Endodotic Practice US Winter 2016, Vol 9 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Winter 2016 – Vol 9 No 4

Dr. Meera Patel

ENDODONTICS Post-endodontic neuropathy of the trigeminal nerve: part 1 Dr. Tara Renton

Analysis of cutting capacity and apical deviation occurrence Dr. Tiago André Fontoura de Melo and Letícia Feron

Laser-enhanced endodontic treatment

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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

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 4

Shedding light on lasers

he process of light amplification by stimulated emission of radiation (LASER) is a well-known phenomenon being used in various scientific fields. The energy is produced when excited atoms return to their base level and release photons. By using different laser mediums, the wavelength of the laser device is regulated and produces various energy levels. This energy was found to be applicable to various aspects in dentistry such as cavity preparation, bleeding control, soft tissue cutting, and disinfection. Therefore, it is not surprising that many studies have been conducted on laser technology for endodontic treatment (Green J, Weiss A, Stern A, 2011). Common lasers Dr. David Keinan such as Er: YAG, Nd:YAG are used for cleaning, while CO2 lasers have been used for soft tissue surgery. The main use of endodontic lasers includes smear layer removal and canal disinfection. Laser treatment was found efficient for reducing bacterial infection and can significantly enhance the long-term success of endodontic treatment (Siqueira JF Jr, 2001). Studies have demonstrated variable cleaning into dentinal tubules with Nd: YAG or diode lasers. The disinfection effectiveness of Er: YAG laser was found to be similar to sodium hypochlorite at various concentrations (Arnabat J, Escribano C, Fenosa A, et al., 2010; Folwaczny M, Mehl A, Jordan C, et al., 2002). This lethal effect of lasers can be increased by increasing the number of irradiation cycles (Moritz A, Schoop U, Goharkhay K, et al., 1999). Except for the photon effect on the bacteria, lasers can activate and increase the flow of the irrigants during root canal treatment. Laser active irrigation (LAI) was shown as an advanced technique to effectively remove debris from the canal walls (de Groot SD, Verhaagen B, Versluis M, et al., 2009; De Moor RJ, Blanken J, Meire M, et al., 2009; Sahar-Helft S, Slutzky-Goldberg I, Moshonov J, et al., 2011). This goal is achieved by forming large elliptical vapor bubbles that expand and then implode, therefore having a cavitation effect on the biofilm on the canal wall (de Groot SD, Verhaagen B, Versluis M, et al., 2009). In a similar way, the laser tip coronally positioned produces a forced streaming in a technique called photon-induced photoacoustic streaming (PIPS) (Pedullà E, Genovese C, Campagna E, et al., 2012). The antimicrobial effect of a specific wavelength of lasers can be enhanced by using a photosensitizer on the treated area. This antimicrobial photodynamic therapy (aPDT) was considered for use against different oral pathogens, especially in the form of biofilm (Mang TS, Tayal DP, Baier R, 2012; Mang TS, Mikulski L, Hall RE, 2010). It was also noted that the weakened or changed biofilm matrix may be more easily removed or destroyed (Mang T, Rogers S, Keinan D, et al., 2016). Laser treatment also has been also utilized to reduce dentinal hypersensitivity (Kimura Y, Wilder-Smith P, Yonaga K, et al., 2000; Senda A, Gomi A, Tani T, et al., 1985; Stabholz A, Neev J, Liaw LL, et al., 1993; Matsumoto K, Funai H, Wakabayashi H, et al., 1985). The mechanism of action may have two effects. The first involves physical blockage of the opened dentinal tubules by melting the dentin (Stabholz A, Neev J, Liaw LL, et al., 1993), and the second involves nerve analgesia by the energy of the laser (Matsumoto K, Funai H, Wakabayashi H, et al., 1985). The Er:YAG laser was found to have less pulpal damage from thermal changes during the irradiation (Belal MH, Yassin A, 2014). In conclusion, lasers present contemporary uses in the field of endodontics, especially for refractory cases and mainly for smear layer removal and biofilm disinfection. The use of laser in endodontics is still limited mainly due to costs, but further studies are needed in order to explore their superiority over current methods of treatment. Full references available upon request.

Dr. David Keinan is the chief dental officer, medical corps for the Israel Defense Forces.

Endodontic practice 1

INTRODUCTION

Winter 2016 - Volume 9 Number 4

TABLE OF CONTENTS

Clinical

Financial focus Is your 401(k) plan a ticking time bomb of personal and professional liability? Tom Zgainer discusses how small business owners may be overlooking a significant source of liability in their practices: their 401(k) plans

12 2 Endodontic practice

Technology insight Laser-enhanced endodontic treatment Dr. Gregori M. Kurtzman discusses the benefits of laser implementation ....................................................... 14

Continuing education The management of avulsion and dental trauma Dr. Meera Patel discusses the immediate and long-term management of an avulsed upper central incisor .......................................................20

Volume 9 Number 4

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TABLE OF CONTENTS

Banding together Brooks’ heroes Managing editor Mali SchantzFeld shares an unforgettable act of kindness..........................................32

Technology Defining our terms. Refining endodontics

Continuing education

Post-endodontic neuropathy of the trigeminal nerve: part 1

In the first of two articles, Dr. Tara Renton presents a literature review for the post-endodontic neuropathy of the trigeminal nerve

Sonendo® discusses the mechanism behind its new standard of clean .......................................................34

KontrolFlex™ NiTi Files Take the stress out of shaping difficult canals. Take control with KontrolFlex .......................................................36

Practice management

Legal matters Letters to referring doctors may keep you out of court Dr. Robert M. Fleisher discusses the importance of proper documentation .......................................................42

Seven keys to growing your endodontic practice in today’s market

Small talk

Dr. Garth Hatch discusses seven proven strategies that lead to practice growth.............................................38

Dr. Joel C. Small offers direction in the quest for happiness and balance ........................................................44

Become an essentialist to find happiness in your success

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

Practice development Endospective

WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com

What you need to know about online reviews for your practice

E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com

Ian McNickle, MBA, discusses the importance of a strong online presence ...................................................... 40

Product profile MTAFlow Repair Cement ™

What sets it apart?..........................41 4 Endodontic practice

Hang it up, or rev it up? Dr. Rich Mounce explores re-examining enthusiasm for endodontics............. 46

Practice development Am I getting the best deal? Lisa Radman White discusses how to make the purchase process beneficial for the buyer and seller.....................48

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 4

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CLINICAL

Analysis of cutting capacity and apical deviation occurrence after preparation of curved canals with ProTaper® Universal instruments, ProTaper NEXT®, and HyFlex® CM™ Dr. Tiago André Fontoura de Melo and Letícia Feron analyze instruments after preparation of curved canals with three rotary systems Abstract This study aims to analyze the cutting efficiency and apical deviation after preparation of curved canals with three rotary systems. For this analysis, 45 simulated curved canals with 35° of curvature were divided according to the endodontic instrument tested in three experimental groups: ProTaper® Universal, ProTaper NEXT®, and HyFlex® CM™. Each set of instruments was used in five simulated canals by a single operator. At each use, the instruments were cleaned and sterilized. For the cutting efficiency analysis, the canals were weighed on an analytical balance before and after instrumentation. The difference in weight was used to measure cutting efficiency. As for the deviation analysis before and after instrumentation, the canals were filled with ink and photographed on a platform. The images were superimposed in Adobe Photoshop® software; with the ruler tool, the measurement was performed at the 1 mm and 3 mm from working length (WL) deviations. The data was processed by one-way ANOVA followed by post hoc Tukey test with 5% significance level. ProTaper Universal and ProTaper Next instruments showed a higher cutting capacity than HyFlex CM, as the first and second use showed the highest average cut than the fifth use. At 1 mm from the WL, there was no difference between the instruments. Just at 3 mm from the WL, the HyFlex CM instruments promoted a greater deviation.

Introduction In recent years, the NiTi alloy from the endodontic instruments has undergone

heat treatment by manufacturers in order to improve their properties (Gambarini, et al., 2011). This heat treatment provides a better arrangement of the crystalline structure, which leads to a greater flexibility of the material, as well as changes in the phase percentages (different grain structure) of the alloy, which leads to improved resistance or plastic behavior (Al-Sudani, 2014). Two existing innovative systems on the market have undergone changes in their alloys. The HyFlex CM rotary files (Coltene/Whaledent, Allstetten, Switzerland; Cuyahoga Falls, Ohio) are made from a new type of NiTi wire — controlled memory (CM), a wire that has been subjected to proprietary thermomechanical processing. It is manufactured by a special thermomechanical process, making the files extremely flexible but without the shape memory of conventional NiTi files (Zhao, et al., 2013). These instruments display a lower percentage in weight of nickel (52 Ni %wt) compared with the great majority of commercially available NiTi rotary instruments (54.5-57 Ni %wt) (Zinelis, et al., 2010). For this reason, in addition to its specific manufacturing process, HyFlex CM files do not rebound to their original shape as do conventional NiTi instruments, which, combined with their greater flexibility, may lead to a reduced risk of ledging, transportation, and perforation (Ninan, Berzins, 2013). The file system ProTaper NEXT (Dentsply Sirona) is also subjected to thermomechanical processing, resulting in the M-Wire NiTi that increases the flexibility of the material as reported (Alapati, et al., 2009).

Tiago André Fontoura de Melo, PhD in Endodontics, is a teacher in the Clinical Department, Dental School, College of Serra Gaúcha (FSG), Caxias do Sul/RS, Brazil. Letícia Feron is a graduate student in the Clinical Department, Dental School, College of Serra Gaúcha (FSG), Caxias do Sul/RS, Brazil.

6 Endodontic practice

The qualities of these materials with respect to the resistance to cyclic fatigue (Braga, et al., 2014; Capar, et al., 2014c), extrusion of debris (Capar, et al., 2014a; Koçak, et al., 2015), and crack formation in dentin (Capar, et al., 2014b) have been proven in numerous studies. However, very little is known with respect to the cutting capacity and effectiveness of the preparation.Therefore, this study aims to analyze the cutting ability and the occurrence of apical deviation after preparation of curved canals with ProTaper NEXT and HyFlex CM instruments in relation to a system already established in endodontics, the ProTaper Universal.

Materials and methods Obtaining simulated canals and rotary systems Forty-five blocks of simulated canals with 35º curvature, 16 mm in length, and apex diameter of 0.15 mm were used. Endodontic instruments analyzed were ProTaper Universal, ProTaper NEXT, and HyFlex CM. Preparation of the simulated canals During the completion of the preparations, the simulated canals were fixed on a small vise (Vonder®, Curitiba, Paraná, Brazil) in order to facilitate the instrumentation. In addition, the canals were laterally wrapped in foil (Wyda Industry In-packings Ltda., Sorocaba, São Paulo, Brazil), with only the idea of the tilt direction of curvature positioned in a standardized way and always facing the right of the operator. Before and during the canals’ preparation with the three rotary systems for each change of the endodontic instrument, the canals were irrigated with distilled water (Iodontosul - Dental South LTDA Industrial, Volume 9 Number 4

Analysis of apical deviation For the deviation analysis, before and after the completion of instrumentation of the canals, the simulated canals were placed on a platform and photographed by a digital camera D3200 (Nikon Corporation, Nagoya-shi, Tokyo, Japan) always following the same position and the same focal length. To improve the contrast in the photographic display, ink was injected (Corfix, Porto Alegre, Rio Grande do Sul, Brazil) within the simulated canals with the help of a disposable syringe. After the photographic stage, the images were manipulated in Adobe Photoshop version 6.0. To transform the image in millimeters, a proportion was used associating the original size of the simulated canals with Volume 9 Number 4

the image size on the computer screen, keeping the images’ sharpness and not reducing image pixels. With the same program, the images were subjected to contrast adjustment. Each postoperative image was transformed into a 50% layer of transparency and superimposed the preoperative image. Thus, we observed by transparency, two images, one atop the other. Next, we used the tool ruler to find the exact locations of the image where the deviations were measured; the predetermined analysis was 1 mm from WL and at a point located in the middle of the curvature area (3 mm from WL). The measure of the deviation was performed with the help of the rule tool on the two points to be analyzed. The distance was measured from the opposite side wall of the curvature area of the canal before instrumentation (A) and measured from the same point for the canal position after instrumentation (B) (Figure 1). Analysis of the cutting efficiency Regarding the verification of cutting efficiency, each simulated canal was duly numbered and weighed on a high-precision analytical balance (Ohaus Adventurer™, Parsippany, New Jersey). This weighing was done before and after the completion of the canal preparation. The preparation was finished, the simulated canal was irrigated, and the solution was aspirated. Immediately after, absorbent paper points No. 30 were used (Dentsply Maillefer Instruments SA, Ballaigues, Switzerland) in order to completely dry the canal. Next, the final weight of the simulated canal was weighted. Previously, the rotating instruments for instrumentation of the canals passed through a cleaning and sterilization process. All endodontic instruments were cleaned before their first use, or after being removed from their original packaging, and at the end of each use. This cleaning procedure was done in two stages, starting with the ultrasonification of the instruments in an ultrasonic tank model 151-7 (Baumer, Joinville, Santa Catarina, Brazil) containing enzymatic detergent Descrost (Multionic-Industry and Co-Mercian Products Chemical Ltd., Taubate, São Paulo, Brazil), the proportion of 10 ml to a liter of water in the ultrasonic frequency of 40 KHz, and a time of 20 minutes according to the manufacturer’s recommendations.

CLINICAL

Porto Alegre, Rio Grande do Sul, Brazil) to remove the resin scrapings and then anionic detergent Tergensol (Inodon, Porto Alegre, Rio Grande do Sul, Brazil) used for lubrication. The preparation of the canals was performed by a single operator trained in the use of all systems. Each set of instruments was used to prepare five simulated canals. For each of the three rotary systems, at each instrument change, an endodontic instrument type K No. 15 (Dentsply Maillefer, Ballaigues, VD, Switzerland) was manually used to WL in order to promote the removal of resin scrapings from the apical region of the canal. The WL was standardized across all simulated canals to a 15 mm in length. The actuation of the endodontic instruments for all three mechanized systems was carried out by an electric motor X-Smart™ (Dentsply Maillefer, Ballaigues, Switzerland) with the speed and torque recommended by the manufacturer. The technique sequence in the ProTaper Universal system follows: • shaping file No. 1 (3 mm below the WL) • shaping file X (cervical preparation) • shaping files Nos. 1 and 2 • finishing files Nos. 1, 2, and 3 (in WL). For the ProTaper Next system, the instruments used were X1, X2, and X3 (in WL). For the HyFlex CM system, the following instrumentation sequence was used: step 1 (.08/25 for orifice opener) followed by step 2 (in WL) for apical enlargement with .04/20. For step 3 (in WL), a .04/25 file was used to continue apical enlargement; step 4 used .06/20 (in WL) for middle part shaping, and finalizing was done with step 5 (in WL) using .04/30 file for apical enlargement.

Figure 1: Schematic drawing of the location of pre-established points for measurement of apical deviation

Next, the brushing of the instruments was performed with a soft toothbrush (Oral B, São Paulo, Brazil) humidified with a standard liquid soap (Clonex Products and Cleaning Systems Ltda., Porto Alegre, Rio Grande do Sul, Brazil) under running water until visible residues were no longer detected on the active part of the instruments. Subsequently, the endodontic instruments were placed in a metal tray (Metallurgical Fava Indústria e Comércio Ltda., Franco da Rocha, São Paulo, Brazil) and allowed to dry randomly. After completely dried, the instruments were individually placed in envelopes for sterilization. Sterilization took place in a Vitale 12 autoclave in which the instruments have been sterilized by exposure to moist heat to 01 atm and 127ºC for a total sterilization time of 20 minutes. Cleaning protocol was always performed by the same operator, with a total of six cleaning and sterilization procedures for each of the instruments during the experimental part of this study. Statistical analysis Analysis of cutting efficiency and apical deviation between the rotary systems tested was performed by one-way variance analysis (one-way ANOVA), complemented by the post hoc Tukey test. Significance level was 5% (P ≤ 0.05). Statistical analysis was performed using SPSS 22.0 software (SPSS Inc., Chicago, Illinois).

Results For the cutting efficiency analysis, it was possible to verify that there was no interaction between group and use (Table 1). As for the Endodontic practice 7

CLINICAL main effects of group and use (Table 2), both were significant; therefore, regardless of use, systems ProTaper Universal and ProTaper NEXT had significantly higher average than the HyFlex CM. Regardless of the group, the first and second use had significantly higher averages than the fifth use. Regarding the presence of apical deviation at 3 mm from WL, no interaction was detected between group and use (Table 3). As for the main effects of group and use, only group was significant; therefore, regardless of use, the HyFlex CM system showed a significantly higher average than

Table 1: Represents interaction between the group and the use in relation to cutting efficiency Variation cause

Sum of squares

Degrees of freedom

Group

0.0006

10.82

<0.001

Use

0.0005

4.04

0.010

Group versus Use

0.0001

0.33

0.947

Errorexperimental

0.0008

Total

0.0184

the instruments ProTaper Universal and ProTaper Next (Table 4). In the presence of apical deviation at 1 mm from WL, no interaction between group and use was found (Table 5). As for the main effects of group and use, both were not significant; therefore, the apical deviation at 1 mm from WL showed no statistical difference between the mean values of the three systems (Table 6).

