Endodontic Practice US - August/September 2013 - Vol 6 No 4

clinical articles • management advice • practice profiles • technology reviews August/September 2013 – Vol 6 No 4

PROMOTING

EXCELLENCE

IN

ENDODONTICS

Top ten tips

8

#

Tip irrigation in endodontics

Ultrasonics in orthograde endodontics

Dr. Sanjeev Bhanderi

Dr. Tony Druttman

ProTaper Next: a clinical study Dr. Edmond Koyess

Corporate profile TDO Software

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Practice profile Dr. Anthony Horalek

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IMAGING

UTILITY ROOM

MERCHANDISE

No. 2 in a Series

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

T

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

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he axiom in implant dentistry is “implant dentistry is a restorative treatment with a surgical component,” meaning that the restoration dictates how the implant needs to be placed and where. But, endodontics also is restorative-driven. Essentially, it does not matter if we can find the canals and instrument and obturate them IF we cannot predictably restore that tooth.

Basic concepts of restorative dentistry seem to have fallen by the wayside as the bonding evolution has rolled forward. Practitioners have forgotten the concept of a ferrule when placing a crown on a tooth, as bonding can retain the crown to whatever minimal tooth is present. The use of posts among the younger practitioners is not necessary because a core can be bonded to the remaining tooth structure.

Long-term survival of endodontically treated teeth is dependent on load handling of the restored tooth. When a ferrule is not present or minimally present, as supported by the literature, stress concentrates at the interface between the root and crown margin.

Over time, with repeated loading, recurrent decay can result at the micro gap that opens at the crown margin and/or the crown dislodges often with whatever core material was placed still within the crown. This is more critical in the maxillary anterior due to its offaxis loading under function. Auxiliary procedures such as osseous crown lengthening or orthodontic forced eruption can improve a ferrule but need to be weighed both timewise and financially, compared to extraction and placement of an implant.

When after crown preparation, native tooth structure is not present circumferentially to encircle the core, loading on the crown is on the core-tooth interface. A post should be considered to help retain that core to the remaining tooth and again improve longevity of the restoration.

Conservative dentistry is often looked on as minimally preparing the tooth. But we need to view this as removing only as much tooth structure as is needed to achieve the treatment goals we have planned. When endodontics is part of the plan for that tooth, conservation of the cervical tooth structure becomes critical and affects the long-term survival of the tooth. Stresses are concentrated at the tooth’s cervical area, and the more dentin that can be maintained in this region, the better stress handling the tooth can sustain.

Prior to the introduction of rotary endodontics, hand files were used for the instrumentation. These files were a 0.02 taper and minimally widened the canal in the cervical region preserving dentin. With the use of rotary files, wider and wider taper files were introduced, with tapers of 0.08 up to 0.12 designed to create canal shapes easier to obturate, but at the expense of cervical tooth structure. As rotary files evolved and the understanding of preservation of cervical tooth structure was understood, files were introduced with less taper (0.04 and 0.06) that provided the best of both worlds, better canal shape to obturate than standard hand files, and less cervical tooth structure removed. Conservative endodontics had arrived.

Evaluation of the tooth presenting with clinical and radiographic indications that endodontic treatment is indicated needs to start with “can this tooth be predictably restored?” If the answer is yes, then we need to determine what needs to be done to restore the tooth. Will a post be needed? Can a ferrule be achieved, and if not, what do we need to do to create that ferrule? When the answer is “No, this tooth cannot be restored predictably,” then extraction is indicated, and we need to look at what options can be utilized to replace the tooth/teeth that will be missing.

Restoration of the tooth is the core of dentistry, and whether it’s implants or endodontics, evaluation and treatment need to start from the restorative aspect. Before determining if the tooth will require endodontic treatment, we need to decide if that tooth can be restored predictably and then determine if endodontics will or can be performed.

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Volume 6 Number 4

Endodontic practice 1

INTRODUCTION

Restorative-driven endodontics

August/September 2013 - Volume 6 Number 4

TABLE OF CONTENTS

Case study

Practice profile

6

Dr. Anthony Horalek: The art and science of endodontics Determination, creativity, and inspirational mentors are guiding lights in this clinician’s search for excellence.

ProTaper Next: a clinical study Dr. Edmond Koyess describes a new approach to shaping, cleaning, and filing canals effectively........... 14 Treatment of a crown-root fracture using a composite endodontic post Drs. Jozef Mincík and Marián Tulenko present a case report detailing the treatment of a crownroot fracture................................. 18

Endodontics in focus Top ten tips: Tip number 8 – Tip irrigation in endodontics Continuing his series on endodontics, Dr. Tony Druttman looks at an important type of disinfection.................................. 22

Corporate profile

10

Make TDO Software your next move Providing endodontists with the tools and resources to build and maintain a successful practice.

2 Endodontic practice

Volume 6 Number 4

simple, adaptable

endodontic solutions

Irrigation amplification

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800.552.5512 ultradent.com Use NaviTip to easily deliver Ultradent irrigants just short of the apex. Available with regular and sideport delivery. *Smaller-volume syringes still available. © 2013 Ultradent Products, Inc. All Rights Reserved.

Irrigants

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Scan to watch a short video about Ultradent irrigants.

TABLE OF CONTENTS

Endodontic concepts Dr. Julian Webber’s 10 steps to endodontic heaven The most important endodontic principles in 10 bullet points ..........46

Practice management Negotiating successful payment

38

UniCore

arrangements Looking for perfect payment arrangements? Janice Keller reveals four easy steps to help you succeed every time, with every patient ........48

Endospective Continuing education Ultrasonics in orthograde endodontics Dr. Sanjeev Bhanderi discusses the role ultrasonics can play in conventional (orthograde) treatment in the contemporary endodontic practice .....................................................26 Intraosseous biocompatibility of an MTA-based and a zinc oxide and eugenol root canal sealer Drs. Osvaldo Zmener, Ricardo Martinez Lalis, Cornelis Pameijer, Carolina Chaves, and Gabriel Kokubu evaluate the biocompatibility of FLPX when implanted in bone tissue of the rat tibia and compare it to Grossman sealer ...........................................32

4 Endodontic practice

Step-by-step

The benefits of a “beginner’s

UniCore Post and Drill System .....................................................38

mind” Dr. Rich Mounce focuses on regaining the excitement of dentistry ............50

Research

Anatomy matters

Comparison of isthmus debris removal using three different irrigation techniques Drs. Kathryn L. Aasen, Brian E. Bergeron, Mark D. Roberts, Van T. Himel, Thomas E. Lallier, and Kent A. Sabey evaluate the effectiveness of debris removal in mesial roots of mandibular molars.........................40

“What’s It All About?” Part 7 Dr. John West recognizes that the best education in the world is an endodontist’s own personal education .....................................................52 Diary.............................................55 Materials & equipment ..............56

Volume 6 Number 4

PRACTICE PROFILE

Dr. Anthony Horalek The art and science of endodontics What can you tell us about your background?

I started out life with humble beginnings in the state of Nebraska. I grew up on farms, in small towns, and in Lincoln, Nebraska. I was in foster homes from the age of 4 to age 12, at which time I was adopted and my name changed to Anthony L. Horalek.

I attended high school in Palmyra, Nebraska. There were only 29 students in my graduating class. I made the best of it by signing up for the most challenging classes in science, math, art, and business.

I was in drama, on the speech team, and I lettered in track and field.

My adopted father passed away when I was 16 years old. A little over a year later, my adopted mother and new stepfather decided to move to Oregon. Rather than move again, I asked to finish high school at Palmyra, Nebraska and finished out my senior year by delivering newspapers and finding odd jobs to pay my bills, so I’ve been on my own since I was 17 years old.

I wasn’t sure what I wanted to do after I graduated high school, so I decided I would enlist in the military and I signed up to start basic training 6 months after high school graduation. My high school guidance counselor advised me to try one semester of college at Peru State College prior to my enlistment date. I focused on art and biology. I was surprised when I was called for an impromptu meeting with the dean of student affairs, former head football coach and athletic director, Jerry Joy, who advised me to stay in college rather than enlist, so I did.

I then transferred to the Kansas City Art Institute (KCAI) on a full-tuition scholarship with only the shirt on my back. I did well; however I met a dentist while working off-campus. He was impressed with my artistic ability and told me that I would make a great dentist. Following his advice, I took some career testing at Rockhurst University in Kansas City and discovered that dentistry might be a better fit for me.

I then switched my focus to dentistry and went on to study at the University of Nebraska.

While at the University of Nebraska, I applied for and received Reserve Officer Training Corps (ROTC), and Health 6 Endodontic practice

Professions Scholarship Program (HPSP) scholarships. After graduating from the University of Nebraska and spending 4 years on active duty, I applied and was selected for endodontic training in the United States Army. This paid for most of my college education. I accumulated a 10-year active duty obligation, which gave me the opportunity to serve with some of America’s finest soldiers, live overseas, and learn more about how our government operates.

I was a full-time training developer and instructor for 2 years, as well as an executive officer for a 350man training company at the Joint Special Operations Medical Training Center (under the auspices of the Special Warfare Medical Group), Fort Bragg, North Carolina. I also taught an introductory biology course for Campbell University during this time. My last duty assignment was in Germany, where I was assigned to Heidelberg Dental Activity (DENTAC) as an endodontist.

I decided to make my home in Raleigh, North Carolina, where I have lived and practiced endodontics for the past 7 years.

