHANIOTIS

1.

_________ is the most ubiquitous irrigating solution in endodontics. a. Sodium hypochlorite (NaOCl) b. Zinc oxide (ZnO) c. Chlorhexidine (CHX) d. Ethylenediaminetetraacetic acid (EDTA)

2.

_______ performs bactericidal cytotoxicity, benefits the dissolution of organic material, and enhances minor lubrication. a. EDTA b. NaOCl c. MTAD d. CHX

3.

The basic biologic objective of root canal treatment, beyond removal of subjective symptomatology, relies on the complete removal of the pulpal tissue and the destruction of residual microorganisms, including _______ often found in infected root canals. a. yeasts b. molds c. viruses d. all of the above

4.

In addition to their cleaning ability, chelators may _______ biofilms adhering to root canal walls. a. mineralize b. enlarge c. detach d. augment

5.

________ has been reported to affect the removal of the smear layer similar to that obtained by EDTA. a. Citric acid b. Clorox c. Hypochlorous acid d. Soap

30 Endodontic practice

6.

(For NaOCl) Different contact times evaluated both at ________ were found to be effective against growth of E. faecalis. a. 15 seconds and 30 seconds b. 1 minute and 5 minutes c. 7 minutes and 13 minutes d. 15 minutes and 20 minutes

7.

NaOCl neutralizes the amino acids forming water and salt. With the output of hydroxyl ions, ________ in the pH occurs. a. an increase b. a reduction c. a reversal d. no reaction

8.

Sodium hypochlorite acts on fatty acids, transforming them into _______ that reduce(s) the surface tension of the remaining solution. a. sulfhydryls (SH groups) b. fatty acid salts (soap) c. glycerol (alcohol) d. both b and c

9.

Chlorine (strong oxidant) presents antimicrobial action inhibiting bacterial enzymes leading to a/ an _______ oxidation of SH groups (sulfhydryl group) of essential bacterial enzymes. a. irreversible b. reversible c. disruptive d. damaging

10.

Beside their wide-spectrum, nonspecific killing efficacy on all microbes, hypochlorite preparations are _______. a. sporicidal b. virucidal c. display enhanced tissue-dissolving effects on necrotic rather than on vital tissues d. all of the above

6.

Moreover, the risk of unexpected instrument separation of _______ poses significant problems during curved canal management. a. stainless steel files b. tapered stainless steel files c. engine-driven nickel-titanium files d. conventional hand-driven files

7.

This ability of resisting stress without permanent deformation — going back to the initial lattice form — is called ______. a. superelasticity b. martensitic transformation c. autensitic elasticity d. radius of curvature

8.

Besides the stress-induced martensitic transformation, the lattice organization of nickel-titanium alloys can be altered also with __________. a. infrared light b. temperature change c. vibration d. compression

9.

Schäfer, et al., 2002, found that ______ of the human root canals studied were curved and 17.5% of them presented a second curvature and were classified as S-shaped root canals. a. 30% b. 50% c. 65% d. 84%

A quantitative analysis based on the model of the fracture process zone showed that the martensite transformation in the shape memory nickel-titanium alloy caused a _____ increase in the apparent fracture toughness. a. 26% b. 47% c. 64% d. 82%

For stainless steel hand files and conventional nickel-titanium hand or engine-driven files, the restoring force of a given instrument is directly related to its ______. a. size b. taper c. length d. both a and b

10. Keeping in mind the complexity of root canal systems and the need to minimize file engagement during instrumentation, a novel approach was developed and named as the _______. a. TCA instrumentation technique b. Leseberg and Montgomery technique c. Weine angle of curvature d. Schneider angle of curvature concept

1.

Traditionally for gutta-percha fillings, root canal shaping should satisfy specific design objectives: The shape of the main root canal should resemble _______ from the orifice to the apex. a. an S shape b. a continuously tapering funnel c. a C shape d. bayonet configuration

2.

Traditionally for gutta-percha fillings, root canal shaping should satisfy specific design objectives: The cross-sectional diameter of the main canals should be ______ at every point apically. a. narrower b. wider c. equal d. increased

3.

The problems of biomechanical instrumentation arise when the internal anatomy of human teeth is ________. a. severely curved b. bifurcated c. anastomotic d. all of the above

4.

5.

Volume 9 Number 3

CE CREDITS

ENDODONTIC PRACTICE CE

Dr. Antonis Chaniotis discusses the tactile-controlled activation technique using controlled-memory files for severely curved and challenging canals

T

he ultimate biologic objective of endodontic therapy is the prevention of periradicular disease and the promotion of healing when disease is already established.

Arguably, mechanical instrumentation and chemical disinfection of the root canal system are considered the foundational principles for the successful accomplishment of these objectives (Schilder, 1974). Although these principles cannot be considered separately, canal preparation is the essential phase that will determine the efficacy of all subsequent procedures (Peters, 2004).

Traditionally, for gutta-percha fillings, root canal shaping should satisfy specific design objectives: • The shape of the main root canal should resemble a continuously tapering funnel from the orifice to the apex.

• The cross-sectional diameter of the main canals should be narrower at every point apically.

• Canal preparation should follow the shape of the original root canal.

• The original position of the apical foramen should be preserved.

• The apical opening should retain its original dimensions as much as possible (Schilder, 1974; Hulsmann, Peters, Dummer, 2005).

The biological objectives of root canal instrumentation consist of: • the confinement of instrumentation to the limits of the roots themselves

Educational aims and objectives

This clinical article aims to describe the application of tactile-controlled activation (TCA) technique with controlled-memory files.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 30 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some challenges of curved canal management.

• Recognize some risks of canal transportation and instrument separation.

• Recognize the use of controlled-memory files to minimize instrumentation risks.

• Define various aspects of the TCA instrumentation technique.

• Identify controlled-memory file sequencing with respect to canal anatomy.

• the avoidance of extruding necrotic debris into the periradicular tissues • the removal of all organic tissue from the main canals as well as from the lateral extent of the root canal system • the creation of sufficient space to allow irrigation and medication by simultaneously preserving enough circumferential dentin for the tooth to function (Hulsmann, Peters, Dummer, 2005) Achieving these objectives in straight canals is considered a simple and straightforward procedure with all instrumentation

systems available today. The problems of biomechanical instrumentation arise when the internal anatomy of human teeth is severely curved or even bifurcated and anastomotic (Figure 1). In such teeth, the accepted basic endodontic techniques and instrumentation protocols might be challenging to follow.

The aim of this article is to describe the application of tactile-controlled activation (TCA) technique with controlled-memory files for the safer and more predictable instrumentation of severely curved and challenging canals.

Antonis Chaniotis, DDS, MDSc, graduated from the School of Dentistry, University of Athens, Greece, in 1998. In 2003, he completed the 3-year postgraduate program in endodontics at the School of Dentistry, University of Athens. He is a clinical instructor affiliated with the undergraduate and postgraduate programs in the endodontics department at the dental school, and he owns a private practice in Athens limited to microscopic endodontics since 2003. He has been clinical fellow of dentistry at the University of Warwick since 2012. Dr. Chaniotis has published articles in local and international journals, and he has lectured at more than 40 local and international congresses. In 2010, he joined the Roots Forum and became well-known for his clinical skills through his microscope-enhanced endodontic video case management series.

Figure 1: Complex root and root canal anatomical challenges in endodontics Volume 9 Number 3

Endodontic practice 31

CONTINUING EDUCATION

Tactile-controlled activation (TCA) technique with controlled-memory files

CONTINUING EDUCATION The challenge of curved canal management The internal anatomy of human teeth can be extremely complicated. Based on canal curvature, Nagy, et al., 1995, classified root canals into four categories: straight or I-form (28% of the root canals), apically curved or J-form (23% of the root canals), entirely curved or C-form (33% of the root canals), and multicurved or S-form canals (16% of the root canals). Schäfer, et al., 2002, found that 84% of the human root canals studied were curved and 17.5% of them presented a second curvature and were classified as S-shaped root canals.

From all curved canals studied, 75% had a curvature of less than 27º, 10% had a curvature with an angle between 27º and 35º, and 15% had severe curvature of more than 35º.

Traditionally, root canal curvatures were assessed by using the Schneider angle of curvature concept (Schneider, 1971).

According to Schneider (1971), root canals presenting an angle of 5º or less could be classified as straight canals, root canals presenting an angle between 10º and 20º as moderate curved canals, and root canals presenting a curve greater than 25º as severely curved canals.