Discussion According to Rapisarda, et al. (1999), the cutting efficiency and flexibility are important

Table 2: Results of the cutting capacity when comparing the three rotary systems in relation to the number of uses Use

Rotary systems (group) HyFlex CM™ ®

mechanical properties to maintain because they affect the ability of the practitioner to safely shape the root canal system. Several studies (Capar, et al., 2014d; Deepak, et al., 2015; Elemam, et al., 2015; Uzunoglu, Turker, 2015) compared rotary instruments for the endodontic canal preparation. Simulated canals used in the study had a standard diameter and were compatible with size 15. Thus, the recommendation of the manufacturers that a glide path of at least size 15 should be established prior to rotary instrumentation was taken into consideration during this study as well as

ProTaper NEXT

Total ProTaper Universal ®

Mean

0.020

0.005

0.025

0.009

0.023

0.003

0.023

0.006

0.018

0.008

0.028

0.008

0.022

0.013

0.003

0.023

0.003

0.018

0.012

0.003

0.020

0.000

0.008

0.003

0.020

0.005

Total

0.014

0.006

0.023

0.006

0.003

0.023

0.007

0.011

0.018AB

0.006

0.017

0.006

0.016

0.005

0.018

0.006

0.015B

0.007

0.020

0.005

0.019

0.007

The mean followed by different capital letters in the column and followed by the mean of different lowercase letters in the bottom row differ significantly by ANOVA complemented by Tukey Multiple Comparison Test at a 5% significance level

Table 3: Represents the interaction between the group and the use in the occurrence of apical deviation at 3 mm from WL Variation cause

Sum of squares

Degrees of freedom

Group

0.0007

5.52

0.009

Use

0.0001

0.48

0.747

Group versus Use

0.0008

1.58

0.174

Errorexperimental

0.0020

Total

0.0184

Table 4: Results of the occurrence of apical deviation at 3 mm from WL when comparing the three rotary systems Use

Rotary systems (group) HyFlex CM™ ®

ProTaper NEXT

Total ProTaper Universal ®

Mean

0.020

0.010

0.020

0.010

0.020

0.010

0.020

0.009

0.020

0.017

0.020

0.000

0.027

0.006

0.022

0.010

0.030

0.010

0.018

0.010

0.000

0.020

0.011

0.033

0.006

0.020

0.000

0.017

0.006

0.023

0.009

0.033

0.006

0.020

0.000

0.017

0.006

0.023

0.009

Total

0.027A

0.011

0.019B

0.006

0.019B

0.008

0.022

0.009

Means followed by different letters differ significantly by ANOVA and complemented by the post hoc Tukey test at 5% significance level

Table 5: Represents the interaction between the group and the use in the occurrence of apical deviation at 1 mm fro WL Variation cause

Sum of squares

Degrees of freedom

Group

0.0005

1.98

0.156

Use

0.0009

1.66

0.185

Group versus Use

0.0006

0.61

0.763

Table 6: Results of occurrence of the apical deviation at 1 mm from WL comparing the three rotary systems Use

Rotary systems (group) HyFlex CM™ ®

ProTaper NEXT

Total ProTaper Universal ®

Mean

0.020

0.010

0.037

0.012

0.033

0.015

0.030

0.013

0.023

0.033

0.006

0.043

0.006

0.033

0.015

0.033

0.012

0.038

0.013

0.035

0.007

0.036

0.010

0.040

0.010

0.043

0.006

0.043

0.006

0.042

0.007

Errorexperimental

0.0040

4 5

0.040

0.010

0.043

0.006

0.037

0.015

0.040

0.010

Total

0.0651

Total

0.031

0.015

0.039

0.009

0.039

0.010

0.036

0.012

8 Endodontic practice

Volume 9 Number 4

Universal and ProTaper NEXT was higher than the HyFlex CM. The cutting ability of root canal instruments involves a complex interrelationship of different parameters such as the cross-sectional design, which seems to be a decisive parameter (Schäfer, Oitzinger, 2008), chip-removal capacity of the instrument, the helical and rake angle, metallurgical properties, and also surface treatment of the instrument (Lam, et al., 1999). In the study conducted by Saber, et al. (2015) a smaller cutting capacity of the HyFlex CM instrument was also observed when compared to ProTaper NEXT. This can be attributed to the conicity difference between the instruments on these two systems (4% and 7% HyFlex CM and ProTaper NEXT). According to Shabalovckaya and Anderegg (1995), the sterilization process by autoclaving causes changes in the concentrations of nickel and titanium and a decrease on the cutting properties of endodontic instruments. In the present

study, we observed a decrease in cutting efficiency on the fifth use of the all three rotary systems tested when compared to the first and second use. Rapisarda, et al. (1999) found a decrease of 20% in the cutting efficiency of the instruments when subjected to seven cycles of sterilizations and 50% when subjected to 14 cycles. When instruments are subjected to a large number of sterilization cycles, they have large amounts of titanium oxide on its surface and therefore show a decrease in cutting efficiency. However, a study from Seago, et al. (2015) observed no effect in reducing the cutting efficiency of the HyFlex CM instruments after 10 consecutive sterilization processes, as well as Borin, et al. (2008) with ProTaper Universal instruments and Becker, et al. (2009) when using ProTaper Universal and K3 systems for the preparation of five simulated canals. Regarding the second purpose of the study — the analysis of apical deviation after the completion of the canal preparation

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OUTSTANDING SEALING PROPERTIES Resin-free - Made from pure calcium silicate and is monomer-free ensuring zero shrinkage1 Pure mineral formulation - will not stain2 Hydrophilic - Continues the sealing process in the presence of moisture High alkaline pH Strong Seal - Void-free, tight interface with outstanding adhesion to dentin3 and gutta percha points 1. K. Bentley, S. Janyavula, D. Cakir, P. Beck, L.C. Ramp, J.O. Burgess. "Mechanical and Physical Properties of Vital Pulp Materials". School of Dentistry, University of Alabama at Birmingham, Birmingham, AL.2. Data on file. 3. A. Atmeh, F. Festy, A. Banerjee, F. Mannocci, T. F. Watson. "Mineral Interaction Zone; A Chemo-morphological Chracterization of The Dentine-Biodentine Interface". 2012. King's College London Dental Institute, Biomaterials, Biomimetrics and Biophotonics, London, UK.

Volume 9 Number 4

Endodontic practice 9

CLINICAL

Elnaghy and Elsaka (2014) and Bürklein, et al. (2015). The simulated canals were prepared having the final instrument of the apical preparation diameter of approximately .30 in all of the three systems tested, as well as the study of Read, et al. (2015). According to Schäfer and Dammaschke (2006), in clinical conditions, performing slightly longer preparation could result in accidents within the canal and undesirable weakening of the tooth structure. On the other hand, preparations with smaller diameter instruments can leave tissue debris and contaminated material within the canal, thus perpetuating the process of endodontic infections. To verify cutting efficiency, the method used was initial weight versus final weight of the simulated canal in an analytical balance, due to its highly reliable means, safety, and easy applicability, according to Haikel, et al. (1996). By analyzing the results, it was verified that the cutting efficiency of ProTaper

CLINICAL — an image-overlapping methodology was employed, using before and after images of the instrumented simulated canal. In studies such as Limongi, et al. (2004) and Javaheri and Javaheri (2007) the same methodology for this type of analysis was also used. The definition of the analyzed area in the apical third of the canal, 1 mm from WL, is due to the fact that is the place where deviations normally occur. And the middle of the curvature (3 mm from the WL) is explained by the higher tensile and compression load that the instrument suffers inside a curved root canal. Although we observed a greater deviation at 3 mm from WL using HyFlex CM instruments, the original path of the curvature on the simulated canal at the 1 mm from the WL remained the same. Studies such as Kumar, et al. (2013), Zhao, et al. (2013), Thompson, et al. (2014), and Bürklein, et al. (2014) also achieved the same results with the use of HyFlex CM instruments. Saber, et al. (2015) observed that both the HyFlex CM system and ProTaper Next respected dental anatomy during instrumentation of the root canal. In this study, ProTaper Universal and ProTaper NEXT instruments also respected the simulated canal anatomy. This finding was also observed by Gagliardi, et al. (2015), although Zhao, et al. (2014) and Silva, et al. (2016) have obtained in their studies a greater tendency to deviations with ProTaper Universal instruments than with ProTaper NEXT.

Conclusions According to the results, the following observations can be made. • The cutting capacity of ProTaper Universal and ProTaper NEXT instruments was higher than the HyFlex CM. • The cutting efficiency of the three rotary systems was lower for the fifth use of instruments than it was for the first and second use. • Only the HyFlex CM instruments showed some deviation at 3 mm from the WL when compared to the ProTaper Universal and ProTaper NEXT systems. • None of the three rotary systems tested showed significant deviation at 1 mm from WL. EP

The cutting efficiency and flexibility are important mechanical properties to maintain because they affect the ability of the practitioner to safely shape the root canal system.

REFERENCES 1. Al-Sudani D. Topographic Analysis of HyFlex(®) Controlled Memory Nickel Titanium Files. J Int Oral Health. 2014;6(6):1-4. 2. Alapati SB, Brantley WA, Iijima M, Clark WA, Kovarik L, Buie C, Liu J, Bem Johnson W. Metallurgical characterization of a new nickel-titanium wire for rotary endodontic instruments. J Endod. 2009;35(11):1589-1593. 3. Becker AN, Borin G, Oliveira EPM, Melo TAF, Echeveste SS. Effect of the sterilization on the cutting efficiency of ProTaper® and K3® endodontic instruments. RGO. 2009;57(4):389-393. 4. Borin G, Becker AN, Oliveira EPM, Melo TAF, Echeveste SS. Influence of the sterilization on the cut capacity of rotatory endodontics instruments ProTaper®. Rev Odontol Univ São Paulo. 2008;20(1):14-18. 5. Braga LC, Faria Silva AC, Buono VT, de Azevedo Bahia MG. Impact of heat treatments on the fatigue resistance of different rotary nickel-titanium instruments. J Endod. 2014;40(9):1494-1497. 6. Bürklein S, Börjes L, Schäfer E. Comparison of preparation of curved root canals with Hyflex CM and Revo-S rotary nickel-titanium instruments. Int Endod J. 2014;47(5):470-476. 7. Bürklein S, Mathey D, Schäfer E. Shaping ability of ProTaper NEXT and BT-RaCe nickel-titanium instruments in severely curved root canals. Int Endod J. 2015;48(8):774-781. 8. Capar ID, Arslan H, Akcay M, Ertas H. An in vitro comparison of apically extruded debris and instrumentation times with ProTaperUniversal, ProTaper Next, Twisted File Adaptive, and HyFlex instruments. J Endod. 2014a;40(10):1638-41. 9. Capar ID, Arslan H, Akcay M, Uysal B. Effects of ProTaper Universal, ProTaper Next, and HyFlex instruments on crack formation in dentin. J Endod. 2014b;40(9):1482-1484. 10. Capar ID, Ertas H, Arslan H. Comparison of cyclic fatigue resistance of nickel-titanium coronal flaring instruments. J Endod. 2014c;40(8):1182-1185. 11. Capar ID, Ertas H, Ok E, Arslan H, Ertas ET. Comparative study of different novel nickel-titanium rotary systems for root canal preparation in severely curved root canals. J Endod. 2014d;40(6):852-856. 12. Deepak J, Ashish M, Patil N, Kadam N, Yadav V, Jagdale H. Shaping ability of 5(th) generation Ni-Ti rotary systems for root canal preparation in curved root anals using CBCT: an in vitro study. J Int Oral Health. 2015;7(Suppl 1):57-61. 13. Elemam RF, Capelas JA, Vaz MA, Viriato N, Pereira ML, Azevedo A, West J. Evaluating transportation by com paring several uses of rotary endodontic files. J Contemp Dent Pract. 2015;16(12):927-932. 14. Elnaghy AM, Elsaka SE. Evaluation of root canal transportation, centering ratio, and remaining dentin thickness associated with ProTaper Next instruments with and without glide path. J Endod. 2014;40(12):2053-2056. 15. Gagliardi J, Versiani MA, de Sousa-Neto MD, PlazasGarzon A, Basrani B. Evaluation of the Shaping Characteristics of ProTaper Gold, ProTaper NEXT, and ProTaperUniversal in Curved Canals. J Endod. 2015;41(10):1718-1724. 16. Gambarini G, Plotino G, Grande NM, Al-Sudani D, De Luca M, Testarelli L. Mechanical properties of nickel-titanium rotary instruments produced with a new manufacturing technique. Int Endod J. 2011;44(4):337-341. 17. Haikel Y, Serfaty R, Lwin TTC, Alleman C. Measurement of the cutting efficiency of endodontic instruments: a new concept. J Endod. 1996;22(12):651-661. 18. Javaheri HH, Javaheri GH. A comparison of three Ni-Ti rotary instruments in apical transportation. J Endod. 2007;33(3):284-286.

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19. Koçak MM, Çiçek E, Koçak S, Sağlam BC, Furuncuoğlu F. Comparison of ProTaper Next and HyFlex instruments on apical debris extrusion in curved canals. Int Endod J. In press. 20. Kumar BS, Pattanshetty S, Prasad M, Soni S, Pattanshetty KS, Prasad S. An in vitro Evaluation of canal transportation and centering ability of two rotary Nickel Titanium systems (Twisted Files and Hyflex files)with conventional stainless Steel hand K-flexofiles by using Spiral ComputedTomography. J Int Oral Health. 2013;5(5):108-115. 21. Lam TV, Lewis DJ, Atkins DR, Macfarlane RH, Clarkson RM, Whitehead MG, Brockhurst PJ, Moule AJ. Changes in root canal morphology in simulated curved canals overinstrumented with a variety of stainless steel and nickel titanium files. Aust Dent J. 1999;44(1):12-19. 22. Limongi O, Klymus AO, Baratto-Filho F, Vanni JR, Travassos R. In vitro evaluation of the presence of apical deviation with employment of automated handpieces with continuous and alternate motion for root canal preparation. J Appl Oral Sci. 2004;12(3):195-199. 23. Ninan E, Berzins DW. Torsion and bending properties of shape memory and superelastic nickel-titanium rotary instruments. J Endod. 2013;39(1):101-104. 24. Rapisarda E, Bonaccorso A, Tripi TR, Fragalk I, Condorelli GG. Effect of sterilization on the cutting efficiency of rotary nickel-titanium endodontic files. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88(3):343-347. 25. Saber SE, Nagy MM, Schäfer E. Comparative evaluation of the shaping ability of ProTaper Next, iRaCe and Hyflex CM rotary NiTi files in severely curved root canals. Int Endod J. 2015;48(2):131-136. 26. Schäfer E, Dammaschke T. Development and sequelae of canal transportation. Endodontic Topics. 2006;15:75-90. 27. Schäfer E, Oitzinger M. Cutting efficiency of five different types of rotary nickel-titanium instruments. J Endod. 2008;34(2):198-200. 28. Seago ST, Bergeron BE, Kirkpatrick TC, Roberts MD, Roberts HW, Himel VT, Sabey KA. Effect of repeated simulated clinical use and sterilization on the cutting efficiency and flexibility of Hyflex CM nickel-titanium rotary files. J Endod. 2015;41(5):725-728. 29. Shabalovskaya SA, Anderegg JW. Surface spectroscopic characterization of TiNi nearly equitamic shape memory alloys for implant. J Vac Scie Technol. 1995;13:2624-2632. 30. Silva EJ, Vieira VC, Tameirão MD, Belladonna FG, Neves Ade A, Souza EM, DE-Deus G. Quantitative transportation assessment in curved canals prepared with an off-centered rectangular design system. Braz Oral Res. 2016;30(1):e43. 31. Thompson M, Sidow SJ, Lindsey K, Chuang A, McPherson JC 3rd. Evaluation of a new filing system’s ability to maintain canal morphology. J Endod. 2014;40(6):867-870. 32. Uznoglu E, Turker SA. Comparison of canal transportation, centering ratio by cone beam computed tomography after preparation with different file Systems. J Contemp Dent Pract. 2015;16(5):360-365. 33. Zhao D, Shen Y, Peng B, Haapasalo M. Micro-computed tomography evaluation of the preparation of mesiobuccal root canals in maxillary first molars with HyFlex® CM, twisted files, and K3 instruments. J Endod. 2013;39(3):385-388. 34. Zhao D, Shen Y, Peng B, Haapasalo M. Root canal preparation of mandibular molars with 3 nickel-titanium rotary instruments: a micro-computed tomographic study. J Endod. 2014;40(11):1860-4. 35. Zinelis S, Eliades T, Eliades G. A metallurgical characterization of ten endodontic Ni-Ti instruments: assessing the clinical relevance of shape memory and superelastic properties of Ni-Ti endodontic instruments. Int Endod J. 2010;43(2):125-34.

Volume 9 Number 4

What our new name means for better endodontics â&#x20AC;&#x201C; and you. DENTSPLY Tulsa Dental Specialties is now Dentsply Sirona Endodontics. The endodontic brands and local support you trust are now backed by the largest R&D and clinical education platforms in all of dentistry. For better, safer, faster endodontics, call 1-800-662-1202 or visit dentsply.com or endomatters.dental

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ADDSA1 REV.0 09/16

FINANCIAL FOCUS

Is your 401(k) plan a ticking time bomb of personal and professional liability? Tom Zgainer discusses how small business owners may be overlooking a significant source of liability in their practices: their 401(k) plans

lass-action lawyers seeking plaintiffs are reaching out to employees in businesses of all kinds with opportunistic letters that highlight how they have been harmed by excessive fees in their 401(k) plans. These letters encourage plan participants to join lawsuits against their employers for breach of their fiduciary obligation to provide a retirement plan that is set up for the sole benefit of the employees. While you are busy running your practice and offering a 401(k) as a benefit for your team, a recent ruling by the Supreme Court has officially started the clock on this ticking time bomb. Larger employers in a variety of industries are already under attack, and many others have paid to settle such suits. Smaller companies (under 100 employees), where excessive fees are most prevalent, are now also in litigation. Employee Benefit Advisor, an industry trade publication, recently prophesied that Tom Zgainer is CEO and founder of America’s Best 401k and has helped thousands of companies repair or rescue their retirement plans over the past 15 years. You can learn more at http://americasbest401k.com/feechecker-medmark.

12 Endodontic practice

an “onset of 401(k) lawsuits should prompt rigorous plan evaluations.” The 401(k) is a great piece of tax code, but the problem lies in the method by which 401(k) plans are sold — and the surprising number of hands in the retirement plan pie. Over the past 3 decades, 401(k) plan providers have been making big money through hidden or opaque fee arrangements. In fact, it took a full 30 years before the industry was required to disclose just how much they make on your plan! Only since 2012 are they now required to produce a fee disclosure document (known as a 408b2), that plan sponsors are required to review, articulate, and take action if necessary, yet the actual fees are often buried in fine print. This is why over 60% of Americans think they pay no 401(k) fees when nothing could

be further from the truth. So just how do plan providers make their money? Primarily by taking a cut of the fees charged by the mutual funds offered in the 401(k) plans they sell. And those fees directly subtract from your returns. Or if that’s not enough to wet their beaks, they layer on additional fees such as “asset management charges” or “contact asset charges.” And so we have a business model where nearly all the major plan providers are conflicted. They choose funds for your plan that charge hefty fees so that there is plenty to go around (or worse, they just sell you their own name-brand funds, which are more profitable for them). Did you think the funds were chosen because they were the best performing? Think again. They were probably chosen because the fund company will “pay to play”— which is why superior-performing, low-cost index funds tend to be a rarity in 401(k) plans. But it doesn’t stop there. The broker who sold the plan wants his cut. So he too will receive commissions from the funds or simply layer on additional fees. And let’s not forget the third-party administrator. They typically charge a fee directly to the employer, Volume 9 Number 4

Do fees really matter? Although the fees your plan charges might sound like small percentages, they have a massive impact over time. Fees subtract directly from your returns. John Bogle, founder of Vanguard, says that costs can cut returns by 66% over the course of our saving years. Said another way, simply controlling costs could double your future nest egg in size. The Department of Labor (DOL) says that hidden fees and backdoor payments in retirement plans are costing Americans over $17 billion annually. The head of the DOL, Secretary Thomas Perez, rightly stated, “The corrosive power of fine print and buried fees can eat away like a chronic illness at a person’s savings.”

It’s your problem At first glance, you might be thinking these issues and conflicts should be the

liability of the provider. After all, they sold you the plan. But ERISA rules make you, the employer, the fiduciary to the plan and to your employees. As the plan sponsor, it’s your job to make sure the plan is set up for the sole benefit of the employees. It’s your job to review and periodically benchmark your plan against other options. For many employers, this is alarming news, as running a business is already challenging enough. So where do you go from here? There are five key steps we advise all plan sponsors to take: 1. Benchmark your plan to determine how it compares to alternatives. A periodic benchmark is required by the DOL anyway, so it’s an exercise that can reap great rewards while also taking care of your duty as a plan sponsor. Beware that if you use a broker to do this, they will typically show other similar plan options where they will also make big commissions. As Warren Buffet says, “Never ask a barber if you need a haircut.” 2. Eliminate layers of fees wherever possible. The first and easiest way is to eliminate the use of a broker who is paid by commission. Brokers typically add little ongoing value short of

Costs can cut returns by 66% over the course of our saving years. Said another way, simply controlling costs could double your future nest egg in size.

bringing donuts to your office twice a year to keep everyone happy. Many employers were sold their plans by brokers who may also be personal friends. Breaking up is hard to do, but a personal relationship is not a defensible position with the Department of Labor. 3. Remove conflicts of interest. If you are using a plan where the provider is being paid by the mutual funds in the plan, they have an inherent bias to select more expensive funds or sell you their own name-brand proprietary funds. This is nearly always the case with plans offered by insurance companies, payroll companies, or mutual fund companies. You can simply ask your provider if they are “revenue sharing” with the mutual funds they offer. 4. Install a third-party fiduciary on your behalf. This is known as a 3(38) fiduciary, who will take over nearly all of the responsibilities and much of the liability of the plan sponsor. Their job is to make sure that the plan is continually operated in the best interests of the plan participants. This is a best practice adopted at many Fortune 500 companies but is rarely seen in small to midsize plans. 5. Look for a plan that has access to the lowest-cost index funds. Index funds consistently outperform nearly all actively managed mutual funds over the long term. One note of caution: Many providers don’t make money off these funds due to their rock-bottom fees, so they sometimes charge additional layers of fees, or they will say your plan isn’t big enough to qualify. Nonsense! Every 401(k) participant in America should have access to the same low-cost funds regardless of the balance in their company’s 401(k) plan. The 401(k) is an amazing retirement solution when there is alignment between the provider and the saver. It’s time that Americans wake up and take back their retirement plans from the providers that have been milking them for every dime they can get. It’s time for business owners to feel proud of the plans they offer, knowing that they will give themselves and their employees the absolute best chance at a successful retirement. EP

Check to see how your 401(k) plan compares to industry averages here: http://americasbest401k.com/fee-checker-medmark. Volume 9 Number 4

Endodontic practice 13

FINANCIAL FOCUS

but many will also accept a portion of the mutual fund fees. This often buys their loyalty to specific providers. The net result is an industry with layers upon layers of incestuous relationships that funnel excessive fees from your plan and puts numerous conflicts of interest in play — hence the lawsuits.