Is your practice endodontics?

limited

to

My practice, North Raleigh Endodontics, is limited in its scope, based on my training, experience, abilities, and in accordance with state law. As dental specialists, I believe we should narrow our scope to match our training and expertise. The breadth of this scope and the language that defines endodontics as a specialty are debatable, and these will also change over time.

Why did you decide to focus on endodontics?

I’ve always been a curious person and

fascinated about what happens “inside” of things. So I was always curious about the inside of teeth. I pondered prosthodontics and endodontics.

I’ve always been interested in what can be termed precision science and precision arts.

I think endodontics has some characteristics of a precision science and of a precision art.

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

I’ve been practicing dentistry since 1995 or the past 18 years. I was a general dentist for 5 years, and I’ve been an endodontist (residency included) for the past 13 years.

I use The Digital Office (TDO) software, Carestream 3-D imaging (Carestream 9000 3D), Carestream 6100 radiographic sensors, and Ultradent Products, Inc., as some of my favorite products and systems.

What training undertaken?

have

you

I attended the Kansas City Art Institute as an illustrator in-training for 1 year, but my study in this area started in junior high school, when I started teaching myself how to draw.

My formalized dental training after dental school was an Advanced Education in General Dentistry (AEGD) with the U.S. Army at Fort Lewis, Washington.

After endodontic residency at Virginia Commonwealth University (VCU) School of Dentistry, I took 3 years of continuing education on dental implants. I continue to study implants, although it is not the core of my practice.

My military training consisted of Reserve Officer Training Corps (ROTC) and other courses related to military service.

A few courses were cadet Basic Camp, Volume 6 Number 4

PRACTICE PROFILE

The North Raleigh Endodontics team

CBCT post-op findings of type 4 canal configuration

Advanced Camp, the U.S. Army Airborne Course, the U.S. Army Jumpmaster Course, the Combat Care and Casualty Course (C4), the Advanced Trauma Life Support (ATLS) Course, the Expert Field Medical Badge (EFMB), the Instructors’ Training Course, the Training Developers’ Course, and the Collateral Duty Safety Officers’ (CDSO) Course. Suffice it to say these short training courses of 2 to 8 weeks in duration each have also influenced how I think and work today.

Who has inspired you?

In chronological order, the following people have inspired me: James and Alycemae Archer (Lincoln, Nebraska), Dr. Ken Anderson (art professor, Peru State College, Nebraska), Jerry Joy (former college football coach and dean, Peru State College, Nebraska), Jack Lew (illustrator professor, Kansas City Art Institute, Missouri), Jay and Jary Johnson (Des Moines, Iowa), Dr. Sreenivas Koka (UNMC School of Dentistry, Nebraska), Dr. Gary Carr (San Diego, California), Dr. John Khademi (Durango, Colorado), Dr. Joey Dovgan (Phoenix, Arizona), Dr. Jeff Janian (UCSF School of Dentistry, California), Dr. David Sarrett (dean of students, VCU School of Dentistry, Virginia), Dr. Fred Liewehr (U.S. Army Endodontic Program Director/VCU School of Dentistry, Department of Endodontics, Virginia), Dr. Marga Ree (private practice, the Netherlands), Dr. Marc Balson (Phoenix, Arizona), Dr. Rick Schwartz (San Antonio, Texas), and Dr. Nicholas Pediaditakis, (Raleigh, North Carolina). Each of these people has given me something that I try to emulate today, and I am grateful.

Volume 6 Number 4

What is the most satisfying aspect of your practice?

This might sound trite, but the most satisfying aspect of my practice is being able to help patients with complex dental problems. I do this by integrating each patient’s endodontic diagnosis and treatment with his/her comprehensive treatment.

My professional development has been greatly enhanced by participating in forums that are part of our practice management software. By viewing and exchanging opinions on 20-30 cases per day from top clinicians, as well as posting my own cases for comments, I have found that my development as a clinician has been helped immeasurably. Being part of a community with a shared vision has helped me refine my understanding of what the standards are and enabled me to improve my skills and understanding both in clinical and practice management matters.

Professionally, what are you most proud of?

I’d have to say I am most proud of a goal I set when I was in dental school. I set a goal as a freshman that I would achieve straight A’s throughout dental school. I fell slightly short and received a 3.98 grade point average. As a result of that goal, I was the first student in the 100-year history of the University of Nebraska Medical Center (UNMC) College of Dentistry to graduate With Highest Distinction. I had not planned for that; it just happened as a product of the other goal. I felt like I had established excellence in something for the first time.

I look at grades, credentials, and degrees differently today than I did then.

I am now more interested in learning than

Dr. Horalek and Kara treating a patient

“getting the grade,” as these are often two different things. The way in which we measure grades may or may not be a reflection of learning and understanding.

What do you think is unique about your practice?

I make an illustration for every patient and write out my findings and the patient’s treatment options on the illustration. I give that drawing and treatment plan (a visual algorithm) to the patient as a gift after an assistant scans it into our practice management software. I can do this in less than 2 minutes. It seems to amaze patients and referring doctors alike, but it comes naturally to me. It also helps the referring doctor understand what is going on with his/her referred patient because the illustration is included in my report back to the referring office. The illustration also helps me understand what happened long after I saw the patient, without having to search through several pages of treatment notes and documentation. The illustration also serves as part of the informed consent to the patient for the treatment that I provide or do not provide.

What has been your biggest challenge?

My biggest challenge in life has been finding direction. Picking the right direction or goal is just as important, if not more important, than achieving an established goal to me.

I believe that selecting and achieving the most optimal goals helps one achieve his Endodontic practice 7

PRACTICE PROFILE or her potential. We only have so much time and energy, so it is imperative to set goals wisely.

My biggest challenge in endodontic practice was becoming established the first 2 years after the practice opened. I started the practice from scratch, right after I exited the military. I made many mistakes the first 2 years. I am a fast learner though, and I have always been attracted to outstanding mentors. I continue to study what traits and qualities of my mentors have made each one successful. I try to adapt those traits and principles to me and into my practice.

This has helped me become successful.

What would you have become if you had not become a dentist?

I would have become an illustrator or a designer. I may still become these things if I am able to. As a child, I wanted to become a police officer.

What is the future of dentistry and endodontics?

I have not thought about the future of dentistry profoundly, but I am concerned about the many new dental schools cropping up in the United States, without rigorous study on “needs assessment” of the number of dentists needed to serve our population. Are the dental schools opening because there is an underserved population that has a need? Or are they opening as a revenue source for universities? This issue requires more study.

Corporate dentistry (without dentist ownership) is also a hot topic presently. I think non-dentist owned corporations have the potential to harm the entire profession if put into the wrong hands. Corporate dentistry without dentist ownership puts the control of practices in the hands of business men, investors, or corporate boards that know very little about the profession of dentistry, other than it has a high margin for potential profit. There is a great danger here that profit-motive could take over dentistry completely if not regulated by dental professionals. I understand there are two sides to this issue, and that not all non-dentist-controlled, corporately-owned dental offices are practicing badly, and some serve underserved sectors of the public. It will be interesting to see how this plays out.

Another troubling concern is the possibility that the excessive numbers of dentists that will likely be produced by these extra universities could feed into the 8 Endodontic practice

(non-dentist owned) corporate dentistry business models.

This could result in strengthening these types of entities to the point that our present model of private practice, as we know it, will be snuffed out. Dentists could be nothing more than employees whose treatment decisions are largely determined by business models and insurance policy-driven algorithms.

One of my mentors predicts that dental office business models might gravitate toward two different directions: 1) the elite fee-for-service boutique practice, where the patient seeks out the best possible treatment, even if it is more costly, or 2) the corporately controlled, HMO, PPO, insurance-driven, mega-practice.

I think endodontics has a bright immediate future, but there is great room for improvement. Cultural problems exist within our specialty that include some of our colleagues prioritizing financial (money) and personal dominion (power) over professional service. While this is endemic to humankind, it is clear to me and others that this culture, taken to the extreme, has negatively impacted the quality and outcomes of endodontic treatment provided in the United States.

There’s a lie that says something like this: “The more money I make in practice, the better doctor I am.” This is nonsense.

Unfortunately, this is a philosophy that is prevalent within the minds of many dentists in the U.S. today. This has led to the “churn-and-burn” endodontic practice model, where endodontists and dentists complete all treatments (to include complex molars and premolars) in 4560 minute treatment sessions. I fear this practice business model is driven by a forprofit-only motive, not by a professionalservice motive. As a past president of the American Association of Endodontists, Dr. Marc Balson, once exclaimed, “We have met the enemy, and it is us!”

Many patients have been damaged by this philosophy, and our reputation as endodontists has been damaged amongst our sister specialties and referring doctors. I strongly believe it is a hoax to think that we can treat all patients like this and achieve favorable patient-centered outcomes, which should be our top priority as clinicians.

While understanding and discussing disease-specific and process outcomes and how they might relate to the patientcentered outcomes are still important as a scientific endeavor, the misplaced focus on

those outcomes has probably jeopardized the most important outcome....what matters to the patient.

On a very positive note, our specialty has a lot of extremely bright and talented people that can help us navigate through these problems. With hard work, integrity, forward-looking plans, and the right leaders, the endodontic specialty will morph scientifically, biologically, clinically, and politically into a specialty that will remain viable and successful. There will be no status quo.

What are your top tips for maintaining a successful practice?

1) Surround yourself with only the very best people 2) Strive for excellence at every opportunity 3) Be as honest as you can be 4) Have a vision, and plan, plan ahead

What advice would you give to budding endodontists?