Many decades later, Pruett, et al., 1997, reported that two curved root canals might have the same Weine angle of curvature but totally different abruptness of curvature. In order to define the abruptness of curvature, they introduced the concept of the radius of curvature. The radius of curvature is the radius of a circle passing through the curved part of the canal. The number of cycles before failure for rotary endodontic instruments significantly decreased as the radius of curvature decreased and the angle of curvature increased.

Further attempts to describe mathematically and unambiguously root canal curvatures in two-dimensional radiographs introduced parameters such as the length of the curved part of the canal (Schäfer, et al., 2002) and the location of the curve as defined by curvature height and distance (Günday, Sazak, Garip, 2005).

Estrela, et al., 2008, described a method to determine the radius of root canal curvatures using CBCT images analyzed by specific software. Radius of canal curvatures was classified into three categories: small radius (r≤4mm), intermediate radius (r>4 and r≤8mm) and large radius (r>8mm). The smaller the radius of a curvature, the more abrupt it becomes.

32 Endodontic practice

Figure 2: The effect of flaring in the curvature parameters

All these attempts to describe the parameters of root canal curvature had one common denominator, the preoperative risk assessment for transportation and unexpected instrument separation.

The risks of canal transportation and instrument separation According to the AAE Glossary of Endodontic Terms (2012), transportation is defined as the “removal of the canal wall structure on the outside curve in the apical half of the canal due to the tendency of the files to restore themselves to their original linear shape.” For stainless steel hand files and conventional nickel-titanium hand or engine-driven files, the restoring force of a given instrument is directly related to its size and taper. The bigger the size or taper of a given file, the bigger the restoring force becomes due to the increase of the metal mass of the instrument.

If root canals were constructed precisely on the dimensions of our instruments, then transportation wouldn’t be a problem, and our instruments would be well constrained inside the root canal trajectories. Unfortunately, instruments are not well constrained by the canal in a precise trajectory because instruments are not precisely shaped to fit the canal dimensions. As a result, each instrument may follow its own trajectory inside a curved canal guided by its restoring force and transporting the canal (Plotino, et al, 2010). Usually, the greater increase in apical enlargement is targeted in curved canals, the more excessive the dentin removal toward the outer apical curve becomes (Elayouti, et al., 2011) and the more excessive the inner curvature (danger zone) widening can get.

In order to avoid these complications, the more severe the canal curvature, the more we tend to increase flaring and reduce the apical instrumentation size (Roane, Clement, Carnes, 1985). Increasing flaring under such circumstances would result in the reduction of the angle of curvature, in shortening the length of curvature, in increasing the radius of curvature, and in relocating the curvature apically (Figure 2). Smaller apical preparations in highly curved canals would be preferable for two reasons: 1. Smaller diameter preparations are related to less cutting of the canal walls, less file engagement, and, consequently, a lesser likelihood for the expression of undesirable cutting effects.

2. Small diameter files are more flexible and fatigue resistant, and, therefore, less likely to cause transportation during enlargement (Roane, Clement, Carnes, 1985).

The aforementioned instrumentation approaches, although safer, have inherent disadvantages. Unfortunately, flaring the canal entrance in order to achieve easier negotiation to the apical third of curved canals will result in unnecessary removal of dentin from a level that is considered irreplaceable. Moreover, smaller apical preparations may result in increased difficulties for the irrigation solutions to be delivered to an appropriate canal depth.

In highly curved canals, the ability of irrigation solutions to be delivered to the critical apical third depends directly on the ability of our instruments to create adequate apical preparations and on the selection of the appropriate delivery techniques (Boutsioukis, et al., 2010).

Volume 9 Number 3

Controlled-memory files to minimize instrumentation risks Nickel-titanium alloys are softer overall than stainless steel, have a low modulus of elasticity (about one-fourth to one-fifth that of stainless steel), greater strength, are tougher and more resilient, and show shape memory and superelasticity (Baumann, 2004). The nickel-titanium alloys used in root canal treatment contain approximately 56% (wt) nickel and 44% (wt) titanium (Walia, Brantley, Gernstein, 1988). They can exist in two different temperature-dependent crystal structures (phases) called martensite (lowtemperature phase, with a monoclinic B19’ structure) and austenite (high temperature or parent phase, with the B2 cubic crystal structure). The lattice organization can be transformed from austenitic to martensitic and return again to austenitic phase by adjusting temperature and stress. During this reverse transformation, the alloy goes through an unstable intermediate crystallographic phase called R-phase.

Preparation of the root canal causes stress to nickel-titanium files, and a stressinduced martensitic transformation takes place from the austenitic phase of conventional nickel-titanium files to the martensitic phase within the speed of sound. A change Volume 9 Number 3

Achieving adequate apical preparations for disinfection without over-flaring the coronal part of highly curved canals is one of the greatest challenges in endodontic instrumentation.

in shape occurs, together with volume and density changes.

This ability of resisting stress without permanent deformation — going back to the initial lattice form — is called superelasticity. Superelasticity is most pronounced at the beginning of the applied stress when a first deformation of as much as an 8% strain can be totally overcome. After 100 deformations, the tolerance is about 6%, and after 100,000 deformations, it is about 4%. Within this range, the so-called “memory effect” can be observed (Baumann, 2004).

Besides the stress-induced martensitic transformation, the lattice organization of nickel-titanium alloys can be altered also with temperature change. When a conventional nickel-titanium austenitic microstructure is cooled, it begins to change into martensite.

The temperature at which this phenomenon begins is called the martensite start temperature (Ms). The temperature at which martensite is again completely reverted is called the martensite transformation finish temperature (Mf). When martensite is heated, it begins to change into austenite. The temperature at which this phenomenon begins is called the austenite transformation start temperature (As). The temperature at which this phenomenon is complete is called the austenite finish temperature (Af), which means that at and above this temperature, the material will have completed its shape memory transformation and will display its superelastic characteristics (Shen, et al., 2011).

Before 2011, the Af temperature for the majority of the available nickel-titanium endodontic instruments was at or below room temperature. As a result, conventional nickel-titanium endodontic instruments were in the austenitic phase during clinical use (body temperature), showing shape memory and superelasticity. In 2011, so-called controlled-memory files were introduced in endodontics. These files had been manufactured utilizing a thermomechanical

processing that controls the material’s memory, making the files extremely flexible and fatigue resistant but without the shape memory and restoring force of other nickeltitanium files (Coltene/Whaledent, 2012).

The Af transformation temperature of controlled-memory files is found to be clearly above body temperature. As a result, these files are mainly in the martensite phase in body temperature (Shen, et al., 2011). When the material is in its martensite form, it is soft, ductile, without shape memory, can easily be deformed, yet it will recover its shape and superelastic properties upon heating over the Af temperature. Moreover, a hybrid martensite microstructure (like the HyFlex® CM™ controlled-memory files) is more likely to have more favorable fatigue resistance than an austenitic microstructure. At the same stress intensity level, the fatigue crack propagation speed of austenitic structures is much faster than that of martensite ones.

A quantitative analysis based on the model of the fracture process zone showed that the martensite transformation in the shape memory nickel-titanium alloy caused a 47% increase in the apparent fracture toughness (Wang, 2007).

Very recently, controlled-memory thermomechanical processing was combined with an innovative machining procedure for the manufacturing of rotary nickel-titanium endodontic files. The procedure is called electrical discharge machining (EDM) and results in instruments of increased surface hardness cutting efficiency and extreme fatigue resistance. In the first paper published evaluating these files (Pirani, et al., 2015), spark-machined peculiar surface was mainly noticed, and low degradation was observed after multiple canal instrumentations. The authors also found high values of cyclic fatigue resistance and a safe in vitro use in severely curved canals. In agreement with these previews researchers, Pedulla, et al., 2015, reported higher values of fatigue Endodontic practice 33

CONTINUING EDUCATION

Achieving adequate apical preparations for disinfection without over-flaring the coronal part of highly curved canals is one of the greatest challenges in endodontic instrumentation. This is very true especially under the current concepts of dentin preservation in endodontics.

Moreover, the risk of unexpected instrument separation of engine-driven nickeltitanium files poses significant problems during curved canal management. There are two mechanisms that have been implicated with engine-driven instrument fracture — cyclic fatigue and torsional failure.