TECHNOLOGY INSIGHT

Laser-enhanced endodontic treatment Dr. Gregori M. Kurtzman discusses the benefits of laser implementation

ndodontic success is predicated on the ability to debride and clean the canal system. That canal system is a complex array of accessory and lateral canals, fins, and other anatomical areas inaccessible to endodontic files (Figure 1). As practitioners, we are able to clean the main canals with files, either hand or rotary, but cannot mechanically remove pulpal tissue and debris from the canal anatomy adjacent to the main canals. Treatment success requires elimination of the pulpal tissue and associated bacteria from this anatomy so that it can be sealed during the obturation phase of treatment. As only one thing can occupy a space at a time, obturation material cannot fill areas still occupied by pulpal tissue. Success is dependent on disinfection and debridement of the canal system so that it may be sealed during obturation. Irrigation has long been accepted as a key factor of treatment to achieve those goals. Yet complete clearing of residual bacteria, especially in the apical portion of the canal system, has been difficult to achieve with traditional methods using even sodium hypochlorite (NaOCL) solutions (Figure 2). Studies have demonstrated that addition of an Er:YAG laser to activate the irrigation solution greatly enhances not only greatly enhances the efficiency of the irrigation solutions advocated (NaOCL and EDTA,) but also improves disinfection of the canal system, clearing accessory so that it may be sealed during obturation (Figures 3-4).

Gregori M. Kurtzman, DDS, MAGD, DICOI, DADIA, is in private general practice in Silver Spring, Maryland, and is a former Assistant Clinical Professor at University of Maryland and a former AAID Implant MaxiCourses® assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of restorative dentistry, endodontics, and implant surgery and prosthetics, removable and fixed prosthetics, and periodontics and has over 510 published articles. He has earned Fellowship in the AGD, AAIP, ACD, ICOI, Pierre Fauchard, ADI; Mastership in the AGD and ICOI; and Diplomate status in the ICOI and American Dental Implant Association (ADIA). Dr. Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006 and was featured on their June 2012 cover. He can be reached at dr_kurtzman@maryland-implants.com.

14 Endodontic practice

Figure 2: SEM showing bacteria and pulpal debris in the apical one-third that was not removed fully using standard irrigation protocol (Courtesy of Prof. Georgi Tomov, Plovdiv, Bulgaria)

Figure 1: Anatomy of the canal system demonstrating accessory canals, fins, and lateral canals that are not accessible with endodontic files as shown in cleared teeth

Irrigation: the key to endodontic success Although instrumentation with files is important to enlarging the canals and readies them to be obturated, debris consisting of pulpal tissue and associated bacteria is not effectively removed by files. Irrigation with an appropriate solution is required to remove that debris from the canal walls. NaOCL is still the accepted irrigant due to its tissuedissolving ability and antibacterial nature. Yet it cannot effectively reach far beyond the main canals to remove the residual tissue. Tissue dissolution can be enhanced to more effectively remove pulpal tissue/bacteria and also reach further into the accessory anatomy to allow better sealing of the canal system improving treatment success. Smear layer within the canal system plays a factor in success of endodontic treatment. The smear layer contains bacteria, which when left within the canal anatomy may lead to reoccurrence of infection endodontically. When compared to traditional irrigation methods, laser-enhanced irrigation has demonstrated better intracanal smear layer

Figure 3: SEM showing complete removal of bacteria and pulpal tissue in the apical one-third after irrigation using the LT-IPI™ protocol (Courtesy Prof. Georgi Tomov, Plovdiv, Bulgaria)

Figure 4: SEM cross section showing complete removal of bacteria and pulpal tissue in the apical one-third after irrigation using the LT-IPI™ protocol leaving dentin tubules open (Courtesy Prof. Georgi Tomov, Plovdiv, Bulgaria)

removal.1 As Enterococcus faecalis has been routinely linked to endodontic failures and is a common occupant of the oral cavity, elimination of this bacteria is critical to prevention of reinfection of the canal system. NaOCL as an irrigant has not shown to be effective in elimination of E. faecalis, yet when combined Volume 9 Number 4

Laser-enhanced irrigation Laser energy has been documented to enhance the known effects of NaOCL irrigation through both heating the solution within the canal system and its distant antibacterial effects. But not all laser wavelengths have demonstrated to be equal in effectiveness. The best effects are when NaOCL is combined with an Er:YAG laser as compared to NaOCL alone or when utilized with other type lasers.3 Antibacterial effects were reported to be the best with this combination of irrigant and laser.4 The higher wavelength of the Er:YAG compared to the Nd:YAG or diode was more effective in smear layer removal, hence better at bacterial elimination within the canal system.5 Utilization of a EDTA as an irrigant alternated with NaOCL provides the best debridement of the canal system with enhancement with a Er:YAG laser, as these two solutions have a synergistic effect complementing each other’s effects in the canal anatomy.6 Additionally, the Er:YAG laser (LiteTouch™, distributed in USA by AMD LASERS, Indianapolis, Indiana) creates hydrodynamic pressure following cavitation bubble expansion and collapse when the irrigation solution is activated in the chamber.7-9 Placement of the laser tip does not require entry into the canals to achieve the desired effects, and activation of the irrigation solution in the chamber is sufficient to affect the entire canal system. The LiteTouch™ Er:YAG laser energy is set at a subablative power level that allows its use without structural changes to the hard tissue within the tooth. This eliminates the risks of ledging and perforation of the pulpal floor, allowing safe usage within the tooth. When the Er:YAG laser is activated, a heat pulse is generated by the laser radiation delivered via a sapphire tip into an absorbing liquid (irrigant). This results in tensile stress with cavitation being induced in the liquid in front of the sapphire tip at a distance far below the optical penetration depth of the laser radiation. Bubble expansion and collapse cause the surrounding fluid to flow at a speed of up to 12 m/s traveling throughout the canal system. This causes rapid displacement of intracanal fluid via radial and longitudinal pressures sufficient to drive irrigant into the canal anatomy and clean the dentinal tubules significantly. This photomechanical activation of the irrigant Volume 9 Number 4

Figure 5: LiteTouch™-Induced Photomechanical Irrigation protocol (LT-IPI™): 5A. Establishment of glide path with hand files. 5B. Canal and chamber filled with NaOCL. 5C. Placement of the LiteTouch™ tip into the irrigant in the chamber and activation of the Er:YAG laser (Illustrations courtesy of Dr. Parvan Voynov, Plovdiv, Bulgaria)

Laser energy has been documented to enhance the known effects of NaOCL irrigation through both heating the solution within the canal system and its distant antibacterial effects. But not all laser wavelengths have demonstrated to be equal in effectiveness. includes a temperature rise in the irrigant increasing its effectiveness in debridement of dentinal walls and its tubules and increases the chemical properties of the irrigants.

LiteTouch™-Induced Photomechanical Irrigation (LT-IPI ™) Endodontic treatment is initiated with access to the pulp chamber, which may be performed by traditional methods using burs or by ablation of the enamel and dentin with the LiteTouch™ Er:YAG laser. As the laser is ineffective in removal of ceramics and metals, such as those used in fixed prosthetics and also amalgam, carbides and diamonds are needed create access through these materials. Once dentin has been reached, the laser may be utilized to unroof the pulp chamber (hard tissue mode). An additional benefit of the Er:YAG laser to access the pulp chamber is that it provides decontamination and removal of bacterial debris and pulpal tissue to yield a cleaner chamber aiding its identification of the canal orifices (soft tissue mode). Once the canal orifices are identified, hand files are utilized to establish a glide path to the apical working length in each canal. Canals are then enlarged to the desired ISO canal size with either hand or rotary

files (Figure 5A). Laser-assisted canal irrigation requires canal preparation to an apical preparation ISO 25/30 at a minimum. A canal taper of 0.04 or 0.06 for the final instrumentation is recommended. Sodium hypochlorite (NaOCL) is utilized within the chamber and canals during instrumentation both as a pulpal tissue dissolvent and to lubricate the files within the canal, decreasing the potential of file separation that can occur when instrumenting a dry canal (Figure 5B). Photo-activation of the irrigant within the canal system is performed using the Er:YAG laser with a 0.4/17 or 0.6/17mm tip that assists in removal of the debris created by the files. Between each rotary file, the chamber is filled with NaOCL, and the tip of the laser is placed into the chamber and the solution activated with the laser at 40mJ at 10Hz with an average power of only 0.5W for 20 seconds (Figure 5C). The chamber is suctioned, and fresh NaOCL is placed into the tooth, and the next file is used for instrumentation. It is unnecessary to place the laser’s tip into the canals themselves, as activation of the solution within the chamber transmits down the irrigant into the canals to the apical aspect of the roots. Laser activation may also be performed with 17% EDTA solution alternated with NaOCL. The benefit of EDTA Endodontic practice 15

TECHNOLOGY INSIGHT

with laser-enhanced irrigation with NaOCL, this bacteria has been eliminated in the canal anatomy.2

TECHNOLOGY INSIGHT

Figure 6: Accessory anatomy evident in the apical that has been filled with sealer accessible due to use of the LiteTouch™ Er:YAG laser (Photo courtesy of Dr. David Guex, Lyon, France)

solution is its chelation effect opening canal anatomy so that the next round of NaOCL can reach more pulpal tissue not accessible to the files in fins, as well as accessory and lateral canals. Following final instrumentation of the canals with rotary files, the chamber is filled with NaOCL, and the Er:YAG tip is placed into the chamber again and activated for a minimum of 60 seconds. This allows the photo-activated irrigant to clear debris and remaining pulpal tissue from the complete canal system. The irrigation solution is suctioned from the chamber and fresh irrigant placed and photo-activation repeated until no visible debris (cloudiness) is noted in the chamber fluid. This indicated that all accessible debris has been removed from the canal system. Any remaining solution is suctioned from the tooth, and the canals are dried with paper points. Obturation is then accomplished using the practitioner’s preferred method and materials allowing obturation of anatomy inaccessible by instrumentation with files (Figures 6-7). 16 Endodontic practice

Figure 7: Accessory apical anatomy filled with sealer due to use of the LiteTouch™ Er:YAG laser (Photo courtesy of Prof. Georgi Tomov, Plovdiv, Bulgaria)

Conclusion The key to endodontic success is two pronged, cleaning the system and sealing it. Although rotary files have improved the efficiency of instrumentation, they are unable to reach any more of the anatomy than hand files are able to reach. Cleaning of the canal system is keyed to irrigation of the canal system to improve debris removal in anatomy that the files are unable to contact. When anatomy is not fully cleaned, sealer is unable to fill this, leaving bacteria to inhabit those areas that may lead to endodontic failure over time. Laser-enhanced activation of endodontic irrigants cleans more anatomy adjacent to the main canals so that a more complete obturation of the canal system can occur. An added benefit is that the laser has an antibacterial effect, killing bacteria within the canal anatomy as well as distant to where the irrigation solution may reach essentially sterilizing the entire tooth to the periodontal ligament. EP

REFERENCES: 1. Takeda FH, Harashima T, Kimura Y, Matsumoto K. A comparative study of the removal of smear layer by three endodontic irrigants and two types of laser. Int Endod J. 1999;Jan;32(1):32-39. 2. Meire MA, Coenye T, Nelis HJ, De Moor RJ. Evaluation of Nd:YAG and Er:YAG irradiation, antibacterial photodynamic therapy and sodium hypochlorite treatment on Enterococcus faecalis biofilms. Int Endod J. 2012 May;45(5):482491. Epub 2012 Jan 14. 3. Asnaashari M, Safavi N. Disinfection of Contaminated Canals by Different Laser Wavelengths, while Performing Root Canal Therapy. J Lasers Med Sci. 2013 Winter;4(1):8-16. 4. Cheng X, Guan S, Lu H, Zhao C, Chen X, Li N, Bai Q, Tian Y, Yu Q. Evaluation of the bactericidal effect of Nd:YAG, Er:YAG, Er,Cr:YSGG laser radiation, and antimicrobial photodynamic therapy (aPDT) in experimentally infected root canals. Lasers Surg Med. 2012 Dec;44(10):824-31. Epub 2012 Nov 20. 5. Guidotti R, Merigo E, Fornaini C, Rocca JP, Medioni E, Vescovi P. Er:YAG 2,940-nm laser fiber in endodontic treatment: a help in removing smear layer. Lasers Med Sci. 2014 Jan;29(1):69-75. Epub 2012 Dec 5. 6. DiVito E, Peters OA, Olivi G. Effectiveness of the erbium:YAG laser and new design radial and stripped tips in removing the smear layer after root canal instrumentation. Lasers Med Sci. 2012 Mar;27(2):273-280. Epub 2010 Dec 1. 7. Koch JD, Jaramillo DE, DiVito E, Peters OA. Irrigant flow during photon-induced photoacoustic streaming (PIPS) using Particle Image Velocimetry (PIV). Clin Oral Investig. 2016 Mar;20(2):381-386. Epub 2015 Aug 26. 8. DiVito E, Lloyd A. ER:YAG laser for 3-dimensional debridement of canal systems: use of photon-induced photoacoustic streaming. Dent Today. 2012 Nov;31(11):122, 124-127. 9. Olivi G, DiVito E, Peters O, Kaitsas V, Angiero F, Signore A, Benedicenti S. Disinfection efficacy of photon-induced photoacoustic streaming on root canals infected with Enterococcus faecalis: an ex vivo study. J Am Dent Assoc. 2014 Aug;145(8):843-848.

Volume 9 Number 4

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CONTINUING EDUCATION

The management of avulsion and dental trauma Dr. Meera Patel discusses the immediate and long-term management of an avulsed upper central incisor

vulsion is defined as the complete displacement of a tooth from its socket in alveolar bone owing to trauma (Andreasen, et al., 2003) and is one of the most serious of all dental injuries. Avulsion of a permanent tooth is estimated to represent 0.5% to 16% of all dental injuries (Andreasen, Andreasen, Andersson, 2007). It occurs most frequently between the ages of 7 to 14 years, affecting the maxillary central incisors (Trope, 2011). Andreasen, et al. (2003), found that in the permanent dentition, peak incidences for boys are found to be at 9 to 10 years, when energetic playing and sporting activities become more popular (Figure 2) — a scenario similar to what the author has been presented with.

Educational aims and objectives

This clinical article aims to discuss the immediate and long-term management of a 10-year-old with an avulsed upper central incisor.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 25 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the protocols for the immediate and long-term management of an avulsed tooth using support from the literature. • Determine pulp and periodontal ligament (PDL) factors that affect the prognosis of the avulsed tooth. • Identify some storage options to facilitate root resorption and pulpal healing. • Recognize the effect of apical maturity on the avulsed tooth. • View some guidelines from various sources for the management of avulsed teeth.

Case presentation This article aims to discuss the immediate management of a 10-year-old who had knocked out his upper central incisor 45 minutes before attending the dental surgery. In order for the author to determine the best course of treatment for this case, it is very important to elicit careful medical, dental, and accident history. The author would use the clinical records, which allows the recording of clinical and historical data associated with the injury, ensuring no pertinent information has been missed (Andreasen, et al., 2003). Another important reason for good dental records in trauma cases is the possibility of legal action on the part of the parent, guardian, or patient. Several options exist for managing this case (Figure 5). The simplest long-term solution is to replant it. In 1980, Andreasen

Meera Patel, BDS, MFGDP, RCS, qualified from Barts and the Royal London in 2003 and is currently in her final year of her MSc in endodontics. She has worked on Harley Street and gained distinction in dental public health; psychological, ethical, and legal aspects of dentistry; adult oral health; and child dental health. Dr. Patel has worked in a number of dental practices in England and Scotland. She is also the author of a dental textbook, Dental Public Health: A Primer, published in 2007. Later that same year, she organized a successful smoking cessation in Edinburgh, which targeted 40,000 people from all walks of life. She was highly commended as Best Young Dentist in Scotland at the 2007 Dentistry Awards.

20 Endodontic practice

Figure 1A: Loss of tooth (Source: Dental Trauma Guide, 2010)

found that in monkeys, under ideal conditions, complete healing of the pulp and periodontal ligament (PDL) of replanted teeth can occur. However, the success of replantation depends on appreciating and working with the human biological processes. Table 1 illustrates the factors that need to be considered in optimum patient management. The author will consider each of these factors in order to determine how best to treat this 10-year-old boy. The aims of this treatment are to re-establish normal tooth

Figure 1B: Empty socket appearance (Source: Dental Trauma Guide, 2010)

Figure 1C: Radiographic image (Source: Dental Trauma Guide, 2010)

position (esthetically pleasing tooth form, color, and gingival contour) and tooth function (able to incise food without pain and mobility). Tooth factors The health of the pulp and periodontal ligament (PDL) are the key tissues that affect the prognosis of the avulsed tooth (Andreasen, et al., 2003). PDL cells are critical in allowing the tooth to reattach back into the socket. When there is too much damage

Table 1: Factors affecting management Tooth factors

Patient factors

Extra-alveolar time: 45 minutes

Age: 10 years

Storage media: Dry

Gender: Male

Apical maturity: Assumption: Open apex

Medical history: Assumption: Fit and well

Caries/Periodontal disease: Assumption: Healthy

Attendance: Assumption: Good

Alveolar socket: Assumption: Intact

Other injuries: Assumption: Nil

Volume 9 Number 4

Figure 3: Pulpal and PDL healing related to dry extra-alveolar period (Andreasen, et al., 2003) (Source: Dental Trauma Guide, 2010)

Figure 4: Tooth survival after replantation (Source: Dental Trauma Guide, 2010)

to the ligament, healing occurs by bony replacement, and the tooth is replaced by bone and lost over a few years. This is known as “bony healing”/ankylosis/replacement resorption (RR) (Andreasen, 2007). Pulpal cells help fight against infection, necrosis, and, in turn, prevent inflammatory resorption (Andreasen, et al., 2003). Immediately after avulsion, both pulpal and PDL cells begin to suffer ischemic injury, which can be worsened by drying, bacteria, and chemical irritants. These factors cause the loss of vitality to these PDL cells and dehydration to the pulpal cells, which are invaluable for tooth survival (Andreasen, et al., 2003; Barrett, Kenny, 1997; Gregg, Boyd, 1998; Andreasen, et al., 1995). Figure 3 illustrates that as the dry extra-alveolar time is increased, both the pulp and PDL healing is reduced. Numerous studies by Andreasen, et al., in 1995 have shown the treatment outcome is strongly dependent upon: • Extra-alveolar time • Storage media Andreasen, et al. (1995), demonstrated in a clinical study that immediate replantation (within 5 minutes) was one of the most critical factors necessary for PDL regeneration and return to normal function. Andersson and Bodin (1990) discovered that teeth replanted within 15 minutes have a favorable long-term prognosis, and most teeth replanted within 10 minutes experienced no resorption. More recently, it has been found that dry storage of greater than 15 minutes causes precursor cells on the root side of the PDL to fail to reproduce and differentiate into fibroblasts (Kenny, Barrett, Casas, 2003). Even if the avulsed tooth is then placed in a liquid medium prior to replantation, this results in the unfavorable “repair” as opposed to the favorable “regeneration” and leads to ankylosis, root resorption, and eventual tooth loss (Donaldson, Kinirons, 2001). Thus, ideally, replantation at the site of the injury leads to the best long-term prognosis. Hence, education or information of dental trauma care among teachers, coaches,

caregivers, parents, medical personnel and, above all, dentists, is essential. A study in 2001 by Blakytny, et al., showed the reasons for reluctance in replantation among teachers, coaches, and caregivers were the following: • Inadequate training • Reluctant to induce pain/fear in child • Fear of blood-borne infection • Fear of incorrect replacement • Fear of legal consequences

• Bioactive substances (enamel matrix derivative, Straumann® Emdogain™): Facilitates PDL regeneration. Further research required. Tap water is an unsatisfactory medium, as it ruptures PDL cells through osmosis (DPB, 1999).