Find your talent, and do it better than anyone else.

Work hard, work smart, and put your heart into it.

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

I like to cycle, run, and draw. I like to travel a lot on weekends. I like to read and think profoundly about things. EP Top Ten Favorites • The Digital Office (TDO) software, the TDO organization, and the many friends that I have met at TDO meetings and through the different forums connected to or spun off from TDO. • Ultradent Products, Inc. I love the quality of the products (Skini Syringes, Valo® curing lights, bonding systems, bleaching systems, delivery devices, tubes and brushes, UniCore® glass fiber post system). I’m fascinated by the history of the company, and think highly of Dr. Dan Fischer for his innovation, integrity, work ethic, and generosity to underprivileged young people in his part of the country.

• Traveling and meeting my endodontic friends at meetings, to include Dr. Marga Ree! • Playing tricks on Dr. John “Bayes” Khademi.

That is really one of my favorite things to do.

• The International Academy of Endodontics (IAE), the best new endodontic academy in the world.

• North Carolina. I love the beauty and people of this state.

• Dr. Gary Carr and his approach to using the “classics” as a basis for teaching and learning.

It’s very powerful.

• The Iron Horse Classic bicycle race. Memorial Day weekend every year. You need to try it.

• My cousin, Wade Jensen. First Sergeant, United States Marine Corps (Retired). A true American hero with a heart of gold, who risked it all, to serve his country with true faith, allegiance, and dedication.

• “Super Rick” Schwartz and his relentless work ethic. The man is an animal!

Volume 6 Number 4

Achieve the Optimal Treatment Room with ASI The Cart, With Only One Foot Control The versatility of ASI’s custom integrated cart system allows for infinite positioning of the cart to easily maneuver within close reach during procedures and then out of patient view after procedures. Adding a monitor mount creates an intimate environment for both patient education and clinical use.

Side Delivery An ASI cart positioned at the doctor’s dominant side requires the least amount of tasking movements during a procedure and works efficiently with microscope dentistry.

Foot Control Placement The foot control tubing of an ASI system can be run underneath the floor through a conduit from the junction box to the patient dental chair. The end result creates easy access to the foot control without tubing running across the floor.

The Junction Box In addition to attractively concealing the standard connections of compressed air, suction and electricity, ASI’s unique in-wall junction box allows computer connections such as video, USB, network and other IT connections throughout the office to be easily organized and safely hidden from view.

“The ASI Endodontic carts are a great convenience. This space saving design allows me to be organized and efficient with only one foot control and without all of the cords draped over my counters.”

– Dr. Kelly Jones

1-800-566-9953 • asimedical.net

CORPORATE PROFILE

Make TDO Software your next move TDO is a community of quality-centered endodontists working together to practice at the highest level within our specialty. When you join the TDO family, you are getting far more than the most comprehensive endodontic practice management software available, you are tapping into the knowledge base and clinical expertise of a global network of today’s most respected and accomplished endodontists.

From the clinical to the administrative, for the well-established practitioner or the clinician just starting out, TDO provides endodontists with all the tools and resources they need to build and maintain a successful practice.

TDO mentors postgraduate residents

A Message from our CEO The future at TDO Software is as bright as ever.

As I take the helm of TDO as the new CEO, I look forward to continuing to build strong relationships with each of our software users.

TDO users are the foundation of our company, for they have embraced the legacy that Dr. Gary Carr has built over these past 15 years.

We have had tremendous growth at TDO Software recently, which is a true testament to Dr. Carr’s central vision and his innovation in the field of Endodontics. We have gone from having three employees and 10 users to having nearly 20 employees and 2,000 users in 22 countries across the world. Our growth as a company has been incredible, and TDO is truly the gold standard in endodontic practice management software.

In addition to the dedication from our software users, our internal staff retention is at an all-time high. The majority of our staff, including our technical support team, has worked at TDO Software for over 10 years.

Our products As a working endodontic office, we use all of our own products daily and are continually revising TDO Software to keep pace with the changing needs of both our office and our users. All of our products are designed specifically for the modern day endodontist.

We guarantee that TDO Software will make you a better clinician and help your office run more efficiently. TDO is the complete practice management system for endodontists. > TDO Practice Management Software Anyone can convert a paper form into a 10 Endodontic practice

This is almost unheard of in the technical support industry.

Furthermore, 99% of TDO users recently gave our technical support representatives a superlative rating in the last customer satisfaction survey.

Having worked at TDO Software for the past 12 years, I am continuously inspired by Dr. Carr’s leadership within our company and his ability to attract and retain unique and exceptional people, including our software users. I am inspired by the core values of this company, and I am committed to seeing that those values are embellished even further as I take over the helm. I look forward to what lays ahead for TDO Software and the specialty of endodontics.

Sincerely,

Luiz A. Motta, CEO of TDO Software

Luiz A. Motta CEO

digital form. What makes TDO Software unique is that it was designed and functions the way an endodontist actually works. TDO is the only endodontic practice management software that was created by an endodontist for endodontists and therefore, it is ergonomically designed.

TDO – “The Digital Office for Endodontists” - is universally acknowledged to be the gold standard in clinical documentation. Every detail of our practice management software has been carefully thought out to make you a better, more complete clinician, and help your office run more efficiently. Our Diagnosis Page is the most comprehensive

TDO user meeting in San Diego

radiographic and clinical examination form ever seen in a dental software program.

Our Draw Page makes communication with patients powerful and compelling. The built-in templates and reporting features allow you to stay in touch with referring dentists with a simple click of the mouse.

At every step of the way, TDO Software walks you through all possible diagnosis and treatment options. TDO is a totally integrated, systematic way of Volume 6 Number 4

CORPORATE PROFILE

TDO software users

working that ensures that you don’t miss a single step in the care of a patient. TDO also supports all major digital imaging technologies, including cone beam CT imaging, digital radiography, digital photography, hi-definition video capture, and dental microscopy. > TDO Web Impress new patients before they even set foot in your office with in-home web registration. Patients may complete their contact information, medical history, pain history, and medications in the comfort of their own home, saving valuable time during check in. TDO Web also strengthens your relationships with referring dentists by making patient information available as soon as you finish a case. The patient’s treatment information and images are available immediately on the website, and best of all, TDO Web is completely HIPAA compliant. The ultimate complement to a paperless office, TDO Web is an effortless way to promote your practice that comes complete with a unique web domain, unlimited email accounts, and daily off-site backup. > TDO Mobile Stay connected to TDO Software even when you are out of the office. TDO Mobile allows you to connect to your office anywhere, anytime through an iPhone, iPod Touch, or Blackberry device. Show patients they are a priority by staying in touch when you’re out of town. Impress referring doctors with how quickly you Volume 6 Number 4

respond to calls and emails. Cut down on your staff’s workload by using TDO Mobile to stay up-to-date. With TDO Mobile, you can view patient pre- and post-op X-rays as well as other important images right from the palm of your hand. It comes with all of the features you’ve come to depend on in TDO Software, including reports, tasks, and calendar. It’s just like carrying TDO around in your pocket. > TDO Google Groups: TDO Clinical & TDO Chat Connect with leading endodontists all over the world through TDO’s Google Groups.

Access hundreds of clinical cases each week through TDO Clinical, TDO Chat, and our other online forums. By posting onto these TDO Software forums you will gain insight and answers on your most challenging clinical cases. Subscribers may also use the search feature to access the tremendous database of information regarding clinical topics and cases, office design, and other practical information.

TDO makes it easy to stay current with clinical technology, get questions answered, and share your knowledge with other clinicians through the Google Groups forum. > TDO Ergonomic Design Services The plumbing. The flooring. The electrical.

The cart. There are a lot of moving parts in designing an endodontic office in addition to the matter of ergonomics. By joining TDO, you’ll be able to post questions about anything related to the physical plans of

your office on TDO Chat and hear back from 30 to 40 people who have just gone through the process within a matter of days.

Our users know what the construction costs are in different areas. They know where to buy things at the best price. Best of all, they’re willing to share their advice for free simply because someone else did the same for them.

We can’t emphasize enough the importance of having an ergonomically designed office — an office designed around a sound understanding of how an endodontist works with the microscope.

And no one understands efficient ergonomic workflow better than TDO Software, because we introduced the microscope into the endodontist’s office in the first place. We can help you design a fully functional, esthetically-pleasing office for a fraction of the price you’d pay a commercial design company. > TDO Postgrad At TDO, both we and our users are committed to helping young clinicians establish a philosophy of practice that will guide them through their entire career.

We believe this philosophy of practice is the most important gift we can give young clinicians.

This year, hundreds of endodontic postgraduate residents will venture forth into the world as enterprising young clinicians and thankfully, many of them have had the advantage of using TDO Postgrad. With TDO Postgrad, they can avoid the costly mistakes commonly made Endodontic practice 11

CORPORATE PROFILE by new clinicians, from office design to ergonomics, and they can experience a seamless transition into private practice.

With TDO Postgrad, new clinicians also gain access to TDO Clinical­­­– an online forum where they can see and participate in inspiring cases and join in discussions between top clinicians, educators, and residents from around the world, including all of our TDO users. > TDO University TDO is committed to education. We believe educators will determine the future of our specialty. TDO University gives endodontic residents the edge they need to be their best. A state-ofthe-art endodontic educational system, TDO University provides sophisticated educational tools that are easy to use.