As an engine-driven instrument is activated inside a curved canal, continuous tensile and compressive stresses at the fulcrum of the curvature may lead to instrument separation because of cyclic fatigue. If the tip of an engine-driven instrument is locked inside a canal, and the shaft of the instrument keeps on moving, it may exceed an applied shear moment, resulting in torsional failure. Usually during curved canal management, both mechanisms can co-exist. As the complexity of the curvature increases, the number of cycles before failure decreases for a given instrument, making complicated canal management a real clinical challenge.

CONTINUING EDUCATION

Figure 3: Transportation dynamics of shape-memory nickel-titanium rotary files.

Notice that the instrument removes material by touching the outer apical curve and the inner middle curve

resistance for EDM rotary files even when compared with reciprocating files made from M-Wire.

The extreme flexibility and fatigue resistance of these files combined with the lack of restoring force render them ideal to be used for the instrumentation of highly curved and complicated canals. Whenever a conventional superelastic nickel-titanium file is rotating inside a curved canal, it creates its own trajectory guided by the restoring force of the file and transporting the canal toward the outer apical curve (Elayouti, et al., 2011).

The bigger the size or taper of the file used, the more dentin is removed from the outer apical curve, resulting in off-centered preparation at this level.

Leseberg and Montgomery (1991) studied canal transportation at the level of the curve and documented the distal (toward the midline) movement of the original canal.

They showed that canal transportation is caused by a combination of forces resulting from the restoring force of the instrument that rotates around the clinical and proximal view curvatures. These forces produce a transportation vector distally and axially at this level.

From their study, it would appear that for the middle third of a given curved canal, the

Figure 4

greater the clinical and proximal view curvatures, the faster the transportation would progress toward the distal concavity of the root. The dynamics of apical and middle third transportation, as the result of the restoring force of the instrument and the degree of canal curvature, can be seen in Figure 3.

However, controlled-memory files have no restoring force after bending in body and room temperature. Whenever an instrument with controlled-memory characteristics is activated inside a curved canal, it moves passively inside the anatomy producing minimal forces of transportation. In highly curved canals, the lack of restoring force keeps the CM files rotating toward the outer canal wall at the fulcrum of the curvature (Figure 4).

Similar transportation dynamics with controlled memory were also demonstrated during the instrumentation of double-curved canals (Burroughs, et al., 2012). In simulated S-shaped canals, controlled-memory files produced more overall transportation compared to SAF and M-Wire instruments.

Although the overall transportation was found bigger for no shape memory files, they always transported the double-curved canal toward the outer curves. This is very

Figure 5: Cases treated with HyFlex CM files. The arrows point to the areas of dentin preservation 34 Endodontic practice

important in highly curved and doublecurved canals because the initial dentinal thickness of human curved roots is always minimal at the convexity of the inner distal curves (danger zones) or the inner S-apical curves (Figure 5).

TCA instrumentation technique Root canal instrumentation involves the use of hand- or engine-driven files to create sufficient space for irrigation and medication. The tactile feedback of the root canal anatomy felt by the operator during this procedure depends on various factors, including: • the initial canal shape (round, oval, long oval, or flat canals) • the canal length (the longer the canal, the more frictional resistance is expected) • the canal taper (tapering discrepancy between a gauging instrument and the canal may cause false binding sensation) • the canal curvature (curved canals can cause deflection of the instruments and increase frictional resistance) • the canal content (fibrous or calcified canal content can create different degrees of frictional resistance) • canal irregularities (attached pulp stones, denticles, and reparative dentin can create convexities on root canal walls) • the type of instrument used (rigidity, flexibility, tapering, and restoring force can alter the frictional feedback) (Jou, et al., 2004) For a given root canal and a given file, the operator’s tactile feedback during the instrumentation procedure differs according to the kinematics of the file used. Passively inserted files (non-activated) give a tactile Volume 9 Number 3

Volume 9 Number 3

CONTINUING EDUCATION

sensation that is determined by the frictional resistance generated when the file engages the dentinal walls. The tactile sensation with an activated file (rotating or reciprocating), however, as the result of cutting, can more accurately be determined by the ability of the file to resist advancement around curvatures while in action (McSpadden, 2007).

Keeping in mind the complexity of root canal systems and the need to minimize file engagement during instrumentation, a novel approach was developed and named as the TCA instrumentation technique. The TCA technique can be defined as the activation of a motionless engine-driven file only after it becomes fully engaged inside a patent canal (Chaniotis, Filippatos, 2015). TCA utilizes file activation only after maximum engagement of the flutes is reached and a tactile feedback of the anatomy is felt. Inserting files passively (non-activated) inside the root canals and using controlled-memory instruments that can be pre-curved before file insertion is suggested to be advantageous, especially when complicated canal systems are encountered and limited mouth opening hinders canal negotiation and visualization.

The TCA technique can be divided into in-stroke and out-stroke components.

After accessing the pulp chamber and locating the canal orifices, technical patency to length is confirmed (Figure 6A). The first file to be used is mounted on the handpiece of an endodontic motor and inserted passively inside the canal until maximum frictional resistance (Figure 6B – point B). The file is activated and pushed apically (in-stroke) until the activated file resists further advancement (Figure 6C – point A) and withdrawn from the canal (Figure 6D). After file withdrawal, the file is inactivated; the flutes are cleaned and checked for any possible deformations. Irrigation and patency confirmation follows. The second time that the same file will be inserted passively inside the same canal, it will reach deeper inside the anatomy (Figure 6E – point P). Activating the file again the same way will guide the file even more apically closer to length (Figure 6F – point A). The work to be done by this file is completed when the file can reach working length without having to activate it and is then withdrawn (Figure 6G).

Instrumentation to larger apical preparations is achieved the same way until the desired apical instrumentation width is achieved. TCA technique aims to minimize the time of engagement with an activated file by using file activation only when needed for advancement. With this instrumentation technique, most of the anatomical root

Figure 6: Tactile-controlled activation (TCA) technique explained

Figure 7: Instrumentation of challenging cases to larger apical preparations with tactile-controlled activation (TCA) and controlled-memory files

canal variations can be enlarged safely to the desired instrumentation size, irrespective of the degree and complexity of canal curvatures, by maintaining a tactile sensation of the anatomy throughout the whole procedure. For dilacerated canals, the controlledmemory files can be pre-curved in order to negotiate passively below the fulcrum of the abrupt curvature, activated at the point of maximum engagement and withdrawn from the canal (out-stroke) instead of advancing them deeper.

The next time that the same file will be inserted passively inside the dilacerated canal, engagement of the flutes will be felt more apically. The file is activated the same way and withdrawn from the canal. This way, engine-driven files can negotiate the apical third of dilacerated canals safely by maintaining a tactile sensation of the anatomy throughout the whole instrumentation procedure (Chaniotis, Filippatos, 2015). Challenging cases of extreme canal curvature that were managed with TCA instrumentation technique with controlled-memory files can be seen in Figure 7.

Controlled-memory file sequencing The file sequencing during endodontic instrumentation is directly related to the anatomical challenge encountered. In a roentgenographic investigation of frequency and degree of canal curvatures in human permanent teeth, 84% of the root canals were found curved, and 17.5% of them presented a second curvature and were classified as S-shaped root canals (Schäfer, et al., 2002). From all the curved canals, 75% were found to have a small curvature of less than 27°, 15% a medium curvature ranging from 27° to 35°, and 10% a severe curvature of more than 35°.

Usually, patent root canals with a curvature of less than 27º are considered easy and straightforward cases for most instrumentation systems available today, and they pose no significant problems to the clinician. The enhanced physical properties of controlledmemory files manufactured with the electrical discharge machining procedure makes it possible to shape a canal with the use of a single file in 360º continuous movement.

Most of these cases can be shaped quite Endodontic practice 35

CONTINUING EDUCATION

The TCA technique aims to minimize the time of engagement with an activated file by using file activation only when needed for advancement.

quickly, effectively, and safely by using a single HyFlex™ EDM file 25 (Coltene) with the TCA technique.

The one EDM HyFlex file has a tip size of 25 with a 0.08 taper. The taper is a constant 0.08 in the apical 4 mm of the instruments but reduces progressively up to 0.04 in the coronal portion of the instrument. The file has three different crosssectional areas over the entire length of the working part (rectangular in the apical part and two different trapezoidal cross sections in the middle and coronal part of the instrument) to increase its fracture resistance and cutting efficiency (Pedulla, et al., 2015). Whenever larger apical preparations are required, three finishing HyFlex EDM files of constant taper can be used (40/04, 50/03, and 60/02).