Volume 9 Number 4

Storage medium The storage medium prior to replantation has a great effect on root resorption and pulpal healing. The author is presented with 45 minutes dry extra-alveolar time. Hence, during history taking and examination, if the avulsed tooth is not in a wet medium, the author would immediately place the tooth in fresh milk packed in ice to prevent further drying. The tooth would be carefully handled to avoid further PDL damage. Complications such as root resorption are a great danger to tooth prognosis with an occurrence of 50% to 76% when the clinical conditions are far from ideal (Andreasen, et al., 1995). Other mediums the author could consider follow: • Patient’s own saliva: In the author’s opinion, each case should be individually assessed. Risk of aspiration/swallowing should be taken into consideration. It should also be noted that this might not be pleasant for the child after a traumatic injury. • Milk packed in ice: Maintains the ability of the precursor cells to reproduce twice as long as milk at room temperature (Kenny, et al., 2003). • Hank’s balanced salt solution: balanced isotonic salt solution reconstitutes depleted cellular metabolites. Not readily available. • Tissue culture medium (VIASPAN®): Tissue culture medium. Not readily available.

Apical maturity The root of an upper central incisor completes its formation when the child is 10 years old. The guidelines the author will follow for the treatment of this tooth will depend on whether the root apex is open or closed. In this particular case, the author will assume that the apex is open. Figure 4 shows that replanted immature teeth had less than 50% survival after 10 years. More teeth survived with closed apices (Andreasen, et al., 2003). Barrett and Kenny (1997) also found that replanted incisors with open apices had a significantly reduced survival, and the relative risk of failure was 4.2 times greater in immature than in mature incisors. The author will assume that the avulsed tooth is caries free and in good periodontal health, and that the alveolar wall is intact.

Patient factors This avulsion injury has occurred at an age that is crucial to the patient’s facial growth and psychological development. Jaw growth varies noticeably with individual growth, which is not automatically linked with chronological age. Numerous studies have shown that it is hard to define the ideal time for implantation in relation to jaw growth (Lux, et al., 2012). The optimum time for implantation is when the growth has terminated, which can be determined by taking repeated cephalographs/radiographs. This can be planned when considering placing implants; however, when the patient presents unscheduled with an avulsed tooth, the clinician does not have this privilege of time on his/her side. The risk of replantation in this growing boy is ankylosis and subsequent interference Endodontic practice 21

CONTINUING EDUCATION

Figure 2: Trauma incidences in the permanent dentition (Source: Dental Trauma Guide, 2010)

CONTINUING EDUCATION with alveolar growth resulting in infraocclusion. Nonetheless, in the author’s opinion, even maintaining the tooth to maintain the surrounding bone for a few years is considered successful. Kawanami, et al. (1999), found that young girls had a higher risk of infraposition than young boys. However, a more recent study by Petrovic and colleagues in 2010 did not support this finding. More research is required to explore this interesting area. Replantation is contraindicated if the patient is immunosuppressed. If this was the case, the patient’s physician must be consulted, and follow-up appointments must be strictly obeyed. The author will assume the boy is fit and well and on no medications. Follow-up appointments are a must in avulsed replanted cases due to the potential complications of inflammatory resorption, ankylosis (associated infraocclusion), external cervical inflammatory root resorption (ECIR), and discoloration. This should be stressed to the patient and his/her parent(s) or guardian(s). The author will assume there are no other severe injuries that warrant favored emergency treatment. Figure 5 is a flowchart outlining consequences and treatment options of replanting versus not replanting. The author also has an ethical dilemma of whether to replant or not. The authors’ duties of care are (General Dental Council, 2005): • Put patients’ interests first and act to protect them. • Respect patients’ dignity and choices.

Therefore, this decision-making process should involve the parent(s) and the child. They should understand that a decision needs to be made promptly and will follow with consequences (Figure 5). The goal for replanting this still-developing (immature) tooth is to allow for possible revascularization of the pulp and continued root development. Due to the dry time being less than 60 minutes and having considered all the above factors, the author feels obliged to replant the tooth. Despite the lower predictive success rate, there is still that chance of survival. Therefore, if the parent and child consent, the author will replant. It must be stressed if there are obvious signs of failure, root canal treatment would be recommended. Furthermore, the risk of replacement resorption and subsequent tooth loss is high (as discussed previously, 45 minutes dry time, no wet storage media, open apex, and the increased risk of infraocclusion

related to ankylosis). The advantages and disadvantages of replantation in this 10-yearold boy are listed in Table 2. There are numerous guidelines published for the management of avulsed teeth (examples include the American Association of Endodontists, Dental Trauma Guide, International Association of Dental Traumatology, British Society of Paediatric Dentistry, and guidelines from the Journal of Clinical Pediatric Dentistry), all of which are similar in content and widely followed to aid the practitioner to deliver optimum care at a timely manner. However, all the guidelines have a major shortcoming. None have been tested by a formal clinical trial nor have they provided specific outcome information — i.e., there is little evidence to back up the protocols (discussed later). The author will follow the American Association of Endodontists (AAE) (2004) guidelines to manage this case.

Table 2: Advantages and disadvantages of replantation in this boy Advantages

Disadvantages

Survival of natural tooth

Risk of NO regeneration

Immediate esthetic result (correct shade, shape, and position)

Surface resorption

Psychological and attractiveness (social interaction and self-confidence)

Infection-related resorption (IRR)

Space maintainer

Replacement resorption (RR)/ankylosis

Bone maintainer

Infraocclusion

Gingivae maintainer

Discoloration External invasive cervical resorption (EICR)

Figure 5: Flowchart of decisions, consequences, and treatment for avulsed teeth 22 Endodontic practice

Volume 9 Number 4

(in the hope of revascularization) • •

• • •

If contaminated, clean the root surface and apical foramen with a stream of saline. Place the tooth in doxycycline (~100 mg/20 ml saline). In the author’s opinion, this stage is likely to be missed out by clinicians due to the lack of availability and practicality of this in clinical practice. Besides, there is little evidence to back up this protocol. Local anesthesia (LA) (The author feels strongly about administering LA to allow complete seating of tooth in socket. However, the author would use an adrenaline-free LA to prevent vasoconstriction and promote regeneration at the site of implantation.) Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture to the socket wall, reposition it with a suitable instrument. Replant slowly with slight digital pressure.

• • •

Suture gingival laceration, especially in the cervical area. Verify normal position of the replanted tooth radiographically. Apply a flexible splint for 1 week (No longer at risk of ankylosis.)

•

Administer systemic antibiotics: Doxycycline 2 times per day for 7 days at appropriate dose for patients’ age and weight. The author feels happy to prescribe this, as this 10-year-old boy is not susceptible to tetracycline staining. (Third molars are the only developing teeth now.) If the patient was younger and susceptible to staining, the author would consider penicillin V 4 times per day for 7 days at appropriate dose for patient’s age and weight.

•

Hinckfuss and Messer in 2009 demonstrated that there was inconclusive evidence to either contradict or support an association between systemic antibiotics and an increased likelihood of PDL healing outcome. The author would prescribe in this case but feels further research is required to assess the value of systemic antibiotics for avulsions in humans.

•

Refer to physician to evaluate the need for a tetanus booster if avulsed tooth has come into contact with soil, or tetanus coverage is uncertain.

•

Additional treatment

Antibiotics

Postoperative instructions • • •

Soft diet for 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine mouth rinse (0.12%) twice a day for 1 week.

• •

Clinical and radiographic examination Removal of splint

1 week later

(clinical and radiographical examination) 2-3 weeks

•

3-4 weeks

•

6-8 weeks

•

6 months

•

1 year

•

Yearly for 5 years

Postive outcome

Negative outcome

Clinical:

•

Asymptomatic

•

Normal mobility and eruption pattern

Symptomatic (tenderness, sinus, discoloration, resorption, bone loss)

•

Normal sound on percussion

•

High-pitched percussion sound

•

Positive sensitivity test

•

Infraocclusion

Radiographic:

•

Continued root development

•

Root fails to develop

•

Pulp lumen obliteration very common

•

Pulpal lumen — no change in size

• • •

IRR complications IRR ankylosis/RR and infraocclusion Ankylosis/RR and infraocclusion

Complications

Figure 6: The step-by-step management of this case Volume 9 Number 4

The Dental Trauma Guide guidelines are contrary to the AAE guidelines in the following aspects. Splint removal in 2 weeks as opposed to 1 week A systematic review carried out by Hinckuss and Messer (2009) found that there was inconclusive evidence for an association between short-term splinting (14 days) and an increased likelihood of functional periodontal healing, acceptable healing, or decreased development of replacement resorption. Further research is required — until then, the author would abide by the AAE guidelines. Minocycline hydrochloride microspheres instead of doxycycline Animal studies have shown that both these antibiotics enhance revascularization. The Dental Trauma Guide goes by studies carried out by Cvek, et al. (1990), and Yanpiset and Trope (2000), who found the benefits of doxycycline in monkeys’ and dogs’ teeth, respectively. In 2004, Ritter, et al., found minocyclinecovered dogs’ teeth before replantation proved to be successful. It is assumed that the positive effects with antibiotics will also occur in humans. Further research is required. Less frequent follow-ups

Follow-up

•

Comparison of guidelines

Complications and long-term management (open apex) Complications of replantation are common. Infection-related resorption (IRR) may be detected as early as 2 weeks post replantation. Ankylosis may be diagnosed 2 months later; however, it is more frequently detected after 6 months (Andreasen, et al., 1994). Thus, follow-up appointments are key to successful treatment. Infection-related resorption If obvious signs were present (Figure 6), the author would continue to follow the AAE guidelines and carry out immediate pulp extirpation and long-term dressing with calcium hydroxide. The status of the lamina dura and the presence of calcium hydroxide would be evaluated every 3 months until apexification. In contrast, Trope (2011) recommends a disinfection procedure with a triple antibiotic Endodontic practice 23

CONTINUING EDUCATION

The step-by-step management of this case is demonstrated in Figure 6.

Treatment

CONTINUING EDUCATION paste and a “non-vital” revitalization procedure. If this technique fails, the more traditional apexification technique is advised with long-term calcium hydroxide or an apical plug with MTA. It is important to note that IRR may be arrested by the preceding treatment, which removes the source of inflammation, but ankylosis may still occur due to the irreversible damage to the PDL. A very interesting find by some studies have shown that the presence of calcium hydroxide may increase the occurrence of ankylosis (British Society of Pediatric Dentistry, 1999). Ankylosis and infraocclusion Ankylosis and infraocclusions is a likely consequence for this 10-year-old growing boy. Ankylosis can lead to infraocclusions and difficult extractions; both of which are undesirable as they leave a large buccal defect, resulting in major esthetic challenges at final prosthetic replacement. A more recent technique of “decoronation” is based on experimental and clinical studies and has shown to be quite an effective way to manage an ankylosed tooth (Cohenca, Stabholz, 2007). The author would adopt this technique if the 10-yearold were faced with this situation. When the tooth is infraoccluded for about 2 mm, the crown should be removed and the root below the cement-enamel junction (CEJ) submerged, leaving the root to be slowly replaced by bone preventing the collapse of the socket. In addition, the bone will now grow above the submerged root to the level of the CEJ’s of the adjacent teeth. In this way the height and width of the bone and gingival architecture is maintained, allowing for an esthetically pleasing prosthetic rehabilitation. Other complications include surface resorption (self-limiting) and ECIR (relatively uncommon).

Closed apex There is no chance of revascularization and an increased risk of IRR. Thus, there are two main differences in the treatment protocol to prevent this: • Initiation of endodontic treatment 1 week after replantation • Higher dose of penicillin

Conclusion The author has described the immediate and long-term management of an avulsed tooth. An avulsed tooth presents many questions to the treating dentist. The most significant factor in success is immediate 24 Endodontic practice

replantation for both pulpal and periodontal healing. Studies have shown gaps in knowledge when managing avulsions. The author feels there is a need to introduce educational campaigns to broaden knowledge of emergency protocols and to prevent trauma in the first instance. EP

REFERENCES 1. Abu-Dawoud M, Al-Enezi B, Andersson L. Knowledge of emergency management of avulsed teeth among young physicians and dentists. Dent Traumatol. 2007; 23(6):348-355. 2. American Association of Endodontists (AAE). Recommended Guidelines of the American Association of Endodontists for the Treatment of Traumatic Dental Injuries. Chicago, IL: 2004. 3. Andersson L, Bodin I. Avulsed human teeth replanted within 15 minutes — a long-term clinical follow-up study. Endod Dent Traumatol. 1990; 6(1):37-42. 4. Andreasen JO A time-related study of periodontal healing and root resorption activity after replantation of mature permanent incisors in monkeys. Swed Dent J. 1980; 4(3): 101-110. 5. Andreasen JO, Andreasen FM, Andersson L. Avulsions. In: Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Oxford, UK: Blackwell Munksgaard; 2007. 6. Andreasen JO, Andreasen FM, Bakland LK, Flores MT. Traumatic Dental Injuries: A Manual. Oxford, UK: Blackwell Munksgaard; 2003. 7. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 1. Diagnosis and healing complications. Endod Dent Traumatol. 1995;11(2): 51-58. 8. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulp healing. Endod Dent Traumatol. 1995;11(2): 59-68. 9. Andreasen JO, Borum MK, Andreasen FM. Replantation of 400 avulsed permanent incisors. 3. Factors related to root growth after replantation. Endod Dent Traumatol. 1995;11(2):69-75. 10. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995;11(2):76-89. 11. Bakland LK, Andreasen JO. Dental traumatology: essential diagnosis and treatment planning. Endod Topics. 2004;7:14-34. 12. Barrett EJ, Kenny DJ. Avulsed permanent teeth: a review of the literature and treatment guidelines. Endod Dent Traumatol. 1997;13(4):153-163. 13. Barrett EJ, Kenny DJ. Survival of avulsed permanent maxillary incisors in children following delayed replantation. Endod Dent Traumatol. 1997;13(6):269-275. 14. Blakytny C, Surbuts C, Thomas A, Hunter ML. Avulsed permanent incisors: knowledge and attitudes of primary school teachers with regard to emergency management. Int J Paediatr Dent. 2001;11(5):327-332. 15. British Society of Paediatric Dentistry (BSPD). Paediatric Dentistry UK: National clinical guidelines and policy documents. Dental Practice Board for England and Wales: 1999. 16. Chappuis V, von Arx T. Replantation of 45 avulsed permanent teeth: a 1-year follow-up study. Dent Traumatol. 2005;21(5):289-296. 17. Cohenca N, Stabholz A. Decoronation — a conservative method to treat ankylosed teeth for preservation of alveolar ridge prior to permanent prosthetic reconstruction: literature review and case presentation. Dent Traumatol. 23(2):87-94. 18. Cvek M, Cleaton-Jones P, Austin J, Lownie J, Kling M, Fatti P. Effect of topical application of doxycycline on pulp revascularization and periodontal healing in reimplanted monkey incisors. Endod Dent Traumatol. 1990;6(4)48-56. 19. Day P, Duggal M. Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted. Cochrane Database Syst Rev. 2010;20(1):CD006542. 20. de Souza RF, Travess H, Newton T, Marchesan MA. Interventions for treating traumatised ankylosed permanent front teeth. Cochrane Database Syst Rev. 2010; 20(1):CD007820

21. Donaldson M, Kinirons MJ. Factors affecting the time of onset of resorption in avulsed and replanted teeth in children. Dent Traumatol. 2001;17(5):205-209 22. Flores MT, Andersson L, Andreasen JO, et al. International Association of Dental Traumatology. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dent Traumatol. 2007;23(3):130-136. 23. General Dental Council. Principles of Patient Consent. London, UK: 2005. [online] Available at: <https://www. gdc-uk.org/Dentalprofessionals/Standards/Documents/ PatientConsent[1].pdf> 24. Glendor U. Has the education of professional caregivers and lay people in dental trauma care failed? Dent Traumatol. 2009;25(1):12-18. 25. Gregg TA, Boyd DH. Treatment of avulsed permanent teeth in children. UK National Clinical Guidelines in Paediatric Dentistry. Royal College of Surgeons, Faculty of Dental Surgery. Int J Paediatr Dent. 1998;8(1):75-81. 26. Hecova H, Tzigkounakis V, Merglova V, Netolicky J. A retrospective study of 889 injured permanent teeth. Dent Traumatol. 2010; 26(6):466-475. 27. Hinckfuss SE, Messer LB. An evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Part 2: Prescription of systemic antibiotics. Dent Traumatol. 2009; 25(2):158-164. 28. Hinckfuss SE, Messer LB. Splinting duration and periodontal outcomes for replanted avulsed teeth: a systematic review. Dent Traumatol. 2009;25(2):150-157. 29. International Association of Dental Traumatology. The Dental Trauma Guide. 2010) [online] Available at: <www. dentaltraumaguide.org> 30. Kawanami M, Andreasen JO, Borum MK, Schou S, Hjorting-Hansen E, Kato H. Infraposition of ankylosed permanent maxillary incisors after replantation related to age and sex. Endod Dent Traumatol. 1999;15(2):50-56. 31. Kenny DJ, Barrett EJ, Casas MJ. Avulsions and intrusions: the controversial displacement injuries. J Can Dent Assoc. 2003; 69(5):308-113. 32. Lux HC, Goetz F, Hellwig E. Case report: endodontic and surgical treatment of an upper central incisor with external root resorption and radicular cyst following traumatic tooth avulsion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2012;110(5):e61-e67. 33. McIntyre JD, Lee JY, Trope M, Vann WF Jr. Management of avulsed permanent incisors: a comprehensive update. Pediatr Dent. 2007;29(1):56-63. 34. Petrovic B, Markovic D, Peric T, Blagojevic D. Factors related to treatment outcomes of avulsed teeth. Dent Traumatol. 2010;26(1):52-59. 35. Pohl Y, Filippi A, Kirschner H. Results after replantation of avulsed permanent teeth. I. Endontic considerations. Dent Traumatol. 2005;21(2):80-92. 36. Pohl Y, Filippi A, Kirschner H. Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive-regenerative therapy. Dent Traumatol. 2005;21(2):93-101. 37. Pohl Y, Wahl G, Filippi, A, Kirschner H. Results after replantation of avulsed permanent teeth. III. Tooth loss and survival analysis. Dent Traumatol. 2005;21(2):102-110. 38. Protocols for clinical pediatric dentistry: solutions to clinical problems from the Journal of Clinical Pediatric Dentistry (1995) Journal of Clinical Pediatric Dentistry 3: 26-30 39. Ritter AL, Ritter AV, Murrah V, Sigurdsson A, Trope M. Pulp revascularization of replanted immature dog teeth after treatment with minocycline and doxycycline assessed by laser Doppler flowmetry, radiography, and histology. Dent Traumatol. 2004;20(2):75-84. 40. Roberts G, Longhurst P. Oral and Dental Trauma in Children and Adolescents. 1st ed. Oxford University Press, Oxford; 1996. 41. Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377. 42. Trope M. Avulsion of permanent teeth: theory to practice. Dent Traumatol. 2011;27(4):281-294. 43. de Vasconcellos LG, Brentel AS, Vanderlei AD, de Vasconcellos LM, Valera MC, de Araújo MA. Knowledge of general dentists in the current guidelines for emergency treatment of avulsed teeth and dental trauma prevention. Dent Traumatol. 2009;25(6):578-583. 44. Wikipedia (2012) Dental avulsion. [online] Available at <http://en.wikipedia.org/wiki/Dental_avulsion> [Accessed 24/03/2012] 45. Yanpiset K, Trope M. Pulp revascularization of replanted immature dog teeth after different treatment methods. Endod Dent Traumatol. 2000;16(5):211-217.