With just a click of the mouse, our software gives you the ability to perform complex clinical, management, and accreditation queries. TDO University’s EHR certified module is the perfect complement to axiUm Academic software™.

TDO is integrated in the following postgraduate endodontic residency programs: • Albert Einstein Medical Center Pennsylvania • St. Louis University - Missouri • University of California San Francisco California • University of Chester - Chester, United Kingdom • University of North Carolina - North Carolina • University of Paris - Paris, France • University of Tennessee - Tennessee The following universities have had students using the TDO Postgrad edition: • Academic Centre for Dentistry Amsterdam • Baylor College of Dentistry - Texas • Boston University - Massachusetts • Case Western Reserve University - Ohio • College Sao Leopoldo Mandic Campinas, Brazil • Columbia University - New York • Eastman Dental Institute, London London, United Kingdom • Harvard School of Dental Medicine Massachusetts • Indiana University - Indiana • Institute for Dental Research & Education - Dubai • Loma Linda University - California • Louisiana State University - Louisiana 12 Endodontic practice

Ergonomic operatory design by TDO

• Lutheran Medical Center - New York • Medical College of Georgia - Georgia • Medical University of South Carolina South Carolina • Nova Southeastern University - Florida • Saudi Commission for Health Specialties • State University of New York at Buffalo - New York • Tufts University - Massachusetts • United States Naval Dental Clinic Okinawa, Japan • University of Adelaide - Australia • University of Alabama at Birmingham Alabama • University of California, Los Angeles California • University of Connecticut - Connecticut • University of Detroit Mercy - Michigan • University of Florida - Florida • University of Illinois - Illinois • University of Louisville - Kentucky • University of Maryland - Maryland • University of Medicine & Dentistry of New Jersey - New Jersey • University of Melbourne - Australia • University of Michigan - Michigan • University of Minnesota - Minnesota • University of Missouri at Kansas City Missouri • University of Nebraska - Nebraska • University of Pittsburgh - Pennsylvania • University of Texas at Houston - Texas • University of Toronto - Ontario • VA Medical Center Long Beach California • Virginia Commonwealth University Virginia

We invite you to join us at the next TDO User Group Meeting & Scientific Session on September 26th to 28th, 2013 in San Diego, California. Our annual meeting will be held at the Paradise Point Resort & Spa nestled on Mission Bay.

More than 500 of the world’s leading endodontists and their staff join us each year for the 3-day meeting, which combines software training for TDO Practice Management Software with courses on office design, CBCT technology, operatory ergonomics, marketing, HIPAA compliance and much more.

This year’s meeting will also have a fully functional ergonomic operatory complete with dental chair, ASI cart, operating microscope, digital radiography sensors, digital cameras, and even a cone beam CT unit to show how TDO Software works in an actual endodontic operatory.

Each year, clinicians travel from as far away as France, Brazil, and Australia to participate in what has become the largest and most comprehensive meeting for endodontists and their staffs. The TDO Meetings are truly one of a kind. Join us this year in San Diego and find out what TDO Software is all about!

TDO Software is the complete practice management system for endodontists.

For more information, please visit www. tdo4endo.com. EP This information was provided by TDO Software.

Join us in San Diego!

Volume 6 Number 4

ARE YOU A DINODONTIST? You might have the slickest looking office in town, but is your software still from the Stone Ages? At TDO, we believe you deserve a software system that helps your practice grow, not one that gets in your way.

TDO Software allows you to provide the best possible patient care. Only TDO enables your staff to be their best by eliminating time-wasting inefficiencies in the office. TDO makes it easy to keep current with the latest technology, terminology, materials and techniques. With TDO you can create professional-looking referral and CBCT reports and print, email or publish them on your website with just one click.

Take your practice out of the museum and into the world of modern endodontics. Evolve today with TDO Software.

This EHR Module is 2011 compliant and has been certified by an ONCDATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.

CASE STUDY

ProTaper Next: a clinical study Dr. Edmond Koyess describes a new approach to shaping, cleaning, and filing canals effectively

A

40-year-old woman, suffering from acute pulpitis of the UL7, was referred to my practice. The medical exam did not reveal any contraindication for endodontic therapy. The clinical exam confirmed the diagnostic approach made by the referring dentist. The radiographic exam revealed a deep decay cavity on the mesial side of this tooth. I also noticed on the preoperative radiographs that the tooth had three roots with moderate curvatures at the apical third in both the mesial and distal roots and a straight palatal root.

The treatment plan was for root canal therapy in one session. After delivering local anesthesia and placing the rubber dam, the access cavity was executed under the dental operating microscope.

The access cavity revealed four canals: two were located in the mesial root and one in each of the palatal and distal roots.

Locating those canals was facilitated by using the Micro-Opener file 06 10 (Dentsply Maillefer).

Figure 1

Shaping procedure, establishing a glide path As when negotiating any fine canal, I started using the K-file 10 (Dentsply Maillefer) lubricated with a chelating gel.

Working lengths were established using an electronic apex locator. Using the same file, I looked for patency in four canals.

This step is recommended to prevent the development of apical plugs.

For safety measures, developing a glide path has become mandatory before using all rotary nickel-titanium. To this end, the canals were enlarged with a K-file 15 FlexoFile® (Dentsply Maillefer), and irrigated with a 6% sodium hypochlorite solution delivered from a 30G side-vented needle.

Edmond Koyess, DCD, CES, DSO, FICD, is chairperson of the endodontic department at the Dental School of the Lebanese University in Lebanon. His practice is limited to microscopic endodontics. He is past president of the Lebanese Society of Endodontology.

14 Endodontic practice

ProTaper Next™ for shaping the canals I opted to work with the newly-introduced ProTaper Next set (Dentsply Maillefer).

These files are made of M-wire nickeltitanium known for its resistance to cyclic fatigue. They are designed with a rectangular cross section with an offset distribution of the blades that develops a “swaggering” motion to further reduce cyclic fatigue and better evacuate the canal debris toward the access cavity.

The ProTaper Next set comes in multiple taper shapes and has the added advantages of the classic ProTaper for cutting efficiency and easily developing a tapered shape in the canal. The set is essentially composed of only three files (X1, X2, and X3), designed to achieve the whole shaping procedure.

The file selection in this case was as follows: X1 and X2 for both mesial and distal roots, with the X3 added for the palatal canal (for anatomy reasons, taking

into consideration the width of the palatal canal of upper molars).

These files are driven by the X-Smart™ Plus motor (Dentsply Maillefer) with a rotation speed of 250rpm and torque of 4.5 Ncm. The dynamic movement of these files is a brushing in-out in the apical direction for 4-5 seconds. The file is then withdrawn and cleaned on a wet gauze with antiseptic solution.

The canal is continuously irrigated with 2ml of sodium hypochlorite throughout the whole procedure, especially after withdrawing the shaping file from the canal.

The patency K-file 10 is used once or twice in the canal during the whole procedure to prevent a blockage of the canal.

Three passages of the ProTaper Next X1 file were enough to reach the working length in all canals. The X2 needed only two brushing motions to reach the full length while the X3 needed just one brushing motion to fulfill the shaping of the palatal canal after X1 and X2.

Volume 6 Number 4

ENDODONTIC/PERIODONTAL IRRIGATION PROBES

I chose to stop the X3 at 0.5mm of the working length. At the end of the shaping procedure, I gauged the canals with a 25 K-file for all mesial and distal canals, and the palatal canal with a 30 K-file.

The irrigating probe confirmed

THE BEST

Cleaning and finishing procedure Since the introduction of the one-file shaping concept (WaveOne® file or equivalent), the endodontic community has been enchanted by the reduced number of files needed to achieve the shaping procedure. Many people have argued that these files work too fast because they do not give enough time to completely clean the canal. Knowing that sodium hypochlorite needs at least 15 minutes to digest the whole pulpal tissue, this criticism could become scientifically defendable. But does this prevent us from taking advantage of simplifying the shaping procedure with the new concept?

First, we should bear in mind that the huge advancement of M-wire has simplified and reduced shaping procedure, and brings great advantages that should not be underestimated regarding the mechanical aspect of shaping the canal.

Second, years ago, Schilder’s concept of cleaning and shaping has given way to shaping for cleaning procedure. In the second decade of the 21st century, I find that we are standing at the dawn of a new era of shaping then cleaning the canal system.

I am profoundly convinced that shaping with ProTaper Next is of a great help for the dentist to shape the canal. However, files have never been responsible for cleaning the canal system. Research papers on the efficiency of irrigating solutions and disinfecting agents, as well as activating devices to enhance cleanliness of the canal system, are making this reality more convincing.

Taking the latter into consideration, I finished the disinfection of the canal by giving more time to irrigation: renewing the content of the canal with a fresh solution, and allowing it to digest the pulpal tissue and fighting against the microbial flora.

This step is helped by an early suppression of mechanical obstacles along the canal walls, removing soft tissue away of any constraint preventing the irrigation needle to easily reach the apical third. The key to Volume 6 Number 4

in the Journal of Endodontics.

“... the Max-i-Probe removed significantly more bacteria ... the unique side vent of these safety-ended needles produces upward turbulence that enhances complete cleaning of root canals.“

— Journal of Endodontics, Vol.33, No. 6, June 2007

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Others claim a closed tip, but a microscope may reveal a much different story.

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The RINN Max-i-Probe tip is welded closed to protect your patient from fluids expressing past the apex.

Figure 2 Endodontic practice 15

CASE STUDY

MAX-I-PROBE

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CASE STUDY

Figure 3

success is extended time for simple and efficient irrigation.