Constricted and obliterated canals, thin and long roots, curved canals of more than 27º, and S-shaped canals with smaller than

5 mm radius of curvature are considered challenging for all instrumentation systems available nowadays. With controlled-memory files, these cases are more effectively, safely, and predictably enlarged with the soft, ductile, and fatigue-resistant HyFlex CM files by following a simple standardized protocol and TCA technique.

After flaring with the 25/08 HyFlex CM flaring file and glide path creation to 10/02 hand file, HyFlex CM files can be used with the TCA technique in a standardized simple protocol of 15/04-20/04-25/04-30/04 and 35/04. This sequence is easy to remember and can work effectively and safely even in the most challenging situations of root canal instrumentation.

The final enlargement will be dictated by the initial anatomy of each root. For glide path creation, the EDM 10/05 glide path file can also be used after flaring and initial canal scouting. In multi-canal teeth, easier

canals can be instrumented with a single EDM file 25, and the complicated ones with the aforementioned CM file sequence. In this way, safe and predictable instrumentation to adequate apical preparation size that respects canal anatomy can be achieved.

Conclusions • Controlled-memory files have no shape memory effect, increased flexibility, and fatigue resistance. As a result, they move passively inside the highly curved or double-curved canals guided only by the anatomy and not by the restoring force of other files.

• The TCA instrumentation technique minimizes the time that the files are under engagement inside challenging canals and results in maintaining a continuous tactile feedback of the anatomy throughout the whole instrumentation procedure.

• Although the TCA technique can be used with all instrumentation systems available (rotary or reciprocation), controlledmemory systems are the only ones where the files can be pre-bent for easier negotiation of challenging cases (abrupt curvatures, ledges, and limited mouthopening patients).

• EDM files with controlled-memory characteristics have increased cutting efficiency and fatigue resistance. This makes it feasible to use a single file instrumentation protocol for approximately 75% of human root canals. EP

REFERENCES 1. AAE Glossary of Endodontic Terms. 8th edition. 2012.

2. Baumann MA. Nickel-titanium: options and challenges. Dental Clin North Am. 2004 ;48(1): 55-67.

3. Boutsioukis C, Gogos C, Verhaagen B, Versluis M, Kastrinakis E, Van der Sluis LW. The effect of apical preparation size on irrigant flow in root canals evaluated using an unsteady Computational Fluid Dynamics model. Int Endo J. 2010;43(10): 874-881.

4. Burroughs JR, Bergeron BE, Roberts MD, Hagan JL, Himel VT. Shaping ability of three nickel-titanium endodontic file systems in simulated S-shaped root canals. J Endo.

2012;38(12):1618-1621.

5. Burroughs JR, Bergeron BE, Roberts MD, Hagan JL, Himel VT. A case report. Int Endod J. In press.

6. HyFlex® CM™ [brochure]. Cuyahoga Falls, Ohio: Coltene/Whaledent; 2012.

7. Elayouti A, Dima E, Judenhofer MS, Löst C, Pichler BJ. Increased apical enlargement contributes to excessive dentin removal in curved root canals: a stepwise microcomputed tomography study. J Endod. 2011;37(11):1580-1584.

8. Estrela C, Bueno MR, Sousa-Neto MD, Pechora JD. Method for determination of root curvature radius using cone-beam computed tomography images. Bras Dent J. 2008;19(2):114-118.

9. Joe Y-T, Karabucak B, Levin J, Liu D. Endodontic instrumentation width: current concepts and techniques. Dent Clin North Am. 2004;48(1):323-335.

10. Leseberg DA, Montgomery S. The effects of Canal Master, Flex-R, and K-Flex instrumentation on root canal configuration. J Endod. 1991;17(2):59-65.

11. Günday M, Sazak H, Garip Y. A comparative study of three different root canal curvature measurement techniques and measuring the canal access angle in curved canals. J Endod.

2005;31(11): 796-798.

14. Nagy CD, Szabó J, Szabó J. A mathematically based classification of root canal curvatures on natural human teeth. J Endod.1995;21(11):557-560.

15. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review.

J Endod. 2004;30(8):559-567.

16. Plotino G, Grande NM, Mazza C, Petrovic S, Testarelli L, Gambarini G. Influence of size and taper of artificial canals on the trajectory of NiTi rotary instruments in cyclic fatigue studies.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(1):e60-e66.

17. Pirani C, Iacono F, Generali L, et al. HyFlex EDM: superficial features, metallurgical analysis and fatigue resistance of innovative electro discharge machined NiTi rotary instruments. Int Endod J. 2015;49(5):483-493.

18. Pedulla E, Lo Savio F, Boninelli S, et al. Torsional and cyclic fatigue resistance of a new nickel-titanium instrument manufactured by electrical discharge machining. J Endod.

2016;42(1):156-159.

19. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing of nickel-titanium endodontic instruments. J Endod. 1997; 23(2):77-85.

20. Roane JB, Sabala CL, Duncanson MG Jr. The “balanced force” concept for instrumentation of curved canals. J Endod. 1985;11(5):203-211.

21. Schäfer E, Diez C, Hoppe W, Tepel J 2002 Roentgenographic investigation of frequency and degree of canal curvatures in human permanent teeth. J Endod. 2002;28(3):211-216.

22. Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. 2011 Fatigue testing of controlled memory wire nickel-titanium rotary instruments. J Endod. 2011;37(7):97-1001.

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

24. Schneider SW. A comparison of canal preparations in straight and curved root canals. Oral Surg Oral Med Oral Patho. 1971;32(2):271-275.

12. Hulsmann M, Peters O, Dummer P. Mechanical preparation of root canals: shaping goals, techniques and means. Endod Topics. 2005;10(1):30-76.

25. Walia HM, Brantley WA, Gerstein H. An initial investigation of bending and torsional properties of Nitinol root canal files. J Endod. 1988;14(7):346-351.

13. McSpadden JT. Mastering endodontic instrumentation. Chattanooga, TN: Cloudland Institute; 2007.

26. Wang GZ. Effect of martensite transformation on fracture behavior of shape memory alloy NiTi in a notched specimen. Int J Fract. 2007;146(7):93-104.

36 Endodontic practice

Volume 9 Number 3

Don’t Miss the Endodontic Practice US Digital Only Supplement

If you are not currently registered for an Endodontic Practice US digital subscription or our weekly newsletter —

3 Easy Ways to Subscribe VISIT www.endopracticeus.com

be sure to sign up before we release our special edition Digital Only Supplement in October which will feature the “Top 10 Hottest Products” along with the latest in industry technology...

EMAIL subscriptions@medmarkaz.com CALL 1.866.579.9496

PRACTICE DEVELOPMENT

Is your website really working?

Ian McNickle, MBA, discusses how to convert website visitors into new patients

T

he world of websites and online marketing can be confusing. Dentists and their staff often feel as though their website could be doing more for them, but aren’t quite sure how to determine this or what to do about it. The goal of this article is to help you understand how to get more value and new patients from your website.

The goal of online marketing Online marketing is primarily concerned with the following two objectives: 1. Driving traffic to the website 2. Converting that traffic to take the actions you want them to take Driving traffic to your website is achieved by the use of search engine optimization (SEO), pay-per-click (PPC) paid ads, social media, review sites (Google+, Yelp, Facebook, Healthgrades®, etc.), and other methods. Once people arrive at your website, you’ll want them to take action to contact your office via phone call, email, or filling out an appointment request form. These actions are called “website conversion.”

The ultimate marketing goal of the website is to drive new patients to the

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a co-founder and partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Dental Marketing and Dental Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@ weomedia.com, or by calling 888-246-6906.

For more information, you can visit www.weodental.com.

38 Endodontic practice

practice. This is achieved by maximizing both traffic and website conversion.

The focus of this article will be on website conversion, and our next article will focus on driving traffic.

Improve your website conversion rate Far too many dental practices use common, templated websites with stock photos and stock content. This does not differentiate you from other practices and does not reflect the unique personality of your practice. In addition, the calls to action are often poorly implemented.

Instead, consider implementing the following items to improve your website conversion: • A custom website design should properly reflect your practice.

• Phone number should be easy to find at the top of every page in large font.

• Appointment request button (or form) should be easy to find on every page and be located further up the page (not at the bottom).