Volume 9 Number 4

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The management of avulsion and dental trauma PATEL

Post-endodontic neuropathy of the trigeminal nerve: part 1 RENTON

Avulsion of a permanent tooth is estimated to represent ________ of all dental injuries. a. 0.5% to 16% b. 21% to 29% c. 32% to 40% d. 50% It occurs most frequently between the ages of ________ years, affecting the maxillary central incisors. a. 4 to 6 b. 7 to 14 c. 15 to 18 d. 20 to 25 In order for the author to determine the best course of treatment for this case, it is very important to elicit careful _________ history. a. medical b. dental c. accident d. all of the above Several options exist for managing this case. The simplest long-term solution is to __________ . a. allow the area to heal first b. root canal it c. replant it d. prepare the site for an implant The health of the _____ are the key tissues that affect the prognosis of the avulsed tooth. a. pulp b. periodontal ligament (PDL) c. gingiva d. both a and b Immediately after avulsion, both pulpal and PDL cells begin to suffer ischemic injury, which can

Volume 9 Number 4

be worsened by ________. a. drying b. bacteria c. chemical irritants d. all of the above 7.

The root of an upper central incisor completes its formation when the child is ___ years old. a. 8 b. 10 c. 12 d. 14 Due to the dry time being ________ and having considered all the above factors, the author feels obliged to replant the tooth. a. less than 10 minutes b. less than 30 minutes c. less than 60 minutes d. excessively long Infection-related resorption (IRR) may be detected as early as ___________ post replantation. a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks

10. When the tooth is infraoccluded for about _____, the crown should be removed and the root below the cement-enamel junction (CEJ) submerged, leaving the root to be slowly replaced by bone preventing the collapse of the socket. a. 2 mm b. 3 mm c. 4 mm d. 5 mm

The inferior alveolar nerve (IAN) is at risk from a variety of dental procedures, in that the IAN is contained within a bony canal predisposing it to ________. a. ischemia b. trauma c. subsequent injury in relation to dental procedures d. all of the above

Persistent pain after endodontics has been reported to occur in __________ of patients while surgical endodontics resulted in chronic neuropathic pain in 5% of patients. a. 1% to 2% b. 3%-13% c. 15%-24% d. 36%

Persistent pain after routine surgery is an emerging entity; in a study of 221 patients with trigeminal nerve injuries related to dentistry, ______ are reported to have chronic neuropathic post-traumatic pain in patients attending a nerve injury clinic. a. 25% b. 44% c. 57% d. 70%

____________ are chronic pain disorders that develop after a lesion of the peripheral nervous structures that are normally involved in signaling pain. a. Neuropathic pain (NP) syndromes b. Complex regional pain syndromes (CRPS) c. Reflex sympathetic dystrophies d. Causalgias Paresthesias are symptoms typically described by patients that are _______. a. painful b. excruciating

c. bothersome but not painful d. infectious 6.

Furthermore, NP states require different therapeutic approaches such as anticonvulsants, which _______ nociceptive pain, according to NICE guidance. a. are just as effective for b. are not effective in c. can have a rehabilitative effect on d. can totally control

Chronic pain induced by surgery results in significant _______ implications for the patients. a. functional b. psychological c. psychosomatic d. both a and b

All trauma-sensitive neural tissues will result in various neurophysiological effects as the IAN is contained within a bony canal, which predisposes it to _______. a. hypertrophy b. compression c. possible ischemic-type injury d. both b and c

___________ after the IAN injury, permanent central and peripheral changes occur within the nervous system subsequent to injury, which are unlikely to respond to surgical treatment intervention. a. Two weeks b. Six weeks c. Three months d. Six months

10.

If the apex is proximal to the IAN canal, and if the canal is over-instrumented, there ________ damage to the nerve. a. is increased risk of b. is no risk of c. will never be d. will always be

Endodontic practice 25

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Post-endodontic neuropathy of the trigeminal nerve: part 1 In the first of two articles, Dr. Tara Renton presents a literature review for the post-endodontic neuropathy of the trigeminal nerve

ensory disturbances or peripheral neuropathies such as anesthesia, hypoesthesia, hyperesthesia, and paresthesia may present in the trigeminal system due to many local and systemic factors. Spontaneous neuropathy must always be regarded with suspicion (red flag) and neoplasia excluded. However, if the neuropathy coincides with recent dental treatment, then exclusion of post-traumatic neuropathy must be excluded first. The inferior alveolar nerve (IAN) is at risk from a variety of dental procedures, in that the IAN is contained within a bony canal predisposing it to ischemia, trauma, and subsequent injury in relation to dental procedures. This may also result in a higher incidence of permanent damage for inferior alveolar nerve injuries compared with lingual nerve injuries (Pogrel, 2007). Causes of inferior alveolar nerve injury include local anesthetic injections, third molar surgery, implants, endodontics, ablative surgery, trauma, and orthognathic surgery. Endodontists and dentists take for granted the rather unusual characteristics of the dental pulp (the only organ in health to display allodynia [pain] to all stimuli) and to respond innocuously to caustic high pH chemicals that would destroy and burn tissues elsewhere in the body. Thus, many compounds and chemicals routinely used in dentistry can cause severe irreversible tissue damage in structures close to the treated tooth. Iatrogenic trigeminal nerve injuries remain a significant and complex clinical problem. Altered sensation and pain in the orofacial region may interfere with speaking, eating,

Educational aims and objectives

This clinical article aims to provide a review of endodontic-related nerve injuries using the literature.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 25 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the risk factors of post-endodontic neuropathy of the trigeminal nerve. • Realize the incidence of endodontic nerve injuries. • Realize the consequences of endodontic-related nerve injuries. • Realize the mechanism of nerve injury related to endodontic treatment. • Identify various aspects of related to neuropathic pain.

kissing, shaving, applying makeup, tooth brushing, and drinking — in fact, just about every social interaction we take for granted. Thus, these injuries have a significant negative effect on the patient’s quality of life, and the iatrogenesis of these injuries leads to significant psychological effects (Smith, et al., 2013).

Incidence of endodontic nerve injuries The most common nerve affected by endodontic procedures is the IAN (Alves, Coutinho, Gonçalves, 2014). Maxillary branches of the trigeminal nerve can also be damage-related endodontic treatment usually due to sodium hypochlorite leakage (Pelka, Petschelt, 2008) (Figure 1). In one retrospective study examining cases of paresthesia related to endodontic treatment of mandibular premolars, the incidence was 0.96% (8/832) (Knowles, Jergenson, Howard, 2003). In a survey of 2,338 patients, 7% sustained chronic neuropathic

Tara Renton, BDS, MDSc, PhD, FDS, RCS, FRACDS (OMS), FHEA, is a specialist in oral surgery with a particular interest in trigeminal nerve injuries and pain. After completing her oral and maxillofacial surgical training in Melbourne in 1991, Dr. Renton undertook a PhD in trigeminal nerve injury at King’s College London in 1999. She was later appointed senior lecturer at Queen Mary University of London and was then awarded her chair in 2006 at King’s College London. Over the past 7 years, Dr. Renton has lead the teaching of dental students, modernizing the oral surgical teaching with minimal access approach and modern local anesthesia techniques. She has established an academic training program, and in collaboration with the Institute of Psychiatry, Psychology & Neuroscience at King’s College London and Imperial College, Dr. Renton has established an international program of trigeminal nerve injury and orofacial pain research.

26 Endodontic practice

pain after a single endodontic procedure (Klasser et al, 2011). Most reports of endodontic-related nerve injuries are case reports with very little analysis of the clinical impact for the patient, risk factors, or management issues and are solely case reports. These case reports solely focus on over-instrumentation and loss of apical seal leading to endodontic material extrusion into the inferior dental canal (IDC), resulting in “mechanical” damage to the IAN (Figures 2-5). (Rowe, 1983; Yaltirik, Ozbas, Erisen, 2002; Gallas-Torreira, et al., 2003; TilottaYasukawa, et al., 2006; Scolozzi, Lombardi, Jaques, 2004; Zmener, 2004; Vasilakis, Vasilakis, 2004; Poveda, et al., 2006; Pogrel, 2007; von Ohle, ElAyouti, 2010; GonzalezMartin, et al., 2010; Gambarini, et al., 2011; Marques, Gomes, 2011; Lopez-Lopez, et al., 2012; Orr, 1987; 1985; Dempf, Hausamen, 2000; Forman, Rood, 1977; Gallas-Torreira,

Figure 1: Abducent and inferior alveolar nerve injury due to endodontic overfill of mandibular molar (image courtesy of S. Ruggiero) Volume 9 Number 4

CONTINUING EDUCATION

Figure 2: Panoral X-ray illustrating overfill and leakage of endodontic material into inferior dental canal

Figure 3: Panoral X-ray illustrating cases of extruded endodontic materials into the inferior dental canal

et al., 2003; Tilotta-Yasukawa, 2006; Qrstravik, Brodin, Aas, 1983; Vasilakis, Vasilakis, 2004). To date, there are four case series reports on inferior alveolar nerve injuries (IANIs) related to root canal treatment (RCT), including 61 cases (Pogrel, 2007), eight cases (Knowles, Jergenson, Howard, 2003), four cases (Scolozzi, Lombardi, Jaques, 2004), and one case series reported on the treatment of 11 cases (GrĂśtz et al, 1998). These case series predominantly focus on the outcomes surgical exploration and irrigation of damage nerves.

Consequences of endodonticrelated nerve injuries The largest series of endodontic-related trigeminal nerve injuries in 61 patients over Volume 9 Number 4

Figure 4: Panoral X-ray illustrating over-instrumentation of LL6 resulting in inferior alveolar nerve injury

an 8-year period (Pogrel, 2007) reported that eight patients (12.5%) were asymptomatic, which is the only report to proactively highlight that overfilling and extrusion of endodontic materials into the IDC will not always cause neuropathy. However, the majority of the patients reported symptoms (87.5%); 42 exhibited only mild symptoms (3-month-old injuries); 10 patients experienced some resolution; 11 patients were symptomatic and underwent surgical exploration â&#x20AC;&#x201D; five of these within 48

Figure 5: Radiograph illustrating case of over-instrumentation of LR6 into inferior dental canal Endodontic practice 27

CONTINUING EDUCATION hours and others up to 10 days to 3 months. (Four experienced partial resolution and two no recovery.) (Pogrel, 2007). More recently, in a personal communication, Dr. Pogrel has undertaken a further eight cases as urgent cases (within 24 hours) and reports significantly improved resolution of neuropathy and pain in these patients.

Neuropathic pain Persistent pain after endodontics has been reported to occur in 3%-13% of patients (Marbach, et al., 1982; Lobb, Zakariasen, McGrath, 1996) while surgical endodontics resulted in chronic neuropathic pain in 5% of patients (Campbell, Parks, Dodds, 1990). In a previous study of 135 patients with IANI caused by dental treatment or malignancy, 22% presented with dysesthesia, which was significantly associated with the female gender (Caissie, et al., 2005). In another study, the significant factors associated with persistent post-endodontic pain included prolonged preoperative pain, female gender, and previous chronic pain symptoms (Polycarpou, et al., 2005). Two more recent reviews of chronic post-endodontic pain (Nixdorf, et al., 2010; Nixdorf, Moana-Filho, 2011) propose persistent dentoalveolar pain (PDAP) occurs in 1.6-3.6% of cases. The average pain reported as 7.2 on a visual analogue scale (where zero is no pain and 10 is pain as severe as it could be). The neuropathic pain was more common in middle-aged (mean 50.6 years of age) individuals with no sex predilection and occurred more frequently in the mandibular arch without any differences attributable to the number of canals treated. Also, the majority of subjects most frequently endorsed their pain experiences as abnormal sensitivity to touch and pain when the area is pressed or rubbed. Persistent pain after routine surgery is an emerging entity; in a study of 221 patients with trigeminal nerve injuries related to dentistry, 70% are reported to have chronic neuropathic post-traumatic pain in patients attending a nerve injury clinic (Renton, Yilmaz, 2011). Another study confirmed this phenomenon in 91 patients (Benoliel, et al, 2012). Neuropathic pain (NP) syndromes are chronic pain disorders that develop after a lesion of the peripheral nervous structures that are normally involved in signaling pain. Mechanisms for this process have been investigated but as yet elude us (Fried, et al., 2001; Benoliel, Kahn, Eliav, 2012; Forssell, et al., 2007). There are increasing reports of 28 Endodontic practice

Altered sensation and pain in the orofacial region may interfere with speaking, eating, kissing, shaving, applying makeup, tooth brushing, and drinking — in fact, just about every social interaction we take for granted.

persistent pain post-dental surgery, likely to be related to post-traumatic neuropathy due to nerve injury (Queral-Godoy, et al., 2006; Rodriquez-Lozano, et al., 2010; Renton, et al., 2012). This increased recognition of chronic persistent pain after surgery is also occurring in general surgery (Kehlet, et al., 2007), reaffirming that a large proportion of patients attending chronic pain management clinics do, in fact, have post-surgical neuropathic pain. There are relatively few reports of persistent pain subsequent to endodontic procedures (Nixdorf, et al., 2010). Persistent pain after endodontics has been reported to occur in 3%-13% of patients (Polycarpou, et al., 2005). Surgical endodontics are reported to result in chronic neuropathic pain in 5% of patients (Campbell, Parks, Dodds, 1990). Groltze, et al., reported on 11 patients with endodontic associated neuropathy and their management. They similarly reported that the neurological findings were dominated by hypesthesia and dysesthesia with 50% of patients reporting pain. Eleven of 61 patients with endodontic NI presented with significant pain, and only 40% responded to surgery (Pogrel, 2007). Ninety percent of the 10 patients in a later study reported chronic pain with 50% experiencing allodynia (pain evoked to non-noxious stimuli) and hyperalgesia (increased pain to noxious stimuli — for example, a pinprick or partners’ bristles on kissing). The characteristics of NP differ substantially from those of other chronic pain states — i.e., chronic nociceptive pain, which develops while the nervous system that is involved in pain processing is intact. As well as the existence of negative somatosensory signs (deficit in function) there are other features that are characteristic of neuropathic conditions. Paresthesias are symptoms typically described by patients that are bothersome but not painful. Furthermore, NP states require different therapeutic approaches such as anticonvulsants, which are not effective in

nociceptive pain, according to NICE guidance. Thus, symptoms experienced by patients with post-traumatic neuropathy of the trigeminal nerve can range from next to no symptoms, such as minimal anesthesia in a small area, to devastating effects on the patient’s quality of life (Renton, Yilmaz, 2011). There is a lot of confusion in the terminology used for chronic pain related to surgical interventions. Chronic pain after surgery has too many names, including surgically induced neuropathic pain (SNIP), chronic post-surgical pain (CPSP), posttraumatic neuropathy (PTN), postoperative neuropathic pain (PPNP), and phantom limb pain. There are two main types of chronic pain relating to surgery: • Induced intractable neuropathic pain post-surgery (new or worsening pain) • Persistent neuropathic pain preand post-surgery (persistent dentoalveolar pain [PDAP] or pre-existing neuropathic pain before the surgery). The criteria for diagnosing CPSP (Macrae, 2008) include: • Pain developed after surgery • Minimum 2-month duration • Other causes of pain have been excluded (infection, persistent malignancy, misdiagnosis) • Excluded preoperative pain from other cause For CPSP, a neuropathy does not have to be demonstrated in these cases, whereas if post-traumatic neuropathy is present, then a neuropathy will be present. However, other features of neuropathic post-surgical pain will be present, including: • Pain • Hyperesthesia • Allodynia pain with non-noxious stimulus • Pain on touch/cold/hot • Hyperalgesia increased pain to painful stimulus • Altered sensation Volume 9 Number 4

Mechanism of nerve injury related to endodontic treatment All trauma-sensitive neural tissues will result in various neurophysiological effects as the IAN is contained within a bony canal, which predisposes it to compression and possible ischemic-type injury. Compression of peripheral sensory nerves over 6 hours can evoke nerve fiber atrophy (Shimpo, et al., 1987). Ischemia alone without direct nerve damage will cause sufficient neural

inflammation and damage to cause permanent nerve injury (Park, Kim, Moon, 2012). Three months after the IAN injury, permanent central and peripheral changes occur within the nervous system subsequent to injury, which are unlikely to respond to surgical treatment intervention (Yekta, et al., 2010). IANIs related to RCTs can be due to local anesthesia, which is rare and usually associated with acute pain during block injections. IANIs related to endodontic treatment can be due to mechanical, chemical, and hemorrhagic insults. The injury may be to the nerve itself (extraneural or intraneural) of varying sites and/or associated vessels: • Mechanical direct reamer/indirect scarring — excessive root canal preparation often causes enlargement of the apical foramen and loss of constriction, which favors extravazation of irrigation products or filling material beyond the apex, which, in turn, may cause neural injury of chemical or mechanical origin. The diameter of bone lesions of endodontic origin may also influence the occurrence of paresthesia, especially when associated with the premolars and lower molars (Koseoglu, et al., 2006). Rowe (1983) argued that mechanical damage to the nerve caused by an endodontic instrument can be repaired during the healing process and that this form of paresthesia is generally temporary. Figures 2-4 are examples of postendodontic radiographic overfills in our patient sample. • Dental materials may exert damaging effects on nerve conduction as a result of their physical and chemical properties (Table 1). • Even chemically bland materials such as gutta percha may cause irreversible neural injury following their

Table 1: Commonly used endodontic medicaments have very high or low pHs Formocresol

pH 12.45 +/- 0.02

Sodium

hypochlorite pH 11-12

Calcium hydroxide (Calyxl)

pH 10-14

Antibiotic-corticosteroid paste (Ledermix)

pH 8.13 +/- 0.01

Neutral

pH 7.35-7.45

Eugenol

pH 4.34 +/- 0.05

Iodoform paste

pH 2.90 +/- 0.02

EDTA

pH 8.0 with NaOH

MTA

pH 10.2, increasing to 12.5 after 3h then constant

Volume 9 Number 4

• •

•

entry to the inferior dental canal in a molten, thermoplastic state, partially resulting from direct thermal damage, and partly from nerve compression as the material cools and contracts (Fanibunda, Whitworth, Steele, 1998). Pressure ischemia from bleed or endodontic preparation. Periapical infection may also cause IANI (Morse, 1997). The possibility of paresthesia due to extrusion of microorganisms should be considered, given the potential for biological aggression, although this mechanism has not been explored in the literature (Table 1). Chemical toxicity and mechanical pressure produced by leakage of sealers into areas close to the mandibular canal are other potential mechanisms for nerve injury related to endodontic procedures, with the IAN and mental nerve being most affected. The materials most commonly associated with these complications are those containing paraformaldehyde (Ahonen, Tjaderhane, 2011). However, most endodontic materials have very high pHs resulting in immediate nerve damage likely to be permanent (Brodin, et al., 1982; Brodin, 1988; Serper, et al., 1998; Kozam, Newark, 1977). Hemaglobin irritates nerve tissue due to the iron content.

Risk factors Tilotta-Yasukawa and colleagues (2006) determined the proximity of the apex of the premolars and molars in relation to the mandibular canal, as well as the relationship between the IAN and its corresponding artery, with the goal of understanding how endodontic filling material spreads through the bone to penetrate the mandibular canal. They observed that the distance between the dental apex and the mandibular canal was more variable (and generally greater) for the first molar than for the second and third molars (1 mm-4 mm versus less than 1 mm [35 cases in 40 mandibles examined]). The authors concluded that, in the posterior region, the mandibular bone is not very dense and has a greater amount of trabecular bone. In addition, the presence of numerous vacuoles in the mandibular bone in the molar region facilitates the spread of irrigation products and filling material toward the inferior alveolar neurovascular set (Knowles, Jergenson, Howard, 2003). Endodontic practice 29

CONTINUING EDUCATION

• Paresthesia — pins and needles, formication, many descriptions • Dysesthesia — uncomfortable sensations, often burning • Numbness — hypoesthesia Chronic pain induced by surgery results in significant functional and psychological implications for the patients (Smith, et al., 2013; Renton, Yilmaz, 2011). Therefore, holistic assessment and management are imperative to manage these patients. Optimal management of chronic pain will help the patient move forward with support from Liaison Psychiatry Service (Renton, Yilmaz, 2012). Lifelong chronic pain is a likely outcome with endodontic-related IANIs and can mean that patients are on long-term medications. This reinforces the emphasis on prevention of these IANIs as they are so difficult to manage. As a result of these severe consequences, complaints and litigation often ensue. In a review of 16 medicolegal claims related to persistent altered sensation following endodontic treatments, the typical profile of a claim was a female patient who underwent an endodontic treatment for a second mandibular molar, which was associated with overfilling. None of the claims were reported by the practitioners, and all cases were identified as a result of the patient’s demand for financial compensation, either directly or by legal actions (Givol, et al., 2011).