We should at last bear in mind that, at the dawning of the new era, cleaning and disinfection become most efficient at the end of shaping the canal system. For this purpose, at the end of the repeated easy renewing of sodium hypochlorite for 10 minutes while adjusting the master gutta-percha points and the pluggers for compaction, I conclude this step by using the EndoActivator速 (Dentsply Maillefer) with a 25 tip to magnify the efficiency of both solutions of 17% EDTA (for 1 minute) and sodium hypochlorite (for 30 seconds).

Filling the root canal system Adjusting fine gutta percha in all mesial and distal canals, and a fine medium in the palatal is the first step in the filling procedure. The yellow plugger of Calamus速 (Dentsply Maillefer) in all mesial and distal canals, then using the blue plugger of the same device for the palatal canal are sequentially adjusted to reach 5 mm of working length. After drying the canal and placing the sealer in the canals, vertical compaction was done.

The postoperative X-rays showed a full respect of the original trajectory, mainly in the apical thirds of both mesial and distal canals, a good centering of the canals, and an efficient filling of all canals. The apical third of the palatal canal showed a 3D filling of the canal system with evidence of multiple foramina packed with filling material, which was evidence of efficient cleaning enhanced by extending the time taken for simple irrigation. EP 16 Endodontic practice

Figure 4

Figure 5 Volume 6 Number 4

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CASE STUDY

Treatment of a crown-root fracture using a composite endodontic post Drs. Jozef Mincík and Marián Tulenko present a case report detailing the treatment of a crown-root fracture

W

ith crown-root fractures, we are describing tooth fractures in which one or more fracture lines comprise both portions of the crown and the root (Andreasen, Andreasen, 1994). In most cases, a fracture line runs from buccalcoronal to palatal-apical into the cervical root third, where it often takes a very abrupt course before it discontinues in a slight degree toward coronal (Figure 1).

This complicated injury presents the practitioner with a difficult task, since surgical, endodontic, restorative, and also orthodontic treatments are necessary to retain the tooth. We strive to avoid extracting the coronal fragments in most cases. This comes with multiple disadvantages. Firstly, pulp extirpation must be carried out immediately under poor basic conditions (bleeding from the periodontium, poor visibility). Secondly, the gingiva covers the apical fragment within a short amount of time and must be removed. Thirdly, the patient has a massive esthetic impairment.

The best therapeutic alternative is thus conservation of the entire tooth with the assistance of internal splinting (Ebelseder, et al., 1993). We use glass fiber-reinforced, composite endodontic posts (Rebilda® Post, Voco) in our surgery for such cases.

Dr. Jozef Mincík studied dentistry at the University of Košice in Slovakia. He has been a licensed dentist in Košice since 1990 and the director of the conservative dentistry section of the Slovakian Dental Association since 2000. His fields of expertise include esthetic-restorative dentistry, endodontology, and dental traumatology. He has been a specialized author and speaker on these topics. In this capacity, he has authored numerous publications and given many lectures.

Dr. Marián Tulenko studied dentistry at the University of Košice in Slovakia and has worked in Dr. Mincik’s dental practice since 2008. He is a member of the young dentists section of the Slovakian Dental Association and dedicates his publications and lectures primarily to the topics of esthetic-restorative dentistry, endodontology, and dental traumatology.

18 Endodontic practice

Figure 1: Typical progression of a crownroot fracture (Ebelseder/Glockner, 2000)

Figure 3: X-ray of UL1 with the typical progression

Case report A 20-year-old patient presented at our office after an accident during a contact sport.

The crown of UL1 was in a supraocclusion and proved to be very mobile and sensitive.

The cervical range of the crown exhibited a straight fracture that bled slightly (Figure 2).

The diagnosis of a combination crown-root fracture was confirmed with an X-ray, which showed an ill-defined ellipse.

Figure 2: Crown-root fracture: the coronal opening communicates directly with the pulp

Figure 4: Splinting of the fragments that support the crowns using glass fiber strips and composite

The bottom line displayed the intracoronal portion of the fracture opening (C-line), the top line, the intraradicular portion (R-line) [Figure 3].

Exact reposition was carried out under local anesthesia immediately after the diagnosis. We sealed the opening with light-curing, glass ionomer composite cement (Ionoseal®, Voco). The coronal fragment was splinted labially with a glass fiber strip, which was attached to the Volume 6 Number 4

CASE STUDY

neighboring teeth with composite (Figure 4). This immediately provided the patient with the ability to chew, and it only slightly impairs the esthetics.

Trepanation and pulp extirpation were carried out after the splinting. A definitive endodontic treatment was not possible during the first treatment, because the root canal bled heavily. We thus applied calcium hydroxide as a temporary filling. The root canal was then definitively treated in the second appointment (Figure 5).

The Ebelseder (Ebelseder, et al., 1993) method of internal splinting was carried out to secure the refixation result, whereby the two fragments were connected with a glass fiber-reinforced composite endodontic post (Rebilda Post, Voco) [Figure 6].

The root canal was prepared – with the exception of the apical 4 mm – with the appropriate bur. Then we began by trying in the endodontic post and subsequently trimming the post to the necessary length

Figure 5: Definitive endodontic treatment of UL1

Figure 6: Rebilda Post (Voco)

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Volume 6 Number 4

Endodontic practice 19

CASE STUDY extraorally. After the application of a dualcuring, self-etching adhesive (Futurabond® DC, Voco), the endodontic post was inserted in the root canal with a twisting motion (Figure 7).

We eliminated the combined labial splinting after the internal fixation.

Afterwards, we carefully ground out the coronal fracture that was sealed with glass ionomer cement during the initial presentation and then covered it with a layer of highly esthetic, light-curing composite (Amaris®, Voco). The treated tooth could now withstand full chew loading, and the

natural esthetic was restored (Figure 8).

Final remarks It is also possible to restore crown-root fractured anteriors with the utilization of several dental partial disciplines.

The conservation of the entire tooth using internal splinting with composite endodontic posts, such as Rebilda Post, is a good treatment alternative. According to our clinical experience, a durable and biologically faultless restoration can be achieved by employing this treatment alternative. EP

References Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. Copenhagen: Munksgaard; 1994.

Ebelseder K, Cartellieri B, Polanski R, Eskici A. Versuch der erhaltung von frontzähne durch innere schienung oder transfixation. Quintessenz.

1993;44(9):1597-1610.

Ebelseder K, Glockner K. Zahnerhaltung nach kronen-wurzel-fraktur. Stomatologie.

2000;97(6):11-14.

Figure 7: The inserted endodontic post-Rebilda Post (palatal view)

Figure 8: UL1 after treatment

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ENDODONTICS IN FOCUS

Top ten tips: Tip number 8 – Tip irrigation in endodontics Continuing his series on endodontics, Dr. Tony Druttman looks at an important type of disinfection

T

he primary goal of root canal treatment is to remove pulp tissue, necrotic debris and bacteria from the root canal system. As I have explained in earlier issues, the canal anatomy of many teeth is very complex, and studies have shown that the canal system cannot be disinfected by mechanical instrumentation alone.1,2 Irrigants have therefore have to be used in conjunction with mechanical preparation for the following purposes: 1. Removal of debris created during instrumentation 2. Lubrication 3. Elimination of microorganisms 4. Dissolution of soft tissue 5. Removal of smear layer There are a number of different irrigants available and several different techniques for their delivery. No one irrigant can satisfy all the demands, and therefore, an optimal irrigation regime advocates the use of different irrigants in sequence.3 There are many factors that affect the effectiveness of irrigation, including canal anatomy, irrigating solution, concentration and the technique of delivery. Although water and local anesthetics are often used, these have no chemical effect on the canal contents, and their only role is to flush away debris created during mechanical preparation. Regrettably, they are often chosen by clinicians who do not use a rubber dam. Although there are several different irrigants on the market, with new ones being developed, sodium hypochlorite and EDTA continue to be among those most widely recommended.4

Sodium hypochlorite Sodium hypochlorite can be used in different concentrations, and some research has shown that while there is

Tony Druttman, MSc, BChD, BSc, is an endodontist working in central London. He is also a part-time teacher at the Eastman Dental Institute, University of London, and lectures in the UK and abroad.

22 Endodontic practice

no difference in the antimicrobial effect between 0.5% and 5%,2 there is significant difference in tissue dissolving capability, which is also dependant on volume, contact time, and surface area.5 Recent research has shown that 5.25% sodium hypochlorite is more effective in removing bacteria from the dentinal tubules than lower concentrations.6 Heating sodium hypochlorite also enhances its tissue dissolving capability.7 Because there are many uninstrumented areas left during mechanical preparation, we depend on the irrigant to dissolve and flush away the debris left behind (Figure 1).

While bacteria will often exist in planktonic form (in suspension) in the root canals, they may also adhere to the canal walls in the form of biofilms. These are complex communities of bacteria imbedded in a polysaccharide matrix.

Sodium hypochlorite is the most effective irrigant for use against biofilms.8 Much of the canal contents can be removed by mechanical instrumentation, and this is particularly the case where the prepared canal shape matches the size and shape of the instruments used in the preparation of the canal. Unfortunately, this is rarely the case. Research has shown that many canals are not circular in cross section (Figure 2), and that the development of an optimized canal shape will often over prepare some areas of the canal while leaving others completely untouched by instrumentation.9 While much of the debris is brought out of the canal within the flutes of the rotating instruments, some is left behind in the fins, isthmuses, and extremities of the canal. This is borne out both by clinical evidence and by research.10 Looking through the microscope into a prepared canal, one can often see debris left behind.