• Use actual photos of the practice, staff, and equipment with minimal use of stock photos.

• Write unique content that is specific to your treatment philosophy and approach.

• Embed an overview video of the practice on the home page to help

communicate who you are/your personality, what is unique about your practice, highlight technology and training, etc.

Track and optimize results over time In order to properly track conversion, we always recommend using a phone call tracking number that routes to your actual office phone. Using a tracking number will allow you to more accurately understand how many calls are coming from your website. We also recommend recording the phone calls for training purposes.

Dental practices that want to get the most from their online marketing efforts should make it a regular monthly activity to review website traffic and conversion.

Plotting these trends over time will allow practices to understand if their activities to increase traffic are working, if their conversion rate is getting better or worse, and to determine the return on investment (ROI) for this portion of their marketing.

Marketing consultation If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is FREE if you identify yourself as a reader of this publication. EP

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 9 Number 3

A new era in endodontic instrumentation

A

simple, safe, and smart solution for the endodontic specialist, the EndoSync™ Endodontic Handpiece System features the lightest-in-its class EndoSync Cordless Micromotor. Weighing in at only 100 grams, the slim, ergonomic design of the EndoSync provides superior access while reducing hand fatigue. While possessing the ability to work independently, pairing the EndoSync Cordless Micromotor with the EndoSync™ A.I. Apex Locator provides users with a wide variety of automatic settings for increased confidence and safety, even in the most challenging cases.

The high-performance EndoSync Cordless Micromotor provides numerous safety features, including optimized torque reverse (OTR) technology, torque slowdown, and apical action mode, which gives the user the ability to seamlessly connect to the EndoSync A.I. Apex Locator. EndoSync monitors the torque load on the file up to 16 times per second and communicates with the EndoSync A.I. Apex Locator to provide real-time depth readings. When synchronized with the EndoSync A.I. Apex Locator, the display of the EndoSync changes color depending on the location of the file inside the canal to promote safe instrumentation.

With six fully programmable settings, a broad speed range of 50 rpm to 1,000 rpm, auto reverse, and torque control, EndoSync provides the power and versatility required for any case, including re-treatments. The EndoSync is the perfect balance of precision and safety.

The unique clockwise and counterclockwise rotation of OTR maintains the

original shape of the canal without creating ledges or straightening. The OTR technology reduces the risk of file separation, ledge formation, and transportation. When the torque exceeds the set limit, the OTR technology instantly returns to the forward cutting direction, repeating this process if the strain on the file persists. As the only cordless endodontic handpiece with apex locator synchronization combined with its lightweight design and automatic calibration, EndoSync is the ultimate endodontic handpiece system to meet all of your practice needs.

The EndoSync A.I. Apex Locator features the latest innovative design and technology in endodontic measurements, all encompassed in a lightweight, compact system. Equipped with automatic calibration, a memory bar, audible warnings, and a large LCD screen, the EndoSync A.I. is now the industry standard by which all apex locators should be compared.

Brasseler USA’s strong reputation of providing high-quality, clinician-endorsed, and innovative dental and medical instrumentation nationally has spanned 40 years.

They have been offering a full range of products made in the USA since 1976.

Call 800-841-4522 today to schedule a demo. Switch to our NiTi Files, and you could receive a free EndoSync! Ask your Brasseler representative for details.

This information was provided by Brasseler USA®.

EndoSync features • The lightest cordless endo motor on the market.

• The only cordless endo motor capable of providing real-time depth readings while shaping the canal.

• The only cordless endo motor featuring optimized torque reverse (OTR), which provides intuitive disengagement (reciprocation) only when you need it, reducing the risk of file separation, ledge formation, and transportation.

• Six fully programmable settings. Speed range of 50 rpm-1,000 rpm and torque range of .2 Ncm-5 Ncm. Volume 9 Number 3

Endodontic practice 39

PRODUCT SPOTLIGHT

EndoSync™ Endodontic Handpiece System

by Brasseler USA®

ABSTRACTS

The latest in endodontic research Dr. Kishor Gulabivala presents to latest literature, keeping you up-to-date with the most relevant research Effectiveness of the Gentlewave System in removing separated instruments Wohlgemuth P, Cuocolo D, Vandrangi P, Sigurdsson A. Journal of Endodontics (2015) 41(11): 1895-8 Abstract Aim: A separated instrument in a root canal system has the potential of severely affecting the outcome of endodontic therapy.

This study evaluated the effectiveness of the minimally invasive Gentlewave System (Sonendo) in removing separated stainless steel endodontic files from the apical and midroot regions of molar root canals.

Methodology: Thirty-six extracted human molars were accessed, and the glide path was confirmed to the apex. ISO No. 10, No. 15, and No. 20 K-file fragments of 2.5 mm length were separated at the apical (n=18) or midroot (n=18) region of the molars by engaging a weakened file with downward pressure. During analysis, the teeth were divided into two curved groups based on the curvature of the root (less than 30ยบ and greater than 30ยบ). The success rate of instrument removal and the treatment time were noted. Statistical comparison was done with the Fisher exact test and independent twosample t-test (P < .05).

Results: The overall success rate of instrument removal when the separated files were engaged in the apical region was 61%, and for the midroot region, it was 83%. Less curved canals (less than 30ยบ) showed a 91% success rate (n=24), whereas canals with an angle of curvature greater than 30ยบ showed a 42% success rate (n=12). The median treatment time for instrument retrieval was 10 minutes and 44 seconds.

Conclusions: The results revealed that the Gentlewave System is effective Kishor Gulabivala, BDS, MSc, FDSRCS, PhD, FHEA, is professor and chairman of endodontology, and head of department of restorative dentistry at Eastman Dental Institute, University College London. He is also training program director for endodontics in London.

40 Endodontic practice

in retrieving separated instruments while conserving the dentinal structure.

Treatment outcome of repaired root perforation: a systematic review and meta-analysis Siew K, Lee AH, Cheung GS. Journal of Endodontics (2015) 41(11): 1795-804 Abstract Aim: This study aimed to systematically review the reported treatment outcome of repaired root perforation and to identify any preoperative factors that may influence the outcome of such repair.

Methodology: A comprehensive search was conducted by using four electronic databases, as well as a manual search of cited references, to identify reports related to root perforation. Clinical studies published from 1950 to mid-2014 that evaluated the outcome of repaired root perforations were identified. Studies were further screened for similar characteristics for pooling of data for meta-analysis.

Results: Seventeen studies were included for systematic review and 12 suitable for meta-analysis. An overall pooled success rate of 72.5% (confidence interval: 61.9% to 81.0%) was estimated for nonsurgical repair of root perforations. The use of mineral trioxide aggregate appeared to enhance the success rate to 80.9% (confidence interval: 67.1% to 89.8%), but the difference was not statistically significant.

The presence of pre-existing radiolucency adjacent to the perforation site fared a lower chance of success after repair (P < 0.05).

Maxillary teeth demonstrated a significantly higher success rate compared with their mandibular counterpart (P < 0.05).

Conclusions: Within the limitations of this study, it may be concluded that nonsurgical repair of root perforation results in a success rate of more than 70%. Teeth in the maxillary arch and absence of preoperative radiolucency adjacent to the perforation are favorable preoperative factors for healing after perforation repair. In view of the relatively high rate of clinical success, nonsurgical

repair may be considered as the preferred treatment to handle this complication that arises during root canal therapy.

Factors affecting direction and strength of patient preferences for treatment of molar teeth with nonvital pulps Vernazza CR, Steele JG, Whitworth JM, Wildman JR, Donaldson C. International Endodontic Journal (2015) 48(12): 1137-46 Abstract Aim: To elicit the factors affecting willingness to pay (WTP) values for the preferred options of participants for dealing with a molar tooth with a nonvital pulp, a common but difficult problem.

Methodology: A total of 503 patients were recruited from dental practices in North East England and interviewed. Their preferred treatment option for a molar tooth with a nonvital pulp (endodontics, extraction, and various prosthetic restorative options) and WTP for this preferred option were elicited.

Factors affecting preferred option and WTP were analyzed using econometric modeling.

Results: Overall, 53% of the sample wished to save the tooth with a mean WTP of 373. The variance in WTP was high. Of those opting for extraction, the majority chose to leave a gap or have an implant. The preferred option was influenced by previous treatment experience. WTP was only influenced by having a low income.