CONTINUING EDUCATION In a study of 135 patients with inferior alveolar nerve injuries caused by dental treatment or malignancy, 22% presented with dysesthesia that was significantly associated with the female gender and previous chronic pain (Oshima, et al., 2009). GDP inadequacies GDP inadequacies of GDP root canal treatments were highlighted by Jenkins, Hayes and Dummer (2001). Chemical nerve injuries Regarding chemical nerve injuries from leakage through the apex, such as sodium hydroxide — there are several reports of extreme pain and swelling resulting from endodontic irrigation with sodium hypochlorite, with a multitude of associated complications including neuropathy. Kleier, Averbach, and Mehdipour (2008) surveyed 342 Diplomates of the American Board of Endodontics. Of the Diplomates that responded, 132 reported experiencing a sodium hypochlorite accident. The risk factors included women compared with men (p < 0.0001); maxillary teeth compared with mandibular teeth (p < 0.0001); posterior more than anterior teeth (p < 0.0001); a diagnosis of pulp necrosis with radiographic findings of periradicular radiolucency were positively associated with such accidents (p < 0.0001). Table 2 lists potential risk factors for sodium chlorite and other chemical leaks that may contribute to nerve injury. Technical detectable overfill Technical detectable overfill (Figures 2-3) occurred in 60% of cases and overinstrumentation during preparation. Any tooth requiring endodontic therapy, which is in close proximity to the IAN canal, should require special attention, including sodium

hypochlorite (as irrigation) and calcium hydroxide (as sealant; calcium hydroxide medicaments breach the canal roof, precipitating a vascular bleed resulting in hemoglobin irritation of the nerve due to the iron content) (Escoda-Francoli, et al., 2007; Blanas, Kienle, Sándor, 2004). Over-instrumentation (Figures 4-5) The practitioner should be trained in root length assessment and root canal preparation. If the apex is proximal to the IAN canal, and if the canal is over-instrumented, there is increased risk of damage to the nerve. If the canal is overprepared and the apex opened, the nerve may be damaged by preparatory files, overfilling using pressurized thermal filling, and pressure and ischemia due to intracanal hemorrhage. Dental factors Many studies report the most likely teeth related to IANI are first molar and second premolars. Chikvashvili (2011) reported a significant correlation between the tooth location, and the suggested cause of nerve injury was found. Other dental factors can be found in Table 2. Periapical lesions (Figure 6) In one retrospective study, the incidence of mental paresthesia resulting from periapical infection or pathology was 0.96%. In another (0.24% of cases in the same study), mental paresthesia was a complication of root canal treatment (caused by severe overfill in one case and iatrogenic perforation of mechanical instrumentation through the root and into the

mental nerve in the second case). Neuritis neuropathy may be induced by local inflammatory factors related to the periapical lesions and, if persistent, can cause permanent IAN neuropathy. Many case reports that document neuropathies associated with apical periodontitis are scant, but usually involve premolars and sensory disturbance in the distribution of the mental nerve (von Ohle, ElAyouti, 2010; Shadmehr, Shekarchizade, 2015). There is every expectation that carefully conducted RCT that limits instruments and materials within the tooth, or indeed tooth extraction will allow symptoms to resolve (Ahonen, Tjäderhane, 2011). Proximity Proximity of the tooth to the IDC is a risk factor reported in all studies, including teeth apices close to the IDC and premolars adjacent to the mental loop (Scarano, et al., 2007; Köseoğlu, et al., 2006). Mandibular teeth proximal to the IAN canal may have the apex of the tooth and may be adjacent

Figure 6: Panoral X-ray of case of LR3 root canal treatment resulting in leakage of endodontic chemicals causing inferior alveolar nerve injury via cystic lesion adjacent to the inferior dental canal

Table 2: CBCT radiography may assist in risk assessment for nerve injury related to endodontic treatment chemical leakage Predisposing tooth factor that may result in an adverse incident during root canal treatment

Potential adverse incident if tooth factor not recognized

Resorption defects where extent is not identified such as internal/external communicating with root canal and external surface of the root

Extrusion of endodontic filler/hypochlorite accident

Suspicion of a perforation communicating with the external root surface

Extrusion of endodontic filler/hypochlorite accident

Root fracture where there could be a potential communication of the root canal with external root surface

Extrusion of endodontic filler/hypochlorite accident

Sclerosed root canal

Possible perforation with subsequent hypochlorite accident

Dens invaginatus

Possible perforation with subsequent hypochlorite accident

Periapical lesions and other pathology (cysts)

Neurological injury (may occur if lesion close to inferior dental canal)

Lower molar teeth where root apices are is close proximity to the Inferior dental canal and or mental foramen

Neurological injury (over-instrumentation, overfilling with obturation materials or sealer)

30 Endodontic practice

Volume 9 Number 4

REFERENCES 1. Ahonen M, Tjäderhane L. Endodontic-related paresthesia: a case report and literature review. J Endod. 2011;37(10):1460-1464. 2. Alves FR, Coutinho MS, Gonçalves LS. Endodontic-related facial paresthesia: systematic review. J Can Dent Assoc. 2014;80:e13 3. Benoliel R, Kahn J, Eliav E. Peripheral painful traumatic trigeminal neuropathies. Oral Dis. 18(4):317-332. 4. Benoliel R, Zadik Y, Eliav E, Sharav Y. Peripheral painful traumatic trigeminal neuropathy: clinical features in 91 cases and proposal of novel diagnostic criteria. J Orofac Pain. 2012;26(1):49-58. 5. Blanas N, Kienle F, Sándor GK. Inferior alveolar nerve injury caused by thermoplastic gutta-percha overextension. J Can Dent Assoc. 2004;70(6):384-387. 6. Brodin P. Neurotoxic and analgesic effects of root canal cements and pulp-protecting dental materials. Endod Dent Traumatol. 1988;4(1):1-11. 7. Brodin P, Røed A, Aars H, Orstravik D. Neurotoxic effects of root filling materials on rat phrenic nerve in vitro. J Dent Res. 1982;61(8):1020-1023. 8. Caissie R, Goulet J, Fortin M, Morielle D. Iatrogenic paresthesia in the third division of the trigeminal nerve: 12 years of clinical experience. J Can Dent Assoc. 2005;71(3):185-190. 9. Campbell RL, Parks KW, Dodds RN. Chronic facial pain associated with endodontic therapy. Oral Surg Oral Med Oral Pathol. 1990;69(3):287-290. 10. Chikvashvili J. Overcoming unforeseen incidents: what to do when an unlikely event occurs. Compend Contin Educ Dent. 2011;32(5):44-48. 11. Dempf R, Hausamen JE. Lesions of the inferior alveolar nerve arising from endodontic treatment. Aust Endod J. 2000; 26(2):67-71. 12. Escoda-Francoli J, Canalda-Sahli C, Soler A, Figueiredo R, Gay-Escoda C. Inferior alveolar nerve damage because of overextended endodontic material: a problem of sealer cement biocompatibility. J Endod. 2007;33(12):1484-1489. 13. Fanibunda K, Whitworth J, Steele J. The management of thermomechanically compacted gutta- percha extrusion in the inferior dental canal. Br Dent J. 1998;184(7):330-332. 14. Forman GH, Rood JP. Successful retrieval of endodontic material from the inferior alveolar nerve. J Dent. 1977;5(1):47-50.

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15. Forssell H, Tenovuo O, Silvoniemi P, Jääskeläinen SK. Differences and similarities between atypical facial pain and trigeminal neuropathic pain. Neurology. 2007; 69(14):1451-1459. 16. Fried K, Bongenhielm U, Boissonade FM, Robinson PP. Nerve injury-induced pain in the trigeminal system. Neuroscientist. 2001;7(2):155-165.

nerve damage caused by sodium hypochlorite: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(3): e80-e83. 40. Pogrel MA. Damage to the inferior alveolar nerve as the result of root canal therapy. J Am Dent Assoc. 2007;138(1):65-69.

17. Gallas-Torreira MM, Reboiras-Lopez MD, Garcia-Garcia A, Gandara-Rey J. Mandibular nerve paresthesia caused by endodontic treatment. Med Oral. 2003;8(4):299-303.

41. Polycarpou N, Ng YL, Canavan D, Moles DR, Gulabivala K. Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing. Int Endod J. 2005;38(3):169-178.

18. Gambarini G, Plotino G, Grande NM, et al. Differential diagnosis of endodontic-related inferior alveolar nerve paresthesia with cone beam computed tomography: a case report. Int Endod J. 2011; 44(2):176-81.

42. Poveda R, Bagán JV, Fernández JM, Sanchis JM. Mental nerve paresthesia associated with endodontic paste within the mandibular canal: report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(5):e46-e49.

19. Givol N, Rosen E, Bjørndal L, Taschieri S, Ofec R, Tsesis I. Medico-legal aspects of altered sensation following endodontic treatment: a retrospective case series. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(1):126-131.

43. Qrstravik D, Brodin P, Aas E. Paraesthesia following endodontic treatment: survey of the literature and report of a case. Int Endod J. 1983;16(4):167-172.

20. González-Martin M, Torres-Lagares D, Gutierrez-Perez JL, Segura-Egea JJ. Inferior alveolar nerve paresthesia after overfilling of endodontic sealer into the mandibular canal. J Endod. 2010;36(8):1419-1421. 21. Grötz KA, Al-Nawas B, de Aguiar EG, Schulz A, Wagner W. Treatment of injuries to the inferior alveolar nerve after endodontic procedures. Clin Oral Investig. 1998;2(2):73-76. 22. Jenkins SM, Hayes SJ, Dummer PM. A study of endodontic treatment carried out in dental practice within the UK. Int Endod J. 2001;34(1):16-22. 23. Klasser GD, Kugelmann AM, Villines D, Johnson BR. The prevalence of persistent pain after nonsurgical root canal treatment. Quintessence Int. 2011;42(3):259-269.

44. Queral-Godoy E, Vazquez-Delgado E, Okeson JP, GayEscoda C. Persistent idiopathic facial pain following dental implant placement: a case report. Int J Oral Maxillofac Implants. 2006;21(1):136-140. 45. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Postimplant neuropathy of the trigeminal nerve. A case series. Br Dent J. 2012;212(11):e17. 46. Renton T, Yilmaz Z. Profiling of patients presenting with posttraumatic neuropathy of the trigeminal nerve. J Orofac Pain. 2011;25(4):333-344. 47. Renton T, Yilmaz Z. Managing iatrogenic trigeminal nerve injury: a case series and review of the literature. Int J Oral Maxillofac Surg. 2012;41(5):629-637.

24. Kleier DJ, Averbach RE, Mehdipour O. The sodium hypochlorite accident: experience of diplomates of the American Board of Endodontics. J Endod. 2008;34(11):1346-1350.

48. Rodriquez-Lozano F, Sanchez-Pérez A, Moya-Villaescusa MJ, Rodriguez-Lozano A, Saez-Yuguero MR. Neuropathic orofacial pain after dental implant placement: review of the literature and case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(4):e8-e12.

25. Knowles KI, Jergenson MA, Howard JH. Paresthesia associated with endodontic treatment of mandibular premolars. J Endod. 2003;29(11):768-770.

49. Rowe AH. Damage to the inferior dental nerve during or following endodontic treatment. Br Dent J. 1983; 155(9):306-307.

26. Köseoğlu BG, Tanrikulu S, Sübay RK, Sencer S. Anesthesia following overfilling of a root canal sealer into the mandibular canal: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(6):803-806.

50. Scarano A, Di Carlo F, Quaranta A, Piattelli A. Injury of the inferior alveolar nerve after overfilling of the root canal with endodontic cement: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104(1): e56-e59.

27. Kozam G. The effect of eugenol on nerve transmission. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1977;44(5):799-805.

51. Scolozzi P, Lombardi T, Jaques B. Successful inferior alveolar nerve decompression for dysesthesia following endodontic treatment: report of 4 cases treated by mandibular sagittal osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(5):625-631.

28. Lobb WK, Zakariasen KL, McGrath PJ. Endodontic treatment outcomes: do patients perceive problems? J Am Dent Assoc. 1996;127(5):597-600. 29. Lopez-Lopez J, Estrugo-Devesa A, Jané-Salas E, SeguraEgea JJ. Inferior alveolar nerve injury resulting from overextension of an endodontic sealer: non-surgical management using the GABA analogue pregabalin. Int Endod J. 2012;45(1):98-104. 30. Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth. 2008;101(1):77-86. 31. Marbach JJ, Hulbrock J, Hohn C, Segal AG. Incidence of phantom tooth pain: an atypical facial neuralgia. Oral Surg Oral Med Oral Pathol. 1982;53(2):190-193. 32. Marques TM, Gomes JM. Decompression of inferior alveolar nerve: case report. J Can Dent Assoc. 2011;77:b34. 33. Morse DR. Infection-related mental and inferior alveolar nerve paresthesia: literature review and presentation of two cases. J Endod. 1997;23(7):457-460. 34. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, John MT. Frequency of persistent tooth pain after root canal therapy: a systemic review and meta-analysis. J Endod. 2010;36(2): 224-230. 35. Nixdorf DR, Moana-Filho EJ. Persistent dento-alveolar pain disorder (PDAP): Working towards a better understanding. Rev Pain. 2011;5(4):18-27. 36. Orr DL II. Paresthesia of the trigeminal nerve secondary to endodontic manipulation with N2. Headache. 1985;25(6):334-346. 37. Oshima K, Ishii T, Ogura Y, Aoyama Y, Katsuumi I. Clinical investigation of patients who develop neuropathic tooth pain after endodontics procedures. J Endod. 2009;35(7):958-961. 38. Park YT, Kim SG, Moon SY. Indirect compressive injury to the inferior alveolar nerve caused by dental implant placement. J Oral Maxillofac Surg. 2012;70(4):e258-e259. 39. Pelka M, Petschelt A. Permanent mimic musculature and

52. Serper A, Uçer O, Onur R, Etikan I. Comparative neurotoxic effects of root canal materials on rat sciatic nerve. J Endod. 1998;24(9):592-594. 53. Shadmehr E, Shekarchizade N. Endodontic periapical lesion-induced mental nerve paresthesia. Dent Res J (Isfahan). 2015;12(2):192-196. 54. Shimpo T, Gilliatt RW, Kennett RP, Allen PJ. Susceptibility to pressure neuropathy distal to a constricting ligature in the guinea-pig. J Neurol Neurosurg Psychiatry. 1987;50(12):1625-1632. 55. Smith JG, Elias LA, Yilmaz Z, et al. The psychosocial and affective burden of posttraumatic neuropathy following injuries to the trigeminal nerve. J Orofac Pain. 2013;27(4):293-303. 56. Tilotta-Yasukawa F, Millot S, El Haddioui A, Bravetti P, Gaudy JF. Labiomandibular paresthesia caused by endodontic treatment: an anatomic and clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(4):e47-e59 57. Vasilakis GJ, Vasilakis CM. Mandibular endodontic-related paresthesia. Gen Dent. 2004;52(4): 334-338. 58. von Ohle C, ElAyouti A. Neurosensory impairment of the mental nerve as a sequel of periapical periodontitis: case report and review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110(4) e84-e89. 59. Yaltirik M, Ozbas H, Erisen R. Surgical management of overfilling of the root canal: a case report. Quintessence Int. 2002;3(9):670-672. 60. Yekta SS, Smeets R, Stein JM, Ellrich J. Assessment of trigeminal nerve functions by quantitative sensory testing in patients and healthy volunteers. J Oral Maxillofac Surg. 2010;68(10):2437-2451. 61. Zmener O. Mental nerve paresthesia associated with an adhesive resin restoration: a case report. J Endod. 2004;30(2):117-119.

Endodontic practice 31

CONTINUING EDUCATION

or intruding into the IDC canal, and any small degree of leakage or overfilling may compromise the IAN. Assessment of the proximity of the tooth apex to the IAN canal has become significantly improved with cone beam CT (CBCT) scanning with the attendant risk of additional radiation, and may not provide significantly more information than a plane long cone radiograph. Most CBCT assessment of tooth positioning in relation to the IAN canal is based on m3m prior to extraction (Tilotta-Yasukawa, et al., 2006). It is a concern that some endodontic programs are training delegates to overfill past the apex by 1 mm-2 mm for optimal results, as there is insufficient evidence to support this recommendation and no mention of pre-surgical safety zone assessment to avoid nerve injuries in those teeth with apices close to the IDC. The second part of this article will examine CBCT guidance in endodontic-related nerve injuries, as well as the diagnosis, assessment, and management in practice. EP

BANDING TOGETHER

Brooks’ heroes Managing editor Mali Schantz-Feld shares an unforgettable act of kindness

n these high-tech times, news travels fast. Social media, television, newspapers, and the Internet bombard us with stories, and we skim and move on. This story, however, touched the hearts of our entire MedMark team — especially since two of the people involved change lives every day as dental specialists. These heroes banded together and performed an unforgettable act of kindness that saved a toddler’s life. The story starts on a beautiful July day on Newport Beach in California. Twin brothers from Mesa, Arizona, Orthodontist Stuart Frost, Endodontist Steve Frost, cousin Jesse Martin, and many other family members were having a reunion vacation. Down the beach, they heard screams for help and saw a mother frantically searching for her 2-year old son, Brooks. Most people didn’t give the Endodontist Steve Frost and Orthodontist Stuart Frost mother’s screams a second look — maybe because it’s easy for a child have to know how to rescue breathe and do to wander off on a packed beach. compressions, but in reality, it is the chest According to one source, at least compressions that saved this little boy’s 10 children were reported missing in life.” Stuart added, “I went to the beach that Newport on that day. The mother said morning to relax and enjoy the day; I never that she had just turned her head for dreamed I would be using my CPR training a minute to apply sunscreen to her to help save a life. After looking back on that other child. The Frost twins’ mother’s experience, I have realized more than ever words echoed in their minds. “Our before that we have to act in crisis situations mother always taught us that when instead of sitting back and letting someone someone is in need, you step up to else help out. Too many times we may be help them,” said Stuart. tempted to let someone else help, and we While the parents were scanning miss an opportunity to serve someone else the ocean water, the three men had in a life-changing way.” another idea. Noticing that some chilNewport Beach Lifeguard Battalion Chief dren had been digging deep holes Brent Jacobsen noted that entrapment under in the sand near where the toddler the sand is a realistic danger. No one should Steve Frost, Brooks, Jesse Martin, and Stuart Frost was sitting, they remembered warnever dig a hole that is deeper than 1 foot, ings from past years about collapsing and climbing into a tunnel dug in the sand is beach sand. They started digging. Then, as mouth and started compressions — putting extremely hazardous since sand can weigh Stuart recalls, “I’ll never forget it as long as I into action the skills they review every 2 years several hundred pounds. live. Jesse said, ‘I found him!’ and he pulled during CPR training. And then, the boy’s lips A couple of days later, the heroes and the him by the hips out of the hole.” The ordeal started to quiver, he started breathing, and family met on the beach. What do you say was not yet over. After lying face down under screaming for his mother. “It was truly the to people who saved your child’s life? Stuart the sand for about 5 minutes, the boy had most miraculous thing I ever experienced in summed up the reunion: “There were tears sand in his mouth and was not breathing. my life,” said Stuart. Brooks was transported of joy, hugging each other, crying together. Stuart continued, ““He was ash gray; he was to the hospital and made a full recovery. Wow, talk about a happy ending; it was just “After spending 22 years in endodontics dead. So we pulled him out, and the mom spectacular.” EP and recertifying my CPR every other year, I was just beside herself.” felt like instinct took over, and I knew what Before paramedics arrived, the two This article was compiled from news articles, news videos, to do,” said Steve. Many of us think that we dentists cleared the sand from Brooks’ and interviews with the dentists. 32 Endodontic practice

Volume 9 Number 4

ARE YOUR ENDODONTIC CLEANING INSTRUMENTS ONLY DOING HALF OF THE JOB?