The chlorine in sodium hypochlorite is responsible for dissolving organic tissue, but it tends to get used up very rapidly according to published research. Therefore regular and frequent irrigant replacement is required. The term “copious irrigation� is one often used, suggesting that large

Figure1: Sodium hypochlorite digesting tissue in the canal

Figure 2: Cross sectional shape of root canals showing debris left in the isthmus

volumes of irrigant should be delivered into the canal. How the irrigant is delivered into the canal and how it is agitated is more important than the actual volume used.11

A common form of hand irrigation is with a 27g needle with a side vent that allows the irrigant to flow towards the access cavity rather than being forced through the apex (Figure 3). The 27g needle diameter is equivalent to a size 40 hand file. This means that unless the canal is prepared to at least a size 40, the needle will not reach the apex, and however much irrigant is delivered, the debris will never be flushed out of the apical few millimeters unless a different strategy is used.

Irrigant exchange can be improved in a number of ways, including pressure Volume 6 Number 4

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ENDODONTICS IN FOCUS

Figure 3: 27g Monoject irrigating needle

Figure 4: Acoustic microstreaming creating a series of eddy currents along the length of the ultrasonically energized file

alteration, sonics, and ultrasonics. The simplest is to pump hand files in the canal and if using rotary files, this happens naturally as the files are moved up and down the canal. A recent development of the hand file technique is the manual dynamic agitation technique in which the obturating gutta-percha cone is pumped up and down in the canal. This creates alternating pressure and vacuum and has been shown to allow irrigants to enter lateral canals and is particularly effective in curved canals.12 Another very effective technique is to use sonic and ultrasonic irrigation. Utrasonic activation uses an energized file to dislodge debris from the canal walls into the suspension. Research has show that this can be a very effective way of cleaning areas such as the isthmus of debris.13 It does so by creating turbulent flow and acoustic microstreaming along the energized file (Figure 4).

The challenge is always to remove debris that has been compacted into stagnation areas of the canal wall. While sodium hypochlorite is very effective at dissolving organic tissue when there is a large surface area of contact, when the contact surface is minimal, it is difficult for the irrigant to penetrate through the plug of material. An ultrasonically energized file directed against the plug will effectively remove it. IrriSafeโ ข (Satelec Acteon) ultrasonic needles have been developed for passive ultrasonic irrigation and have the advantage that they cannot cut into the canal wall.

bacteria. Sodium hypochlorite and EDTA counter the effect of each other so EDTA should only be used as the penultimate rinse. EDTA gel acts as a lubricant for the files and can be used in narrow canals to reduce the frictional resistance of the canal.

Once preparation has been competed, the canal should be rinsed with sodium hypochlorite and the irrigant exchanged using either active or passive irrigation.

The same is done with EDTA to remove the smear layer and expose the dentinal tubules. The hypochlorite rinse is then repeated to remove residual microbes from the canal walls, and the canal is given a final rinse with water.

EDTA Ethylene diamine tetracetic acid (17%) is used to dissolve the inorganic material within the root canal. During preparation, smear layer forms on the wall of the prepared canal, and this may harbor 24 Endodontic practice

Caution Irrigants such as these should be used with caution when using irrigating needles to avoid accidents such as injection through the apex. The smaller the needle diameter and the closer the irrigating needle can

References 1. Baker NA, Eleazer PD, Averbach RE, Seltzer S. Scanning electron microscopic study of the efficacy of various irrigating solutions. J Endod. 1975;1(4):127-135.

2. Bystrรถm A, Sundqvist G. Bacteriological evaluation of the efficacy of mechanical root canal instrumentation in endodontic therapy. Scand J Dent Res. 1981;89(4):321328.

3. Basrani B, Haapasalo M. Update on endodontic irrigating solutions. Endodontic Topics. 2012; 27(1):74102.

4. Haapasalo M, Qian W, Shen Y. Irrigation: beyond the smear layer. Endodontic Topics. 2012;27(1):35-53.

5. Hand RE, Smith ML, Harrison JW. Analysis of the effect of dilution on the necrotic tissue dissolution property of sodium hypochlorite. J Endod. 1978;4(2):60-64.

6. Berber VB, Gomes BP, Sena NT, Vianna ME, Ferraz CC, Zaia AA, Souza-Filho FJ. Efficacy of various concentrations of NaOCl and instrumentation techniques in reducing Enterococcus faecalis within root canals and dentinal tubules. Int Endod J. 2006;39(1):10-17.

7. Cunningham WT, Balekjian AY. Effect of temperature on collagen-dissolving ability of sodium hypochlorite

be placed to the apex of the canal, the less space there is for the irrigant to flow coronally and the greater the pressure required to create flow. This means that it is quite possible to inject the irrigant beyond the confines of the canal and into the periapical tissues. This can have dramatic and painful consequences for the patient.

It is therefore important that the needle is loose in the canal and that the force on the plunger is just sufficient for the irrigant to flow.

Conclusion Sodium hypochlorite and EDTA are among the most effective irrigants that are available in endodontics. As these are not inert substances, they have to be used safely and should always be used with a rubber dam. EP Next issue: Preparation techniques

endodontic irrigant. Oral Surg Oral Med Oral Pathol.

1980;49(2):175-177.

8. Clegg MS, Vertucci FJ, Walker C, Belanger M, Britto LR. The effect of exposure to irrigant solutions on apical dentin biofilms in vitro. J Endod. 2006;32(5):434-437.

9. Peters OA, Laib A, Gรถhring TN, Barbakow F. Changes in root canal geometry after preparation assessed by highresolution computed tomography. J Endod. 2001;27(1):16.

10. Endal U, Shen Y, Knut A, Gao Y, Haapasalo M. A high-resolution computed tomography study of changes in root canal ithmus area by instrumentation and root filling. J Endod. 2011;37(2):223-227.

11. Druttman AC, Stock CJ. An in vitro comparison of ultrasonic and conventional methods of irrigant replacement. Int Endod J. 1989;22(4):174-178.

12. Bronnec F, Bouillaguet S, Machtou P. Ex vivo assessment of irrigant penetration and renewal during the final irrigation regimen. Int Endod J. 2010;43(8):663-672.

13. Susin L, Liu Y, Yoon JC, Parente JM, Loushine RJ, Ricucci D, Bryan T, Weller RN, Pashley DH, Tay FR. Canal and isthmus debridement efficacies of two irrigant agitation techniques in a closed system. Int Endod J. 2010;43(12):1077-1090.

Volume 6 Number 4

Thinking ahead. Focused on life.

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CONTINUING EDUCATION

Ultrasonics in orthograde endodontics Dr. Sanjeev Bhanderi discusses the role ultrasonics can play in conventional (orthograde) treatment in the contemporary endodontic practice Introduction Endodontic disease is a result of bacterial breach of the hard tissues that protect and house the pulp. If left untreated, microbial advancement occurs into the pulp, and the ensuing inflammatory response ultimately leads to pulp necrosis and then an apical periodontitis. The key to restoring the health of periodontium around all the portals of exit from the pulp space is the judicious removal of infected pulp tissue and securing a seal from apex to crown.

The use of ultrasonics was first reported in the field of endodontics by Richman in 1957. In dentistry, ultrasonics can be generated via two methods. One method is magnetostriction, whereby a “sandwich” of magnetic strips is subjected to an oscillating magnetic field that produces elliptical vibrations at a frequency of around 20kHz. Another method, which is more effective in endodontic practice, is piezosonic. Piezoelectric ultrasonic devices utilize a quartz crystal exposed to an electrical charge; this causes its deformation and produces mechanical vibration in a more linear back-and-forth fashion and at higher frequencies of 3040kHz. Two popular piezosonic devices are shown in Figures 1A and 1B. Work carried out by Martin in the mid-1970s led to the development of the “endosonic” K-type file. These instruments were essentially driven by ultrasonic energy to cut and prepare root canal dentin.

Unfortunately, endosonic files proved to be somewhat unpredictable in their performance, often leading to procedural

Sanjeev Bhanderi, BDS, MSc, qualified in 1993 from Guy’s & St. Thomas Hospitals, London. He completed a Masters program at the University of Manchester in 1997. He has since been working in specialist endodontic practices in Manchester, Liverpool, and London, and is registered on the GDC specialist list for endodontics. He currently runs his own specialist endodontic practice and teaching center at Endo61 in Cheshire, England. He is a part-time clinical lecturer at the University of Manchester Dental School and throughout the UK. He is a council member and ESE representative for the British Endodontic Society.

26 Endodontic practice

Educational aims and objectives This clinical article aims to discuss the role that ultrasonics can play in conventional treatment in contemporary endodontic practice.

Expected outcomes Correctly answering the questions on page 36, worth 2 hours of CE, will demonstrate you recognize that ultrasonics provides a very versatile adjunct at all stages of endodontic treatment and is proving to be a valuable tool in increasing the chemomechanical efficacy of irrigants, in particular NaOCl.

Figure 1A: P5 Newtron ultrasonic device (Satelec, Acteon Group)

Figure 2: ET18D (Satelec, Acteon group)

errors particularly beyond curvatures (Dummer, et al., 1989; Stamos, 1985).