Conclusions: The high level of variance in WTP and its relatively unpredictable nature pose difficult questions for policymakers Volume 9 Number 3

Unfinished root canal treatments and the risk of cardiovascular disease Lin PY, Chien KL, Chang HJ, Chi LY. Journal of Endodontics (2015) 41(12): 1991-6 Abstract Aim: Root canal treatments (RCTs) aim to eradicate pulpal diseases and save the infected teeth by eliminating microorganisms from the root canal system. Starting but not finishing a RCT can perpetuate a dead space for bacterial growth, which can spread to other sites in the body and develop systemic symptoms. The objective of the present study was to investigate the association between unfinished RCTs and the risk of cardiovascular disease (CVD) using a nationwide population-based database.

Methodology: A total of 283,590 participants who received at least one RCT and with no cardiovascular history before 2005 were recruited and followed until the end of 2011. An unfinished RCT was defined as a tooth on which a RCT was started but with no completion code. Cox proportional hazards models were used to estimate the effect of unfinished RCTs on the risk of CVD. Results: A total of 3,626 participants underwent CVD hospitalization during an average observation period of 6.01 years, thus yielding an overall CVD hospitalization incidence rate of 0.21% per person year.

Compared with the participants with no unfinished RCTs, the adjusted CVD hospitalization hazard ratio for the participants with one or two unfinished RCTs was 1.22 (95% confidence interval: 1.11-1.35), and for those with three or more unfinished RCTs, it was 3.61 (95% confidence interval, 2.36-5.51; test for trend, P < 0.0001).

Conclusions: Participants with unfinished RCTs were associated with a higher risk of CVD hospitalization.

Abstract Aim: To determine factors that may influence treatment outcome and healing time following root canal treatment.

Methodology: Root-filled and restored teeth by predoctoral students were included in this study. Teeth/roots were followed up regularly, and treatment outcome was evaluated at every follow-up appointment (healed, healing, uncertain, or unsatisfactory). Host (age, immune condition, pulp/periapical diagnosis, tooth/root type, location, and anatomy) and treatment factors (master apical file size, apical extension, voids, and density of root filling) were recorded from patient dental records. Univariate, bivariate, and multivariate analyses were performed to determine the impact of the factors on treatment outcomes and healing times.

Results: A total of 422 roots from 291 teeth met the inclusion criteria with a mean follow-up period of 2 years. The preoperative pulp condition, procedural errors during

treatment, apical extension, and density of root fillings significantly affected the treatment outcome. The average time required for a periapical lesion to heal was 11.78 months. The healing time increased in patients with compromised healing, patients older than 40 years, roots with Weine type II root canal systems, root canal systems prepared to a master apical file size less than 35, and roots with overextended fillings (P < 0.1).

Conclusions: Multiple host and treatment factors affected the healing time and outcome of root canal treatment. Followup protocols should consider these factors before concluding the treatment outcome: patientâ&#x20AC;&#x2122;s age, immune condition, as well as roots with overextended fillings, root canal systems with smaller apical preparations (size < 35), or roots with complex canal systems. Intervention may be recommended if the treatment quality was inadequate or if patients became symptomatic. EP

THE FUTURE HAS RETURNED.

THE ORIGINAL PLASTIC ENDODONTIC ROTARY FINISHING FILE IS BACK. MANUFACTURER DIRECT.

MADE IN THE U.S.A.

eďŹ&#x20AC;ective is the most cost The Finishing File ca to clean a nal! and simplest way

The Tennessee study: factors affecting treatment outcome and healing time following nonsurgical root canal treatment Azim AA, Griggs JA, Huang GT. International Endodontic Journal (2016) 49(1): 6-16 Volume 9 Number 3

orders@engineeredendo.com

www.engineeredendo.com

Endodontic practice 41

ABSTRACTS

trying to ensure the delivery of an equitable service. For dentists, it is important not to make assumptions about patient preference and strength of preference when making decisions. Ideally, WTP values should be considered alongside effectiveness data, and those on costs, in policymaking.

PRODUCT PROFILE

The Finishing File by Engineered Endodontics® The most cost-effective and simplest way to clean a canal

T

here are a lot of products on the market today aimed at irrigation and agitation of residual canal debris. Most of these products require a number of things — whether it’s expensive equipment to buy, batteries to make the device work, or good old hand filing to clean the canal. There has to be an easier, clinical, and cost-effective way to clean a canal.

There is — the Finishing File The Finishing File just requires your electric slow-speed handpiece, the type that you use with your nickel-titanium files. The Finishing File is made of nontoxic polymer and has two opposing flutes that run the entire length of the file. These flutes agitate the residual sidewall debris, and when in the canal with your irrigation solution, the fluid dynamics of the flutes spinning create a pump that extracts the debris out of the canal. The Finishing File is the only product that agitates AND extracts debris out of the canal.

Finishing Files all come in size 20, .04 taper, and in file lengths of 21 mm, 25 mm, and 31 mm.

They are sold in packs of 6 for $8.00 at www.engineeredendo.com. (That’s $1.33 per treatment.)

Engineered Endodontics sells clinically proven instrumentation for a fraction of the cost compared to the competition. tün® ultrasonic tips

Published research papers on the Finishing File can be found online at our website: www.engineeredendo.com.

Engineered Endodontics other product is our tün® ultrasonic tips. These tips perform just like the other endodontic ultrasonic tips on the market, but they cost only $20 and $24 each. These tips are made of surgical-grade stainless steel, all have water ports and diamond-plated cutting 42 Endodontic practice

tips, and the patented fork design provides maximum cutting efficiency even at lower power settings. So, you can run the tips at a lower setting while not sacrificing performance. Tün tips work on all major brand piezo ultrasonic units. Why keep paying $60 to $100-plus for your ultrasonic tips when you can get the same clinical performance at a fraction of the cost? The cost savings to switch to tün tips per year

can be in the $1,000s for the typical endodontic practice.

We can provide these quality tips at such a low price because all of our products are made at our facility in the USA, and we sell direct to you. You can learn more about our tün tips and order them online at our website: www.engineeredendo.com. EP This information was provided by Engineered Endodontics®.

Volume 9 Number 3

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Protrain for endodontic training Protrain is the first and the only endodontic simulator for training. It was invented to allow and facilitate the simulation of the dentist’s endodontic therapy on extracted teeth during training. The extracted tooth is locked in this system, and the operator can perform each of the steps necessary for a successful endodontic treatment. With this device, the operator can measure the length of the canal through the apex locator thanks to the electro-conducting gel, and then he can perform irrigation, shaping, and obturation of the root canal without any movement because the tooth is locked in the system. Finally the operator can do digital x-ray radiographies.

For more information, visit the website www.protrain.it.

Brasseler USA® introduces the EndoSync™ Endodontic Handpiece System Brasseler USA® has unveiled the EndoSync™ Endodontic Handpiece System, featuring the lightest-in-its-class EndoSync Cordless Micromotor along with the unprecedented accuracy of the EndoSync A.I. Apex Locator. While possessing the ability to work independently, connecting the EndoSync Cordless Micromotor to the EndoSync A.I. Apex Locator provides users with a wide variety of automatic controls for increased confidence and safety, even in the most challenging cases.

The high-performance EndoSync Cordless Micromotor provides numerous safety features including Optimized Torque Reverse (OTR) technology, torque slowdown, and an Apical Action mode which gives the user the ability to seamlessly connect to the EndoSync A.I. Apex Locator.

With six fully programmable settings, a broad speed range of 50-1,000 rpms, auto reverse, and torque control, EndoSync provides the power and versatility required for any case, including re-treatments — the perfect balance of precision and safety.

For more information, visit www.BrasselerUSA.com, or call 800-841-4522.

Brasseler USA® introduces KontrolFlex™ NiTi rotary files Brasseler USA® has introduced KontrolFlex™ NiTi rotary files. Equipped with Brasseler USA’s patented new Controlled Memory technology, KontrolFlex NiTi rotary files are the ideal choice for challenging curved canals as well as hard-to-reach areas of the tooth due to calcification.

Brasseler’s new and innovative Controlled Memory technology strengthens the properties of KontrolFlex to allow the files to be pre-curved, yet highly resistant to cyclic fatigue, unlike other “Controlled Memory” files on the market that can experience a drastic reduction in cutting efficiency as a result of softened metal. Designed with several performance-enhancing features, KontrolFlex strikes the perfect balance between cutting efficiency and safety for a powerfully precise yet minimally invasive performance. All KontrolFlex file surfaces are treated with Brasseler’s exclusive proprietary electro-polished finish that further improves resistance to cyclic and torsional fatigue often associated with the long-term use of dental rotary files.