This initiative is brought to you by Kerr Corporation

Discover the whole truth about how canal cleaning is done today. truthaboutrootcanals.com

TECHNOLOGY

Defining our terms. Refining endodontics SonendoÂŽ discusses the mechanism behind its new standard of clean

ecent discussion about the efficacy of laser technology as an advancement beyond standard root canal treatment is encouraging. It suggests that endodontics is now truly at a crossroads, where methods that have been in place for decades are finally being questioned. This presents an opportunity for a larger conversation about new methods and new alternatives that can advance endodontics into an entirely new era. As with any great turning point, though, there also needs to be a discussion about how terms are defined. Eventually, through a healthy dialogue between informed parties, a consensus can be reached that provides an

optimal way forward. This is the situation that endodontics faces today â&#x20AC;&#x201D; will the future of best practices be centered around laser technology, or is an entirely new alternative going to set the standard, one that is able to provide an even higher standard of clean? Proponents of laser technology in root canal treatments point to its ability to target bacteria and tissue with greater accuracy than standard methods. Lasers represent a marked improvement over standard methods. By more precisely targeting infection, endodontists can reduce the need for retreatment in the long run. In a recent survey, more than 90% of patients placed a high value on keeping their natural tooth.1

The ideal innovation is one that enables patients to keep their natural tooth While laser technology such as an Er:YAG laser activating NaOCl does represent an improvement over non-activated NaOCl for tissue dissolution,2 we still need to define our terms more accurately. The idea of dentin preservation is clearly important, as patients strongly express a desire to avoid an implant if possible. Preserving dentin, though, is only valuable if that dentin has been fully disinfected. Leaving biofilm behind leads to reinfection within the canal space â&#x20AC;&#x201D; and that can lead to retreatments over time. The need to preserve tooth

Low and high magnification images at different regions from a root of a curved molar, after cleaned with the GentleWave System 34 Endodontic practice

Volume 9 Number 4

The ideal innovation is one that ensures maximal dentin preservation and maximal removal of biofilm In other words, we need to define what constitutes true cleaning in endodontics. And in defining that term, we need to consider the realities of the root canal and all of its complexities. In a position paper, the American Association of Endodontists states the following: The advantages of using the laser, however, are balanced by several significant disadvantages. Root canal spaces are rarely straight and more often are curved in at least two dimensions. Root canal instruments used to clean the space throughout its length can be curved to follow the curvatures in a tooth root. In contrast, laser light will travel on a straight path; laser probes should be fabricated in a way that the laser light emerges laterally, uniformly interacting with the root canal wall.3 Consider, too, that clinical efficacy has not been achieved via laser technology in recent studies.4 Evidence suggests laser technology simply cannot navigate the complexities of a root canal. Which means a significant portion of the tooth is not being cleaned or disinfected.

The ideal innovation is one that can navigate all the complexities and curvature of the human root canal system As we define the concept of clean, we must consider what we can call “good enough.” Laser technology represents a different way of thinking, but does it represent a new standard of clean? Achieving that higher standard of clean requires the ability to reach throughout complex anatomies, disinfecting and debriding from the crown into the apical third — and leaving no lateral canal or microscopic tubule behind. The GentleWave® System from Sonendo® accomplishes that goal using patented Multisonic Ultracleaning™ technology. Multisonic Ultracleaning technology enables the GentleWave System to deliver a powerful vortex of degassed NaOCI, EDTA, and distilled water through the entire root canal. The optimized procedure fluids are able to reach into even the most complex anatomies, removing bacteria, biofilm, and Volume 9 Number 4

We need to define what constitutes true cleaning in endodontics. And in defining that term, we need to consider the realities of the root canal and all of its complexities.

smear layer in a way that other technologies simply cannot. By cleaning and disinfecting throughout isthmi, lateral canals, dentin tubules, and curved anatomy, the GentleWave System goes beyond lasers and enables a new standard of clean. Just as importantly, the GentleWave System’s mechanism of action ensures that procedure fluids clean all the way into the apical third. In addition, because the GentleWave System’s fluid management system extracts gases and optimizes the treatment fluid, it prevents the bubbles that can lead to apical vapor lock and restrict the flow of fluids into dentin tubules and throughout the apical third. As the optimized procedure fluids make their way from the crown to the apex, you can achieve highly effective cleaning that’s minimally invasive and relies less on instrumentation. Because there’s less instrumentation involved, GentleWave System users are better able to preserve canal structure and in the process save more teeth. Knowing what we know about patient preferences, that can be very meaningful to individuals weighing their various treatment options. While we at Sonendo are heartened to see that the status quo in endodontics is being challenged on a number of fronts, we believe that an ideal system is one that enables patients to keep their natural teeth, preserves tooth structure, and offers effective cleaning and disinfection into the apical third and throughout the complex

anatomies that are a reality in root canals systems. We invite you to go in-depth and learn more about the GentleWave System and its breakthrough Multisonic Ultracleaning technology. At sonendo.com, you can discover what makes the GentleWave System’s mechanism of action unique. You can also browse case reports, peer-reviewed clinical outcomes, in vitro research, webinars, and more. We offer innovations that are backed by research because we believe the future of endodontics belongs to Saving Teeth Through Sound Science®, and that the ideal innovation — GentleWave technology — has already arrived. EP This information was provided by Sonendo®

REFERENCES 1. Azarpazhooh A, Dao T, Ungar WJ, Da Costa J, Figueiredo R, Krahn M, Friedman S. Patients’ values related to treatment options for teeth with apical periodontitis. J Endod. 2016; 42(3):365-370. 2. Guneser MB, Arslan D, Usumez A. Tissue dissolution ability of sodium hypochlorite activated by photon-initiated photoacoustic streaming technique. J Endod. 2015;41(5):729-732. 3. AAE Position Statement on Use of Lasers in Dentistry. American Association of Endodontists. https://www.aae.org/uploadedfiles/ publications_and_research/guidelines_and_position_statements/lasersnew.pdf. Published 2012. Accessed September 28, 2016. 4. Peters OA, Bardsley S, Fong J, Pandher G, Divito E. Disinfection of root canals with photon-initiated photoacoustic streaming. J Endod. 2011;37(7):1008-1012.

Endodontic practice 35

TECHNOLOGY

structure must be balanced against the ability to offer thorough disinfection throughout the entire canal structure.

TECHNOLOGY

KontrolFlex™ NiTi Files Take the stress out of shaping difficult canals. Take control with KontrolFlex

n today’s market, NiTi instruments are available along a spectrum that spans from pure austenitic (A) phase instruments to pure martensitic (M) phase instruments. These two forms represent two crystalline structures of the same nickel-titanium metal, each with different characteristics. Traditional NiTi files are in the austenite phase at room temperature and are referred to as “Shape Memory” files (for example, Brasseler’s ESX® files). Alternatively, heat-treated files are in their martensitic crystalline phase at room temperature, and these files are referred to as “Controlled Memory” files (for example, Brasseler’s KontrolFlex™ files). The clinical performance of two files of similar design and size can be remarkably different depending on their phase state (“A” or “M”). In general, “A” files are more resistant to excessive torque and less resistant to cyclic fatigue, while “M” files are just the opposite. Also, “A” files will be stiffer and sharper than “M” files of similar size and shape. ESX® (“A”) and KontrolFlex™ (“M”) rotary files are therefore best used for different

KontrolFlex files will rise to their best advantage when treating severely curved canals or cases with limited access where pre-curving is advantageous (advanced cases).

circumstances: ESX files will serve you best when you want to be as efficient as possible (basic cases), while KontrolFlex files will rise to their best advantage when treating severely curved canals or cases with limited access where pre-curving is advantageous (advanced cases).

KontrolFlex (Controlled Memory)

KontrolFlex features Featuring patented controlled memory NiTi* • Superior flexibility and resistance to cyclic fatigue • Extensive range of tip sizes and tapers for constant or variable tapered treatment approach • Ideal for challenging canals • Available in two distinct metallurgies

KontrolFlex files are heat-treated and are available in two distinct metallurgies designated as “Series One” and “Series Two.” The first is a very pure version of a heat-treated file that results in a very ductile, cyclic-fatigue-resistant instrument. It is ideal for severe curves, getting around ledges, and difficult access. It can be pre-curved and will hold its curve once placed as well as any other file available. As a pure “M” phase

instrument, it will be very flexible but softer and subject to unwinding easier than some other “M” phase instruments (but no other instrument will be more flexible and hold its curve better). It is even possible to put a “J hook” on the tip similar to a stainless steel hand file. Series Two is intended for those looking to have a file that “is the best of both worlds.” It is less flexible and cyclic fatigue resistant than the Series One KontrolFlex, but less susceptible to unwinding as the result of torque. Your case selection ultimately dictates what file system(s) are best suited for your practice. Contact Brasseler today to schedule a demonstration of these files in the comfort of your office. EP This information was provided by Brasseler USA®.

* Patent Numbers: 8911573, 9005377

Taper ID Triangular Cross Section

Tip Size ID

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PRACTICE MANAGEMENT

Seven keys to growing your endodontic practice in today’s market Dr. Garth Hatch discusses seven proven strategies that lead to practice growth

Garth W. Hatch, DDS, is President and Founder of Dental Specialist Institute, a dental consulting firm committed to helping specialists receive more referrals, profits, and freedom. As an actively practicing endodontist, Dr. Hatch is aware of the challenges specialists face in today’s dental and economic environment. He coaches endodontists and their teams to better leverage their time, space, and efforts to help minimize stress and maximize results. He is a native of Riverside, California, earned a BS in Exercise Physiology from Brigham Young University and his DDS from Indiana University School of Dentistry. Following graduation from dental school, Dr. Hatch entered the US Army Dental Corps and completed a 1-year AEGD residency at Fort Jackson, South Carolina, and later completed an endodontic residency program at Fort Gordon, Georgia. After serving in Germany, he left the military and purchased an endodontic practice in Kennewick, Washington, where he still practices. Despite moving to a competitive dental market, he was able to grow a solo endodontic practice into a successful three-doctor group practice. Dr. Hatch has authored several articles relating to endodontics and has lectured both nationally and internationally. He is dedicated to helping specialists create the practice of their dreams and achieve more abundance and freedom.

38 Endodontic practice

here are many challenges most endodontists face in today’s current economic environment including lower insurance reimbursements, demographic markets oversaturated with specialists, and some general dentists less willing to refer cases out due in part to their own economic challenges. These and many other issues make the following seven concepts extremely important to grow and thrive despite challenging economic times. 1. Relationship Building Is Critical — Although there are many elements necessary to build and maintain a successful endodontic practice, nothing will make a bigger difference on the success of your practice than building and maintaining solid relationships with your referring dentists. Continually strive to find ways to better serve, support, and help your referring dentists and their patients. For example, how well do you know your top 10 referring dentists on a personal basis? Do you know some of their hobbies, their family situation, and what stresses keep them up at night? Continually ask yourself, “What can we do to better serve and assist Dr. X with his/her needs and goals, both personally and professionally?” 2. Hire a Marketing Coordinator — Your practice needs a marketing coordinator! This must be someone other than the doctor and doesn’t need to be a fulltime position. It can be performed by an existing employee, a spouse, or a part-time hire. They need to be a people person who can build relationships with your referring offices and serve as an ambassador for the practice. They also need to be self-motivated and creative. Their duties can be performed in as little as 10-30 hours per month depending on the size of your practice and referral pool. Their job is to “deliver happiness” on a monthly basis and find affordable, Volume 9 Number 4

Volume 9 Number 4

the world. Is their success due to their amazingly delicious food? I’ll let you be the judge of that, but it’s hard to deny their business systems allow for almost anyone to be hired by their restaurant, quickly learn their systems, and deliver a predictable product that can be reproduced virtually anywhere in the world. Systems within an endodontic practice are critical to delivering high-quality, predictable results on a consistent basis. Everyone within the practice should know and follow the systems. These systems should be improved and updated with time, but should not be left to chance. They should also be based on proven, reproducible systems that continually get efficient, cost effective, and high quality results. 7. Develop a Team of Rock Stars — Highquality staff training in communication skills, phone mastery, scheduling, collections, and exceptional customer service

is one of the best investments you can make for your practice. Get your team trained in proven systems that work for specialists in today’s economy, and review the systems on a continual basis. Help your team members develop a sense of ownership for the success of the practice, and focus on the results that make the biggest impact. When you truly develop a strong TEAM (together everyone achieves more) within your practice, the sky is the limit to the level of success and enjoyment that can be achieved. If you’d like to take your practice to the next level and are interested in seeing how our team at Dental Specialist Institute can help, we are offering a complimentary practice analysis valued at $1,800 for the first 50 Endodontic Practice US readers that respond. Please call us at 509-578-4454, email garth@dentalspecialisti.com, or visit www.dentalspecialisti.com for more information and mention this article. EP

Endodontic practice 39

PRACTICE MANAGEMENT

fun and meaningful ways to do this. A well-trained, motivated, and friendly marketing coordinator can be a major force multiplier for the practice. Create a Monthly Newsletter — Having your own unique monthly newsletter that gets mailed out to your referring offices is a powerful and cost-effective way to “touch” your referring dentists and their staff on a regular basis. If the newsletter is done correctly, it will be meaningful to not only the referring dentists but also their staff. It should be fun and not overly technical, or it will get filed in the trash. Dental Specialist Institute designs custom practice newsletters for our clients that spotlight a case of the month, list upcoming local events such as CE study clubs, etc., and has a trivia contest that referring offices love. We also include brief articles, photos of local dental activities, local events and staff highlights. If the doctor is the one coordinating the newsletter, it will rarely happen, so it’s important that someone else has the responsibility. Consider an Associate or Partner — Although an associate or partner may not be right for every practice, having additional coverage within an endodontic practice can reduce overhead, expand the available practice hours, and allow for faster scheduling of treatment. The practice will require enough patient flow to bring on an associate, but eventually this can help both doctors improve their quality of life as well as provide a better service to your referring offices. Wow Your Patients — Current market trends indicate that patients put a premium on exceptional customer service and are willing to pay more for this level of service. Find ways to go above and beyond the expected level of service within your practice. Do you offer your patients drinks, snacks, or other goodies prior to or after treatment? Are your patients able to listen to music, watch television or other options within your office? Does your practice provide pre- and posttreatment phone calls to your patients and sincerely thank them for choosing your office? One of the biggest gifts you can give your patients is to sincerely listen and strive to alleviate their fears and concerns whenever possible. Systems Are the Secret — McDonald’s is one of the most successful, well-known brands and restaurants in

PRACTICE DEVELOPMENT

What you need to know about online reviews for your practice Ian McNickle, MBA, discusses the importance of a strong online presence

magine you’ve just arrived in a city you’re not very familiar with, and it’s dinnertime. What do you do? Well, if you’re like most people these days, you’ll pull out your smartphone and search online review sites such as Yelp for nearby restaurant reviews. In fact, over 90% of consumers now read online reviews to help them decide where to go and what to buy.* While it is true the most commonly searched category for online reviews is restaurants, most people don’t realize the second most commonly searched category for online reviews is dentists/doctors.* The days of ignoring your online reviews are over.

Why do reviews matter? There is a major trend toward patients researching their healthcare providers before visiting an office, even if they were referred by a friend or another healthcare provider. In fact, recent surveys have found that 80% of consumers trust online reviews just as much as personal recommendations from someone they know.* For many people, this is an amazing statement, but the reality is our society is changing at a rapid pace, and dental practices simply must focus on their online reviews and online reputation.

The “Big Four” review sites for dentistry In the dental industry, the most important review sites are Google+, Yelp, Healthgrades®, and Facebook®. 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 WEO Media online at www.weodental.com.

40 Endodontic practice

Google represents about 65% of all online search traffic and features its own reviews from Google+, so those reviews will generally attract more readers than other review sites. Reviews on Google+ have the added benefit of helping your website SEO perform better in online searches related to dentistry. Yelp has become one of the leading review sites in the country and regularly ranks highly in local search results when people search for dentists. In addition, the Bing search engine displays Yelp reviews as its primary reviews shown in search results. Healthgrades is the largest healthcare directory and review site in North America and has over 1,000,000 visitors per day. As with Google+ and Yelp, a solid Healthgrades profile helps both online reputation and website SEO. Over the last few years, Facebook reviews have become increasingly important since Facebook is the dominant social media site. Facebook has over 1.7 billion regular users, and most of them look at reviews on Facebook business pages when researching a business.

What can you do for your dental practice? To get the maximum benefit from these review sites, we recommend the following strategies:

1. Completely fill out your review site profile pages with business information, photos, videos, office hours, specials, and any other relevant information about your practice. 2. Link to your review sites from your website to encourage existing patients to write reviews, and potential new patients to read your reviews. 3. Implement a proactive strategy to generate more patient reviews on these review sites. However, we highly recommend you contact your state dental association or Dental Board to make sure you understand the rules for soliciting reviews from patients in your state. 4. Embed your positive patient reviews directly into your website.

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

REFERENCE *

Bright Little Light, Ltd. Local consumer review survey 2015. BrightLocal. https://www.brightlocal.com/learn/localconsumer-review-survey/. Accessed September 22, 2016.

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 9 Number 4

What sets it apart?

his past March, Ultradent introduced MTAFlow™ mineral trioxide aggregate (MTA) repair cement, made especially for pulpotomies, pulp capping, root-end filling, apexification, perforation repair, and root resorption. MTA endodontic repair cements, including MTAFlow repair cement, are used in numerous endodontic procedures and form a layer of hydroxyapatite after the clinician expresses the product into the canal. Dr. Carlos Ramos, an endodontist, says: “One of the truly beneficial advancements in dentistry has been the introduction of mineral trioxide aggregate repair cements into endodontic treatment. The development of bioceramicbased materials has greatly improved pulp cappings, pulpotomies, the treatment of open apices, apicoectomies (retrograde fillings), and accidental perforation and resorption repairs.”

Yes, the chemistry itself has indeed greatly improved the science and practice of endodontics for patients and clinicians alike, but it hasn’t been without its downfalls. Dr. Ramos continues: “Even though MTA has proven to be an excellent repair material, the biggest weakness of both white and gray MTA cements is that they are not easy to use. The delivery of MTA to different sites inside the tooth has emerged as a major challenge. The handling of MTA based on powder and pure water mixtures resembles the handling of wet sand in some aspects, or it loses consistency in the presence of excess liquid, even at the proportions recommended by the manufacturer. MTA is not easy to mix and is even harder to deliver to the right spot without making a mess, as it can stick to metal instruments better than it attaches to the cavity walls or to itself. A variety of different tools and guns have appeared on the market to facilitate the placement of MTA, but have not presented the proposed easy and accurate delivery.”

However, Ultradent’s MTAFlow repair cement allows for quick and easy mixing to the clinician’s desired thickness and achieves a smooth consistency thanks to the ultrafinegrained powder and proprietary gel mixing medium. In fact, MTAFlow cement is the only mineral trioxide aggregate repair cement specifically designed for smooth and easy expression through a tip as small as Ultradent’s 29 ga NaviTip® tip. Additionally, the mixing ratio of the powder and water-based gel components of MTAFlow repair cement can be varied in order to achieve various consistencies. A thin consistency can be delivered through a delivery tip for applications that demand more accuracy and control such as apexification, resorption, or an apical plug procedure. A thicker consistency allows for pulp capping, pulp chamber perforation, and pulpotomy procedures. Mixing MTAFlow repair cement into a putty-like consistency allows the clinician to perform root filling procedures as well. To learn more about what sets Ultradent’s MTAFlow repair cement apart from similar products on the market, visit www. ultradent.com. EP This information was provided by Ultradent Products Inc.