Ultrasonics has since seen a reemergence in contemporary endodontic practice, as it can be deployed at all stages of conventional (orthograde) treatment, including: • Coronal access cavity refinement • Canal exploration • Removal of intracanal blockages

Figure 1B: Minipiezon ultrasonic device (EMS)

Figure 3: Start-X tips (Dentsply Maillefer)

• “Activation” of irrigants • Warm condensation of gutta percha

Coronal access refinement It is essential that careful preoperative clinical and radiographic assessment of the affected tooth is performed before making the access. In addition, the alveolar contour over buccal aspect of a tooth can suggest the three-dimensional position and spacial Volume 6 Number 4

Figure 5A: UL7: Dystrophic calcifications in the pulp chamber

Volume 6 Number 4

Figure 4B: Exploration of a calcified MB canal orifice using a Start-X No. 3

Figure 5B: 10Z (Satelec, Acteon group) tip used to remove calcification and clear the pulp chamber to reveal canal orifices

arrangement of the root(s). Knowledge of this information and experience will dictate the shape of the access cavity.

One of the dangers of access cavity preparation with a high-speed bur is the lack of tactile feedback for the clinician.

In a tooth with a naturally open pulp chamber, the high-speed access bur will usually “drop” into the pulp chamber, providing that it is aimed reasonably centrally and perpendicular to the occlusal surface. Difficulty occurs when the pulp space is occluded, for example, by deep restorations, dystrophic calcifications as a result of age and response to insults, and naturally occurring pulp “stones.”

Magnification is mandatory at this stage to discern subtle changes in texture and color of the coronal dentin that indicate the nature of the dentin, i.e., normal (physiological), reparative (“reactionary”/ tertiary), or dystrophic calcifications.

At this depth, ultrasonics are very useful to break down these calcifications and clear the pulp floor. This will refine the “straightline” access, which is a prerequisite for good visualization and exploration of the canal orifices. There are numerous tips that have been designed specifically

CONTINUING EDUCATION

Figure 4A: Start-X No. 3 tip (Dentsply Maillefer)

Figure 5C: Preoperative radiograph of heavily-restored UL7 with occluded pulp chamber

Figure 5D: Postoperative radiograph of completed case

for refinement of the access cavity, e.g., ET18D (Satelec) [Figure 2], Start-X™ tips (Dentsply Maillefer) [Figure 3].

Canal exploration Once the roof of the pulp chamber has been removed, exploration for the canal orifices can begin in earnest but can be a challenge with the presence of reactionary dentin formation. Careful examination under magnification and illumination, and use of ultrasonic tips such as the Start-X No. 3 (Figures 4A and 4B) or 10Z (Figures 5A-5D) can break down larger calcifications and are activated on a 80-100% power setting with water irrigation. An alternative is the narrower ET20 (Satelec) [Figure 6] on a 60-80% setting with water irrigation.

For deeper exploration and opening of canal orifices, finer diamond-coated tips such as the ETBD tip (Satelec) [Figures 7A7E] can be employed to trough and grind away the whiter reactionary dentin that often occludes canal openings; this is used without intermittent irrigation and air on a 60-75% power setting.

Removal of intracanal blockages One of the most challenging situations in

Figure 6: ET20 (Satelec, Acteon group)

endodontics is renegotiating a root canal with an obstruction such as a fractured instrument (Madarati, et al., 2010) or fractured post. The former requires highpower magnification and illumination so that the clinician can precisely apply ultrasonic energy to loosen and cut around the obstruction. This, therefore, requires long fine and non-abrasive tips, e.g., ET25 (Satelec) [Figure 8] and ProUltra™ 6-8 (Dentsply Maillefer) [Figure 9]. These tips are used on 60-75% power setting without water to minimize the buffering effect of moisture on transmission of ultrasonic energy and prevent formation of a dentin “mud” that will impair vision of the working field at these depths.

Endodontic practice 27

CONTINUING EDUCATION A

B

Figure 7A: Preoperative radiograph UL6 with calcified canals

D

Figures 7B-7D: ETBD tip (Satelec) scouring open the occluded DB canal

Figure 8: ET25 (Satelec, Acteon group)

The recommended technique (Ruddle, 1997) firstly requires preparation of a “staging platform” with a modified No. 3 Gates Glidden bur around the top of the fractured instrument. The ultrasonic tip is then activated with a combination of vibrational energy directly onto the fragment and cutting into the dentin platform, which should eventually loosen and unthread the fragment (Figures 10A-10C).

Removal of fractured posts beneath the orifice level utilizes a combination of more sturdy ultrasonic tips on a higher power to apply vibrational energy to loosen the fragment to vibrate the post and shatter the cement lute, e.g., ET40 (Satelec) or Start-X No. 4 (Dentsply Maillefer), and then finer ultrasonic tips similar to those used for instrument removal to carefully trough the canal dentin around the obstruction.

Post-core removal Ultrasonics is an essential tool for loosening post-core units prior to retreatment, either as an adjunct but usually as the primary method. For cast metal post-cores, the key is to reduce the bulk of the metal core, leaving just 2 to 4 mm above the cervical level and a diameter continuous 28 Endodontic practice

C

Figure 9: ProUltra 6-8 (Dentsply Maillefer)

with the radicular part of the post. This will leave an optimum core of metal that will absorb high-power ultrasonic energy without disintegrating. A bulkier tip, e.g., Start-X No. 4 (Dentsply Maillefer) or ETPR (Satelec) [Figures 11A-E] can be used around the circumference of the core with water cooling to loosen and shatter the underlying cement lute.

For prefabricated threaded posts, it is important to preserve the original core as this can be loosened with a similar ultrasonic tip to shatter the cement lute and unthread the post. If available, an appropriate ratchet for the post system or lockable mosquito-type forceps can be used to complete unwinding and retrieval of the post.

Irrigation Instrumentation and irrigation go handin-hand to remove the microorganisms and organic tissue to favor the host’s immune response. Sodium hypochlorite (NaOCl) in varying concentrations (18%) is very effective at killing planktonic microorganisms and is the gold standard for endodontic irrigation. However, it may not be as effective as we assume due to

E

Figure 7E: Postoperative radiograph of completed case

a number of clinical challenges that can prevent its penetration throughout the pulp space: • Dystrophic calcifications • Complex anatomy (Ricucci, Bergenholtz, 2003; Peters, 2004) • Biofilm (Haapasalo, et al., 2005) • Smear layer (Peters, 2000).

In vivo and in vitro studies, therefore, show a disparity in results with respect to the efficacy of NaOCl. Application of ultrasonics in irrigation was first suggested

by Walmsley in 1987. Ultrasonics has been shown to exhibit two properties when applied to aqueous fluids such as NaOCl: cavitation and acoustic microstreaming. In the confines of the root canal, it is acoustic streaming that exerts most influence on an irrigant that immerses an activated instrument (Roy, et al., 1994; Lumley, et al., 1991).

Acoustic streaming is characterized by vortices of fluid movement (Figure 12), which have proportionately large hydrodynamic shearing forces. This turbulence is sufficiently powerful to disrupt bacteria on an intra- and extracellular level and radiates jets of irrigant from the instrument towards the root canal walls (Jiang, et al., 2011) that can extend up to 3 mm away from the energized tip (Malki, et al., 2012). There is the potential to improve the distribution of NaOCl, which is relatively poor when delivered by the traditional “positive pressure” syringe method (Boutsioukis, 2010; Gao, 2009).

Consequently, the turbulence of NaOCl created by ultrasonic activation has been shown to be effective in dealing with numerous clinical challenges faced by the endodontic clinician: • Penetration into complex anatomy (Alves, Volume 6 Number 4

Volume 6 Number 4

for 10 seconds up to 2 mm from WL. Replenish the EDTA and leave for 2 minutes • Final washout with NaOCl solution, and activate with IrriSafe tip for 10 seconds • Blot dry canal(s) with paper points ready for obturation/dressing.

pressure” irrigation systems (Jiang, et al., 2012). Another finding is that ultrasonic energy at low intensity and low frequency has a positive effect on the differentiation and proliferation of odontoblasts-like cells (Man, et al., 2012).

One could speculate that using

Figure 10C: Postoperatve view after fragment removal and completion

Figure 10A: Preoperative view of a retained fractured instrument

Figure 10B: ET25 tip (Satelec) tip working on the platform around the fractured fragment

Figure 11A: Preoperative radiograph.

UL1 and UR1 with failing post-cores and apical pathosis

Figure 11B: Crowns removed to reveal cast cores

Figure 11C: After reduction, the ETPR tip (Satelec) is activated on the metal cores

Figure 11D: Post-cores loosened and removed to allow access for retreatment

Figure 11E: Postoperative radiograph of re-treated UL1 and UR1 with provisional post-crowns

Figure 12: Acoustic streaming around an IrriSafe tip (Satelec, Acteon group)

Throughout PUI, the dental nurse should aspirate close to the access cavity to prevent splatter of solution beyond the tooth. Recent evidence suggests that PUI may be more effective than newer “negative

ultrasonic energy to debride or cut dentin over or around an exposed vital pulp (e.g., traumatic exposure in immature teeth) might be conducive to reparative dentin formation. Or, PUI may influence the Endodontic practice 29

CONTINUING EDUCATION

et al., 2011; Siqueira, et al., 2008; van der Sluis, et al., 2005; Gutarts, et al., 2005; Lee, et al., 2004) • Curvatures (Munoz, 2012; Amato, et al., 2011; Al-Jadaa, et al., 2009) • Dissolution of pulp tissue and removal of smear layer (Al-Ali, et al., 2012; Stojicic, et al., 2010; Zehnder, 2006; Peters, 2000) • Biofilm removal (Neilsen, 2007) • Eradication of persistent bacterial species, e.g., E. faecalis (Harrison, et al., 2010).