For more information, visit www.BrasselerUSA.com, or call 800-841-4522 today for a free no-obligation in-office demonstration.

Volume 9 Number 3

Endodontic practice 43

PRODUCT PROFILE

MTA Repair HP New bioceramic material

A

ngelus Dental with more than 20 years producing endodontic consumables and presented in more than 70 countries is pleased to announce its next generation of bioceramic materials based on MTA technology.

The material of choice for sealing perforations due to its biocompatibility, sealing and hydrophilic abilities, MTA technology is now available in a bioceramic putty-like consistency.

Gradually being launched internationally since January 2016, MTA Repair HP is the new bioceramic material with the same performance, indications, chemical, and biological properties of the conventional MTA, but with significant improvements in its consistency, more plasticity, allowing a friendly manipulation and insertion in the treatment site.

• Putty-like consistency: Provides a product with friendly manipulation and insertion. The handling was a cause of stress reported by clinicians when using convention MTA, due to its “sandy” consistency.

• Does not stain the tooth: MTA Repair HP also has a new radiopaquer — calcium tungstate — which does not cause discoloration of the dental structure.

• Unidose capsules: Another point worth mentioning is the package, designed for single uses. However, in a simple perforation or apical plug, the amount of product in a capsule can achieve two treatments.

• Extended shelf life: Powder and liquid in separate vials prevent the product from deteriorating after initial

usage. With this exclusive packaging, the shelf life is 3 years, no matter if used in a single case and if portioned.

• Fast setting: All the preceding properties are in a product with a setting time of only 15 minutes, reducing the risk of displacement.

Angelus Dental — simplifying procedures through innovation.

To receive more information on MTA Repair HP, visit www.angelusdental.com/ MTA_HP. EP This information was provided by Angelus® Dental.

The material of choice for sealing perforations due to its biocompatibility, sealing and hydrophilic abilities, MTA technology is now available in a bioceramic putty-like consistency.

44 Endodontic practice

Volume 9 Number 3

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Own the legend: DentalEZ® will discontinue its revolutionary J Family of patient chairs by 2017 DentalEZ® recently announced that by 2017 its most famous contribution to the dental industry, the J Family line of patient chairs, will no longer be available for sale. With a limited number of chairs currently in production, the company will phase out the history-making chairs beginning this July. The company will continue to offer dental professionals a chance to own the legend by purchasing the classic J-Chair® and/or the J/V-Generation® Chair until the last remaining chair finds its home.

The company will transition its focus to further educating dental professionals on the many features and benefits of its popular NuSimplicity™ patient chair, an evolved version of the J-Chair. The NuSimplicity features a narrow, tapered back, a base plate design that allows closer placement of operator stools, and height flexibility of 15 inches to 35.5 inches to accommodate sit-down and stand-up dentistry. In addition, options like wireless controls or the exclusive Air Glide technology make for a more efficient operatory, a wide variety of upholsteries, and color combinations to match any office décor.

For more information, visit www.dentalez.com.

R

R

R

R

R

R

R

R

R

R

R

R

KaVo Kerr Group Imaging announces 3D University event Registration is open for the second annual Dental 3D University (3DU), hosted by KaVo Kerr Group imaging brands Gendex™, NOMAD™, SOREDEX™, and Instrumentarium™.

3DU is a one-of-a-kind 2-day event that offers dental professionals an educational environment dedicated to cone beam 3D (CBCT) solutions that will enhance their practices and put them in full control of treatment outcomes. 3DU will be held October 7-8, 2016, in Boston, Massachusetts.

Welcoming doctors, staff, and dental students, 3DU gives attendees the opportunity to earn up to 12 CE credits courtesy of world-class speakers and industry experts.

For a limited time, dental professionals can enter to win free tuition and a 2-night stay in Boston for the event. Go to dental3DU.com/win for details and additional information about the event.

Volume 9 Number 3

Endodontic practice 45

ENDOSPECTIVE

Big money for big cleaning?

Dr. Rich Mounce gets to the root of cleaning systems

C

leaning root canal systems is obviously complex and related to a confluence of variables (debridement, irrigant activation, agents used, and mechanism of delivery).

Mechanisms of irrigant activation include passive ultrasonic, sonic, laser (photoninitiated photoacoustic streaming), multisonic energy, apical negative pressure, and mechanical agitation, among others.

Variables in irrigation include exposure time, canal anatomy, canal contents, volume, refreshment rate, agent utilized, sequence of agents used, achievement of patency and frequency of recapitulation, canal taper, master apical diameter, and drying technique.

In addition, agents utilized vary according to concentration, surface tension, tissue dissolving capacity, substantivity, sequence of agents used, capacity for smear layer removal, cost, shelf life, toxicity, among many potential qualities, attributes, and limitations.

Ask 100 endodontists how they utilize these variables to clean canals, and it’s likely you’ll get 100 different answers. It is not difficult to see why this is the clinical reality; an evaluation of the scientific literature with regard to irrigation methodologies, agents, solutions, delivery, and activation mechanisms provides a diverse array of often conflicting results. Add the laser and multisonic cleaning systems now available into the mix, and the clinical and commercial environment becomes even more confusing.

Part of the challenge of drawing conclusions, among other factors, is the widely divergent methodologies that have been used in many of the previous studies. Interpreting the scientific literature with clinical practice techniques is anything but straightforward.

Dr. Mounce has lectured and written globally in the specialty. He owns MounceEndo.com, an endodontic supply company also based in Rapid City, South Dakota (605-791-7000). He can be emailed at RichardMounce@Mounce Endo.com, and his website can be visited at MounceEndo.com.

Disclosure: Dr. Mounce has no commercial interest in any of the products or companies mentioned in this column.

46 Endodontic practice

Given this background, it is fair to ask if now is the time to spend big money to achieve a reported “big clean” by endodontically utilizing the new and novel GentleWave™ (GW) (Sonendo®) and/or photon-induced photoacoustic streaming (PIPS) technologies. The answer is maybe yes and maybe no. Maybe yes, because mounting science is slowly proving these systems’ advantages relative to conventional methods. Maybe no, because it is valid to ask if it is worth the formidable financial investment for GW and a significant fee per handpiece/per case to gain the advantage these systems represent relative to conventional activation methods.

Currently, the value proposition is unclear to me as to whether it makes sense to be an early adopter immediately or to wait.

If the first wave of machines prove clinically effective and mechanically durable over the long term without iatrogenic accidents, and the scientific literature bears out the superiority of GW, then in the early second wave of adopters, with or without simultaneous obturation, yes, it’s time to buy. Alternatively, give me a PIPS or GW that obturates simultaneously now, and I’m in immediately.

GW, in particular, markets the advantage of its system (in part) as time saved in canal preparation and savings on files.

True to a point, but how much time is spent at the endodontic-specialty level gaining profound anesthesia, patency, and glide path? A great deal. How much time is spent enlarging canals with nickel-titanium once we have the glide path? Not much. The Sonendo handpiece costs much more than all the disposable supplies and files used in virtually any case. GW also claims that tooth structure is saved with minimally invasive endodontics. Again, true to a point, but what is the vertical fracture risk in a properly prepared and restored tooth?

Very little.

The future is headed in the direction of GW and/or a PIPS-like ultra-cleaning that is less technique sensitive and obturates canals. How could it not be? To believe these technologies are a fad and will go away is to put one’s head in the sand and see the future of endodontics as static. It is anything but static. Change is inevitable and embraced; the question is more about timing. I welcome your feedback. EP Volume 9 Number 3

SMALL TALK

Truth and fact Dr. Joel C. Small discusses the need to develop critical thinking as a means to defining and creating our preferred future “Average performers tend to believe truth and fact are the same. The world class knows there is a difference. Champions use their critical thinking skills to make clear distinctions between truth and fact. Fact is reality. Truth is our perception of reality, and perceptions are subjective.”

~Steve Siebold

Secrets of the World Class We have all seen this scenario — it’s a hot summer day, and we see a fly beating its wings against a window pane in a futile effort to get outside. The fly sees where it wants to go, but the glass serves as an invisible barrier that ultimately frustrates and defeats the fly.

The fact, or reality, is that the glass is impenetrable, but the truth, as the fly perceives it, is that the invisible barrier is blocking the fly’s only path to freedom.