Volume 9 Number 4

Endodontic practice 41

PRODUCT PROFILE

MTAFlow™ Repair Cement

LEGAL MATTERS

Letters to referring doctors may keep you out of court Dr. Robert M. Fleisher discusses the importance of proper documentation The following is an excerpt from From Waiting Room to Courtroom: How Doctors can Avoid Being Sued. ..................................................................

ommunication between doctors is an essential part of the healthcare process. It helps to ensure coordination and quality of treatment.1 While most offices have generic, computer-generated letters to communicate with patients and other doctors involved in treatment, there are other ways to provide this communication, including handwritten notes and emails. Always be careful about your correspondence, making sure whatever you write is not going to be regrettable. Also note that patient medical information is protected by rigid HIPAA laws, and as such, any communication must be secured. HIPAA is an area of importance and is described in its own chapter. Specialists are generally the ones who have to keep referring providers with up-todate reports regarding their patients’ treatment. If all is routine, the generic, computergenerated letter works fine; however, for the more involved case that can’t be described by a generic note, the customized letter needs to be sent. You must keep a record of all notes, letters, and emails that you send to anyone regarding your patients. Never jot down

Robert M. Fleisher, DMD, graduated from Temple University School of Dental Medicine and received his certificate in endodontics from The University of Pennsylvania. He taught at Temple University and The University of Pennsylvania and is now a member of the Affiliate Attending Staff – Albert Einstein Medical Center, Philadelphia, Pennsylvania, Department of Dental Medicine, Division of Endodontics, Philadelphia, Pennsylvania. Dr. Fleisher is the founding partner of Endodontics Limited, P.C., one of the larger endodontic practices in the United States. After retiring from practice, he now devotes his time to writing about practice management, aging, sex, relationships, health issues, and fiction with a medical bent. Contact Dr. Fleisher at drfleisher@bedsidemanner.info. Read about all of Dr. Fleisher’s methods to stay out of the courtroom in his book, From Waiting Room to Courtroom: How Doctors can Avoid Getting Sued. The preceding is an excerpt from the book published by JAYPEE, The Health Science Publisher. Available at all medical bookstores or online at www. jaypeebrothers.com/MyShop.aspx.

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notes on your computer-generated letter without scanning or copying it into the patient chart. You don’t want to be surprised by some attorney placing into evidence a clinically relevant letter you wrote that you don’t have in your chart. Even if the content of the letter or note is irrelevant to the case, not having copies of letters you sent makes you look inept in the eyes of the jury. If you find that your practice requires many customized letters, and you prefer to use handwritten notes for expediency versus the dictated letter, you may want to consider NCR (non-carbon-required) paper notes. This allows you to make a duplicate copy of the letter to keep in the patient chart. The alternative is to copy or scan all of your individualized handwritten notes into your records if you have a paperless office.

Routine letters Most areas of practice have routine letters that are used often, and for these situations, you should have scripted, computergenerated letters that address the most common issues. The thank you for referring letter and the treatment completed letter are most common and easily incorporated into any practice. By utilizing “mail-merge,” these letters can appear to be customized with the name of the patient, the treatment provided, as well as being automatically addressed for mailing. A good software program does this for you. Because these letters are essentially all the same, you don’t have to save a hard copy or a computer copy on file. However, you do need to have some way of indicating in the chart that each letter was sent. It can be a check-off box with a date or a full sentence indicating that the letter was sent: “Thank You Letter sent 4-12-15.”

Defensive letters Letters to patients and referring doctors can be used to protect yourself by establishing your defense before any lawsuit is instituted. Because these are not routine letters, copies of all custom, case-specific

letters should be placed into the chart either by hardcopy or scanned copy.

Failure to diagnose protection letter One of the most important ways to protect yourself from failure to diagnose lawsuits includes letters to referring providers that indicate you noticed problems such as pathology or conditions they may have missed. This letter protects you by pointing it out to the other provider; i.e., you fulfilled your obligation to notify the referring provider. And, of course, you noted the problem in the patient chart. You also have an obligation to notify the patient, and that should be resolved by explaining the issue to the patient and making an entry into the chart stating that you had a conversation about the issue. A discrete way to manage that conversation is addressed in The Patient Chart chapter – Duty to Notify.

AMA — Against Medical Advice letter Letters can be used to notify patients about conditions that they neglect to address or remedy. This letter establishes a clear date for the statute of limitations along with patient chart entries indicating the patient was advised — the notation AP (advised patient) is used as a charting shortcut; e.g., AP untreated periodontal condition requires follow-up with dentist. After years of neglecting to engage in a recommended treatment, patients may try to blame the doctor by stating he/she “never told me” about the condition. While every recommendation and refusal should be noted and dated in the patient chart, a follow-up letter adds to a strong defense, especially if it is sent registered, return receipt Volume 9 Number 4

Untoward event letters When complications of treatment occur or in cases where treatment fails, a letter outlining the occurrence should be sent to referring providers explaining the situation. This letter should never place blame on you unless it was your fault and you wish to make that pronouncement. To the contrary, it is best to use this letter to establish your defense by placing blame on causes that are not under your control. For example, if something is perforated, it was the result of the weakened, frail, inflamed tissue, the extreme curvatures of the canals or blood vessels, or blockages that caused the problem. When instruments, files, fiber optics, or implants break, it is due to the calcified tissue, curvatures of the canals/blood vessels, or blockages, or whatever conditions may have caused the problem. Infections that require prolonged care and hospitalization are described as virulent strains rather than iatrogenic in nature. In defending yourself, you must place the blame on the patient as he/she will most certainly try to place the blame on you. These three examples show how a letter should and shouldn’t be constructed: Dear John, I completed the root canal therapy on your patient Jane Doe. A perforation occurred during the procedure that required a surgical intervention (apicoectomy). She is doing well…. Versus: Dear John, I completed the root canal therapy on your patient Jane Doe. I perforated at the level of the apical third. This required a surgical intervention (apicoectomy). She is doing well…. Versus: Dear John, I completed the root canal therapy on your patient Jane Doe. During the course of the treatment I found much calcification and Volume 9 Number 4

curvature of the canals. There was a resultant perforation that required a surgical intervention (apicoectomy). She is doing well. … In the first example, the letter is neutral, just mentioning the occurrence of a perforation with no blame assigned. This letter, while not incriminating, leaves the doctor open to attack where the blame will surely be placed on the endodontist if the patient decides to sue. The second letter, not unreasonably, can be interpreted to state that the doctor was to blame — I perforated — and this admission will be used to win the case for the plaintiff. The third letter clearly assigns blame on the anatomy of the root canal and the calcification of the pulp tissue that caused the perforation. You should always attempt to establish the blame for untoward occurrences on uncontrolled consequences. This should be unmistakably stated in the patient chart as well as in any letters to anyone involved in the case. If you don’t establish blame, the plaintiff’s lawyer will.

If there is a bleeding complication, it wasn’t because you severed the artery intentionally; it was due to the high degree of inflammation or the anatomic anomaly placing the vessel in this most unusual position. When a patient has an allergic reaction to a medication, it isn’t caused by your prescribing the medication. It is due to the patient’s immune system’s allergy to the medication. Besides using these techniques in letters, they can also be used in verbal explanations you have to make to patients when things go wrong. This is not complicated. You must think about why something happened and then explain it in terms that relieve you of blame. This information is not intended to have you consider fabricating your side of the story. It is merely making you aware that whenever the blame for untoward events is not related to your iarogentics; make sure you describe it in the appropriate manner. EP 1. Shannon D. Effective physician-to-physician communication: an essential ingredient for care coordination. Physician Exec. Jan-Feb 2012;38(1):16-21.

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Endodontic practice 43

LEGAL MATTERS

requested. Patients often claim they never receive warning letters just as they never receive your bills. Most practitioners don’t use this level of caution because they believe the chart entries are sufficient. They probably are when properly documented. You decide how much caution and peace of mind you require. Most attorneys will not take a case that is well documented with chart entries that describe patient advice and warnings and follow-up letters that corroborate the chart entries.

SMALL TALK

Become an essentialist to find happiness in your success Dr. Joel C. Small offers direction in the quest for happiness and balance

In today’s world, our values are challenged on a regular basis, and the

have found that doctors who experience a success/happiness imbalance are actually doing too much. Compounding this problem is their failure to identify what they most value, as well as what is essential. Furthermore, they fail to prioritize and delegate the majority of what they do, and finally, they are unaware of the necessity for establishing boundaries. The following are four areas and how they might contribute to the success/happiness imbalance as well as its cure.

most successful and fulfilled doctors are those who make values non-negotiable. It is their self-imposed boundaries that make this possible.

Identify what is most valued I am continually amazed at how many doctors have no sense of what they value. In my opinion, identifying one’s core values and the ability to align these values with actions and behaviors is an absolute necessity in creating both happiness and success. Early in our coaching relationship, each of my clients is asked to conduct an exercise that is specifically designed to identify his/her personal core values. One of the cornerstones of professional and executive coaching is a commitment on the part of the clients to honor these values in all that they do. I have heard coaching colleagues describe core values as being the guiding principles around which we make all of our personal and professional decisions. To many, core values are what is “right” or “true.” They are both the sail and rudder that Joel C. Small, DDS, MBA, ACC, 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 joel@joelsmall.com or www.joelsmall.com.

44 Endodontic practice

guide our ship to a predetermined destination. When viewing core values from this perspective, it seems self-evident that they are critical elements for both success and happiness. Take the time to define your core values, and then honor them as you follow the path to finding happiness and success.

Determine what is essential Greg McKeown in his bestselling book, Essentialism: The Disciplined Pursuit of Less (highly recommended), states that when we fail to purposefully and deliberately choose where to focus our energy and time, other people (bosses, family, patients, staff, etc.) will choose for us, and before long, we will lose sight of everything that is meaningful and important. I can attest to the truth of this statement. By losing sight of what is important and meaningful, we create an imbalance in our success/happiness relationship. One of my clients stated that when she lost sight of what was meaningful, it was as if she were living from a set of values that were not hers. She was financially successful, and yet she felt as if she was working to fulfill someone else’s dream. So how do we determine what is essential? The good news is that essentials are

easy to identify. They are those actions and behaviors that only we can complete successfully and that move us closer to our goal while honoring our values. As an exercise, I have my clients keep a journal of their activities throughout the week. At our next coaching session, we review this journal and collaborate on determining which activities meet these criteria. The rest of the activities are categorized and left to deal with as non-essentials.

Prioritize and delegate John Maxwell once wrote, “It is hard to overestimate the unimportance of practically everything.” Once we adopt the philosophy of essentialism, the truth of this statement becomes very clear. Quite simply, we do too many needless things that fail to advance our cause, honor our values, or serve our purpose. Prioritizing and delegating are vital skills that free us from these needless tasks that drain our energy and distort our focus. When we lose energy and focus, we are no longer able to utilize our skills and time to their best and highest use. Take the essential items list you have now created, and prioritize the items in order of their relative significance to achieving your Volume 9 Number 4

Volume 9 Number 4

We both had a good laugh when we realized that he had recently spent a good portion of his Friday afternoon checking the dates on the drugs in his emergency drug kit. When we came across this item, I couldn’t help but say, “You’ve got to be kidding me!” He laughed as well and knowingly said, “You mean someone else can do this?” Enough said.

Create boundaries Boundaries create clarity with regard to what is or is not an acceptable action or behavior. Consequently, they assist us in avoiding non-essential actions that cause us to deviate from our chosen path. For example, in my office, we want our staff to have the freedom and empowerment to make independent decisions regarding our patients’ overall experience in our office. We also want to expedite the decision-making process by making it as simple and clear as possible. My office staff knows that their actions are bound by only two critical considerations: Is their intended action consistent with our practice values and in the best

interest of the patient? They find that this degree of clarity and simplicity enables them to effortlessly act within these boundaries and function expediently without agonizing over the decision-making process. Values dictate the nature of our boundaries, and boundaries are intended to protect our values. In today’s world, our values are challenged on a regular basis, and the most successful and fulfilled doctors are those who make values non-negotiable. It is their selfimposed boundaries that make this possible. Boundaries are vital to our ability to focus and use our energy efficiently. Boundaries come from a firm sense of commitment to what we value, and they can only exist if we respect ourselves enough to insist upon them. They are the natural progression of the process I have shared: identifying values, determining the essential, prioritizing, and delegating. To receive a free copy of my “Core Values Exercise,” please contact me. I am also available for a complimentary coaching session to discuss your practice-related issues. EP

Endodontic practice 45

SMALL TALK

goal. Those items that are highly significant will go to the top of the list while those that are moderately or minimally significant will go to the bottom of the essentials list or drop from the list entirely. You now have a list of perhaps eight to 10 essential tasks that, once completed, have the greatest potential to provide you with both success and happiness. These are the tasks that should demand the majority of your time and focus. Those items that fail to make your essentials list are considered to be non-essential and should be delegated to staff or out sourced. This is not to say that these unessential tasks are insignificant. They may be quite significant. They just don’t have to be done by you. As an example, I have a doctor-client and friend who finds himself in the office 5 days per week. His is a very successful clinician, but after 30 plus years of practice, he would like to find a way to cut back to at least 4 days per week in his dental office. He admits to being a poor delegator, so I asked him to keep a journal of his weekly activities for us to review.

ENDOSPECTIVE

Hang it up, or rev it up? Dr. Rich Mounce explores re-examining enthusiasm for endodontics

ooner or later, we all stand professionally at a decision fork in our career path. One road requires us to keep revving our professional engines to continue on and the other fork to possibly hang it up and do something else. When confronting these questions, which fork to take? What questions can guide us? Consider these as a starting place: • Does clinical practice energize or deplete us? If depleting, is it reversible? If energizing, what can heighten our experience? • Are we in practice primarily for personal gain, or do we gain some other (and ultimately more important) nonmaterial benefit from practice? • If we could do anything we want in clinical practice, what would it be, and are these goals attainable? Answers to these questions will be as individual as each of us. But, on balance, if we look forward to going to the office, clinical practice energizes us. If we don’t look forward to going to the office, it doesn’t. This energy is gravitational — it is or isn’t. This is not a rational decision that we like or dislike what we do. At a “gut level,” our experience of practice is a reality whose truth, if we are honest with ourselves, cannot be denied. Regardless of what we might tell others, each of us knows privately whether we are in the right occupation and/or whether we enjoy practice as much as we once did, or frankly, if we ever did. Careers do not require linearity. A endodontic career can take myriad forms and combinations ranging from teaching, writing papers, doing research, donating time, or volunteering service, owning an endodontic supply company, consulting, working in the military or public health, and

Rich Mounce, DDS, has lectured and written globally in the specialty. He owns MounceEndo. com, an endodontic supply company based in Neskowin, Oregon (605-791-7000). He can be reached at RichardMounce@MounceEndo.com, MounceEndo.com. Dr. Mounce has no commercial interest in any of the products or companies mentioned in this column.

46 Endodontic practice

When we see reality for what it actually is and not what we think it is (or should be), we can begin to fully utilize all of the resources at our disposal and move in a direction that is authentically ours alone.

being an opinion leader, etc. Each of these represents but a small sample of many nontraditional endodontic career tracks. Having done of a few of these things myself, I can attest to their energizing my long-term desire to be involved in endodontics and in developing other skills. Whether we are ready to retire or simply re-energize ourselves to find a new altitude, we must accept that here are no guarantees of success. There is no list of tasks at whose end is financial success and happiness. There are only clues that can point the way toward success and happiness — clues such as honesty, study, practice, empathy, communication, etc. When we see reality for what it actually is and not what we think it is (or should be), we can begin to fully utilize all of the resources at our disposal and move in a direction that is authentically ours alone. Said differently, as much as I would like to be

the right fullback for Real Madrid soccer club, it is not going to happen. Can MounceEndo. com overtake Dentsply? Probably not, but why not try? Do you believe in the possible? Are you an achiever or a cynic? You can tell an achiever from a cynic instantly. The achiever hears a new path and is interested in how a given task might be accomplished and wants to learn more, even if the outcome appears outwardly fantastic (like overtaking Dentsply)! The cynic listens only to immediately tell you all the reasons something cannot happen, and of course, it never does. Which are you? And if something has been done successfully once, can it be done successfully again and probably better? Of course it can. What is the one step you can take today to re-energize your professional life? Take it. Enjoy the journey. I welcome your feedback. EP Volume 9 Number 4

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PRACTICE DEVELOPMENT

Am I getting the best deal? Lisa Radman White discusses how to make the purchase process beneficial for the buyer and seller

f you are ready to purchase your own practice, you want to make sure that you get the very best deal. No one wants to get taken advantage of or to pay more than necessary for something. Purchasing an endodontic practice is most likely different from anything you have ever purchased before. You are not purchasing a car or a house; you are purchasing something unique. You are purchasing someone’s life’s work, someone’s “baby” — a person’s goodwill. Regarding a car or house, you just want to get the best price you can for the item you are purchasing, but when purchasing an endodontic practice, getting the best deal doesn’t always mean getting the lowest price. I’m not suggesting that you should pay more than the endodontic practice is worth, but I am suggesting that you pay a fair price. How do you know what is fair? The practice should be evaluated by someone who knows what the value of an endodontic practice should be. If the practice has been priced by someone who understands the value in an endodontic office, then the price set should be fair. A brief description of fair is purchasing a practice based off the cash flow to ensure that the dollars you will earn from the practice cover the debt, expenses, and leave you still earning at least 40% of your collections. Should you decide to negotiate off of a fair price, the message that can be received by the seller is that this person does not value what I have to sell. Negotiating can actually cost you, as the seller is not as motivated to help you. A good transition firm will ensure that an effective transition is in place before moving forward, but it’s human nature that we work harder and do more for those we care about and whom we feel have treated us fairly. Let me provide two real-world examples, and then you decide which type of Lisa Radman White is the president of Radman, White & Associates, Inc., a transition firm solely focused on transitioning endodontic practices. She has lectured at the AAE and most of the endodontic residency programs. She can be reached at lisa.white@endotransitions.com or 972-386-7222.

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transition you would prefer to be a party to. Recently, a purchaser made an offer on a practice that was a full-price offer. The practice was appraised fairly, and the seller was so pleased that after receiving the offer, but prior to closing, the seller purchased a new computer and a new compressor for the practice, just to be nice. The seller was eager to introduce the purchaser to the staff and the referrals to make everything flow as smoothly as possible for transitioning to the purchaser. This seller exceeded every requirement for transition, and he was motivated to go above and beyond what was required of him. On the other end of the spectrum is a seller who was motivated to sell and offered the practice for below market value. In addition to the reduced offering price, the purchaser made an even lower offer. This seller also fulfilled his transition requirements, but he just met the minimum transition requirements and was ready for the entire process to be behind him. I can assure you that these two sellers had a different approach and differing enthusiasm for the transition. In the case of the full price offer, the purchaser received more in goodwill

than the small amount they could have negotiated off the price. If you work with a bank that is accustomed to loaning on an endodontic practice, you should be able to get 100% of the purchase price, plus working capital from the bank if there is an appraisal done on the practice. The bank is protective of purchasers as it wants to be assured that the transaction is priced fairly for the purchaser, and thus, the bank will get paid back. Banks are currently lending money at 4%, and the loan term is typically 10 years for an endodontic practice transition. Under these terms, a $50,000 decrease in purchase price is equal to a difference of $6,075 in the first year. So for about the cost of one root canal every other month, you save $50,000 upfront. However, you take a chance at destroying goodwill. Our motto is basic and well-known: Treat others as you would want to be treated. If you proceed in this manner, the goodwill you receive when purchasing a practice should surpass and benefit you in many ways that exceed getting a slight reduction in price and thus result in the best deal. EP Volume 9 Number 4

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