Our initial response to this scenario is to acknowledge that the fly lacks the necessary mental capacity to visualize the obvious alternative paths to freedom that we see so clearly. We say, “How unfortunate. If only the fly was smart like us.” And yet we exhibit the same behavior as the fly on a regular basis.

Albert Einstein famously stated, “We can’t solve problems using the same kind of thinking we used when we created them.”

This quote has meaning at so many levels.

Take the profession of dentistry for example.

Over the past 20 years, we have needed to evolve from the cottage industry that defined our past. We can no longer assume, Joel C. Small, DDS, MBA, FICD, is a practicing endodontist and the author of Face to Face: A Leadership Guide for Health Care 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.

Volume 9 Number 3

as in years past, that simply putting out a sign and practicing in a secluded environment will guarantee our comfortable retirement. Too much has changed, and it has immutably altered the environment in which we practice. We are being challenged on many fronts, and yet we have been slow to respond to these critical challenges. Why? I would submit that we choose the course of inaction because we remain with the same mindset that prevailed from years past. In reality, change is inevitable and necessary.

We are, however, hindered by our perceived truth that the same process from the past, one that required little thought or action on our part, will somehow bring us the same results in the future. We are like the proverbial frog in hot water. Our truth is the water is warm. The fact is the water will soon boil and cause our demise.

Marshall Goldsmith, author of the bestselling book, What Got You Here Won’t Get You There, would say that dentists are highly superstitious. Superstition, according to Goldsmith, is simply the confusion of correlation and causality. As a result of this confusion, we tend to repeat any behavior that is followed by positive reinforcement whether or not the positive reinforcement occurred as “a result of” or ”in spite of” the behavior. So if we are able to experience a degree of success in spite of our habitual inaction and mindlessness, we tend to assume that the same behavior will provide future success. This is our truth, but as Goldsmith states, our reality is that what got us here won’t get us there.

When I started my endodontic practice 38 years ago, “Yelp” was something that happened when you stepped on a dog’s tail, and defending our reputation was something that took place after school at the bike rack, not online. What was “online” anyway? So much has changed that has altered our existence.

Even this old dog has had to learn new tricks.

The time has come for dentistry and dentists to develop the necessary critical

thinking skills that will allow us to distinguish between truth and fact. It is time for us to align our truth with the facts, so we can see our world as it truly exists. Is feefor-service a dying concept? Will corporate dentistry overwhelm traditional dentistry?

Solutions to these and other critical issues will require a different type of thinking. The solutions require action as opposed to our habitual inaction of years past. I truly believe that creating dentistry’s preferred future depends on our willingness and ability to develop our critical thinking skills.

If dentistry as we know it is to survive, future dentists must be true entrepreneurs with the same, or better, critical thinking skills as those possessed by corporate non-dentists who seek to forever change our profession to meet their own needs. Once we discard our old way of thinking and learn new critical thinking skills, we will begin to see the alternative paths that take us where we need to be.

So how do we acquire these vital skills?

One obvious way would be to include this training as part of the dental school curriculum, but I fear that we are a long way from seeing this become a reality. Another way would be to create a highly skilled team of professional advisors and use their counsel as a guide for entrepreneurial endeavors and decision-making. Some dentists have even chosen to return to school to study business and organizational development.

In conclusion, learning how to think is just as important as learning what to think.

This is a process of challenging our truths and aligning them with facts. By removing barriers that diminish our clarity, we are able to see and deal with reality at a whole new level. With the help of advisors or professional coaches, we can learn to cast away subjective self-limiting beliefs and assumptions that keep us tied to the status quo and prevent us from finding the alternative paths to success. EP Endodontic practice 47

PRODUCT PROFILE

EndoUltra™ New cordless ultrasonic activator significantly improves disinfection

T

he goal of root canal cleaning and shaping is the removal of vital or necrotic tissue, microorganisms, and their byproducts while providing space for placing obturation material. The ultimate goal is the complete removal and disinfection of the endodontic space.

EndoUltra™ is the only cordless, compact, battery-operated activation device capable of creating acoustic streaming and cavitation required to provide improved cleanliness, penetration, canal sealing, and the removal of vapor lock.

Studies show that conventional instrumentation leaves as much as 35% of the canal anatomy untouched. Instrumentation and irrigation, although important factors in canal disinfection, cannot in themselves be relied upon for optimal canal cleanliness.

Research has also shown that irrigants are more effective when they are electromechanically activated. Acoustic streaming and cavitation have been proven to significantly enhance cleaning of difficult anatomy.

Low frequency (sonic) oscillation (160190Hz) is simply not sufficient in creating acoustic streaming and cavitation within the canal space.

The EndoUltra™ is the first device to utilize Vista’s (patent-pending) miniaturization of piezo energy technology. EndoUltra™ Activator 15/02 stainless steel tips release ultrasonic energy along the entire length of the tip and do not engage tooth structure.

Activator tips feature depth markers at 18 mm, 19 mm, and 20 mm.

Test No. 1 materials and methods In order to evaluate the fluid movement throughout the canal, a canal block was filled with water. Methylene blue dye was placed in the two outer openings. The canal block was sealed on the proximal openings to mimic canal pressure. Each endodontic product was activated and placed within the canal block. The simulation was recorded with a video camera.

The videos taken were analyzed through Image J to quantify the dye intensity throughout the canal (apical, middle, lateral, coronal) areas. The quantitative data was then 48 Endodontic practice

converted into a percentage scale in order to compare the mixing of dye caused by each of the commercialized endodontic products, as well as a 15/02 millimeter hand file.

Results The EndoUltra™ caused more mixing of the dye in the canal compared to the EndoActivator®* and 15/02 millimeter hand file after 5 seconds, and after 20 seconds of total activation within the canal.

The EndoActivator®* was unable to mix any dye within the lateral canal at either time point. The EndoActivator®* had a maximum of 15% dye that was mixed, which occurred in the coronal area of the canal. The EndoUltra™ resulted in significantly more dye mixed throughout all areas of the canal compared to the EndoUltra™ after 5 seconds and also after 20 seconds of activation.

Figure 1: The percentage of dye mixed within the canal areas after 20 seconds of activation. The EndoActivator®* was unable to provide mixing of dye within the lateral area of the canal

Conclusion In comparing two commercialized endodontic products (EndoUltra™, EndoActivator®*, and a 15/02 millimeter hand file), the EndoActivator®* and hand file were unable to sufficiently mix methylene blue dye within a canal block. The EndoUltra™ was able to mix dye within the canal block after 5 seconds of activation and produced significantly higher percentages than the EndoActivator® and hand file in all areas of

the canal. Clinically, this implies that the EndoUltra™ is able to disperse irrigating solution throughout the anatomical canal to provide improved, faster cleaning of the canal and success rates compared to other endodontic devices.

Test No. 2 materials and methods Cavitation is the generation and subsequent collapse of vapor bubbles in a solution due to localized pressure reductions.

In endodontics, this change in pressure is caused by an object moving at ultrasonic frequencies. The cavitation effect can be measured quantitatively using sonochemistry. The amount of cavitation can be increased by the addition of surfactants into solution. This is due to the ability of surfactants to decrease the intermolecular forces between water and solute molecules.

Figure 2: UV/Vis absorbance spectrums following activation of KI solutions with endodontic activation devices. The EndoActivator®* and PiezoFlow do not yield any cavitation via the absence of absorbance at 355 nm, whereas the EndoUltra™ yields significantly more cavitation and triiodide formation

Conclusion All commercially available activation devices tested, with the exception of the EndoUltra™, were unable to produce cavitation.

For more information, call Vista Dental Products at 877-418-4782, or visit www. vista-dental.com or www.EndoUltra.com. EP *EndoActivator® is a registered trademark of ENDO INVENTIONS, LLC. This information was provided by Vista Dental Products.

Volume 9 Number 3

SEE BEYOND THE SURFACE

PRECISE IMAGE QUALIT Y MADE EASY FOR YOU Š Carestream Health, Inc. 2016. RVG is a trademark of Carestream Health. 14295 EN IN AD 0816

To plan and perform any procedure with confidence, the details are important. You need crystal clear images that display detailed root and canal morphology and enhance your diagnostic abilities. With Carestream Dental, high-quality images and customizable filters let you look deeper and see with more precision.

For more information, call 800.944.6365 or visit www.carestreamdental.com