One example of an ultrasonic irrigation tip is the IrriSafe™ 20/25 tip (Satelec) [Figure 13] that can be activated on a 3545% power setting. This design has flute spaces that may provide a greater surface area for irrigant contact and generation of acoustic streaming.

Another design is the Endosoft instrument (EMS) [Figure 14], which has a smooth non-fluted tip that may have less potential to fracture with its constant diameter but with arguably less effective turbulence patterns at an equivalent power setting.

Both instruments are made from stainless steel but differ from traditional endosonic files in that they have no cutting edges, hence why the term passive ultrasonic irrigation (PUI) is often used to describe their use during irrigation. They can also be prebent to conform to canal curvatures.

Clinically, PUI is employed after canal preparation to the desired taper and apical dimension at full working length has been completed. The PUI tip is activated in the canal with the access cavity filled with NaOCl. Frequent replenishment of NaOCl provides a continuous release of nascent Cl that is released by ultrasonic energy, and works on the organic dissolution of pulp tissue (Zehnder, 2006).

The author’s recommended protocol for the IrriSafe 25 (Satelec) tip is as follows: • Three 20-second ultrasonic bursts on a 35-45% power setting, replenishing the NaOCl in between each activation • The IrriSafe tip should be kept mobile with slight vertical movements up to 2 mm short of WL and gentle prebending of the ultrasonic tip in curvatures to limit contact and dampening against canal walls • Blot dry each canal with paper points to remove NaOCl • Irrigate canal(s) with 15-18% EDTA solution, and activate with the IrriSafe tip

CONTINUING EDUCATION healing response of the apical tissues just beyond the root canal terminus after canal preparation. This may be an interesting area for future research.

Sonic vs PUI? Sonic endodontic instrumentation has been described in the late 1980s (Walmsley, et al., 1989) but fell out of favor as its performance was unpredictable and risked procedural errors in the more complex canal anatomy. However, in the light of a resurgence of PUI to “energize” irrigation, sonic devices have also seen a reemergence in the shape of the EndoActivator® (Dentsply Maillefer) [Figure 15] developed by Dr. Clifford Ruddle.

Unlike an ultrasonic instrument that is characterized by a multiple oscillations along its length (a sinusoidal wave pattern of nodes and antinodes), a sonic instrument produces just a single waveform with one node and antinode along its entire length.

It is therefore suggested that there is less dampening effect upon contact with the canal wall with a sonic (Walmsley, Williams, 1989) rather than an ultrasonic device. In addition, EndoActivator utilizes a polymeric tip rather than metallic without the risk of fracture or cutting canal walls.

With a lower frequency (up to 10kHz) but high amplitude, the novel sonic device maximizes hydrodynamic agitation of an irrigant when immersed.

However, evidence for its performance over PUI remains questionable (Sabins, 2003; Stamos et al., 1987). It has already been mentioned that PUI is effective in curved canals and, contrary to what has been claimed, may in fact outperform sonic irrigation (Paragliola, et al., 2010). Another study showed superior performance by this sonic device (Rodig, et al., 2010; Jensen, 1999); however, both studies used a size No. 15 endosonic file and the former on a low power setting of 25%, which is not comparable to the recommended protocol for using the IrriSafe tip, for example.

It has also been shown that the taper of an energized instrument can affect performance. PUI seems to perform better in conservative 04 tapered canals than a wide-tapered sonic device (Merino, et al., 2012; Munoz, 2005), probably due to the fact that the narrower .02 taper of PUI instruments can produce a greater volume of activated irrigant by acoustic streaming.

Future research will no doubt determine the most effective and predictable protocol for irrigant activation but certainly the choice of 30 Endodontic practice

Figure 13: Turbulence of the NaOCl around an IrriSafe tip created by acoustic streaming

Figure 14: Endosoft instrument (EMS, Optident Ltd)

Figure 15A

Figure 15B

either sonic or PUI is a step forward in our ability to achieve the common goal of canal disinfection.

Obturation with gutta percha (GP) One of the features of ultrasonic instruments is the transfer of this energy form into heat when an activated instrument contacts and “dampens” against another material surface. In fluids such as irrigants, this serves to increase its temperature, and the same effect can apply to gutta percha (Bailey, et al., 2004).

One suggested technique utilizes a No. 15 endosonic file activated on high power and is driven into the mass of master/accessory gutta-percha cones

Figure 16

or a matched greater tapered guttapercha cone fitted to working length. The endosonic file is immediately dampened by the gutta percha, and the local heat Volume 6 Number 4

References Ahmad M, Pitt Ford TR, Crum LA, Walton AJ. Ultrasonic debridement of root canals: acoustic cavitation and its relevance. J Endod. 1988;14(10):486-493.

Al-Ali M, Sathorn C, Parashos P. Root canal debridement efficacy of different final irrigation protocols. Int Endod J. 2012;45(10):898-906.

Al-Jadaa A, Paqué F, Attin T, Zehnder M. Acoustic hypochlorite activation in simulated curved canals. J Endod. 2009;35(10):1408-1411.

Alves FR, Almeida BM, Neves MA, Moreno JO, Rôças IN, Siqueira JF Jr. Disinfecting oval-shaped root canals: effectiveness of different supplementary approaches. J Endod. 2011;37(4):496-501.

Amato M, Vanoni-Heineken I, Hecker H, Weiger R. Curved versus straight root canals: the benefit of activated irrigation techniques on dentin debris removal. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(4):529-534.

Bailey GC, Ng YL, Cunnington SA, Barber P, Gulabivala K, Setchell DJ. Root canal obturation by ultrasonic condensation of gutta-percha. Part II: an in vitro investigation of the quality of obturation. Int Endod J. 2004;37(10):694-698.

Boutsioukis C, Verhaagen B, Versluis M, Kastrinakis E, Wesselink PR, van der Sluis LW. Evaluation of irrigant flow in the root canal using different needle types by an unsteady computational fluid dynamics model. J Endod. 2010;36(5):875-879.

Burleson A, Nusstein J, Reader A, Beck M. The in vivo evaluation of hand/rotary/ultrasound instrumentation in necrotic, human mandibular molars. J Endod.

2007;33(7):782-787.

Carver K, Nusstein J, Reader A, Beck M. In vivo antibacterial efficacy of ultrasound after hand and rotary instrumentation in human mandibular molars. J Endod. 2007;33(9):1038-1043.

Dummer PM, Alodeh MH, Doller R. Shaping of simulated root canals in resin blocks using files activated by a sonic handpiece. Int Endod J. 1989;22(5):211-255.

of working length for the first couple of activations, this may provide a predictable and economical alternative to currently available warm vertical condensation obturation devices.

Conclusion It is the clinician’s prerogative to rise to the

Jensen SA, Walker TL, Hutter JW, Nicoll BK. Comparison of the cleaning efficacy of passive sonic activation and passive ultrasonic activation after hand instrumentation in molar root canals. J Endod.

1999;25(11):735-738.

Jiang LM, Verhaagen B, Versluis M, Langedijk J, Wesselink P, van der Sluis LW. The influence of the ultrasonic intensity on the cleaning efficacy of passive ultrasonic irrigation. J Endod. 2011;37(5):688-692.

Jiang LM, Lak B, Eijsvogels LM, Wesselink P, van der Sluis LW. Comparison of the cleaning efficacy of different final irrigation techniques. J Endod.

2012;38(6):838-841.

Lee SJ, Wu MK, Wesselink PR. The effectiveness of syringe irrigation and ultrasonics to remove debris from simulated irregularities within prepared root canal walls.

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Lumley PJ, Walmsley AD, Laird WR. Streaming patterns produced around endosonic files. Int Endod J. 1991;24(6):290-297.

Madarati AA, Qualtrough AJ, Watts DC. Endodontists experience using ultrasonics for removal of intra-canal fractured instruments. Int Endod J. 2010;43(4):301-305.

Malki M, Verhaagen B, Jiang LM, Nehme W, Naaman A, Versluis M, Wesselink P, van der Sluis L. Irrigant flow beyond the insertion depth of an ultrasonically oscillating file in straight and curved root canals: visualization and cleaning efficacy. J Endod.

2012;38(5):657-661.

Man J, Shelton RM, Cooper PR, Scheven BA. low-intensity low-frequency ultrasound promotes proliferation and differentiation of odontoblast-like cells.

J Endod. 2012;38(5):608-613.

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

Merino A, Estevez R, de Gregorio C, Cohenca N. The effect of different taper preparations on the ability of sonic and passive ultrasonic irrigation to reach the working length in curved canals. Int Endod J. 2013;46(5):427-433.

Munoz HR, Camacho-Cuadra K. in vivo efficacy of three different endodontic irrigation systems for irrigant delivery to working length of mesial canals of mandibular molars. J Endod. 2012;38(4):445-448.

Gao Y, Haapasalo M, Shen Y, Wu H, Li B, Ruse ND, Zhou X. Development and validation of a threedimensional computational fluid dynamics model of root canal irrigation. J Endod. 2009;35(9):1282-1287.

Nielsen BA, Craig Baumgartner J. Comparison of the EndoVac system to needle irrigation of root canals. J Endod. 2007;33(5):611-615.

Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod. 2005;31(3):166-170.

Paragliola R, Franco V, Fabiani C, Mazzoni A, Nato F, Tay FR, Breschi L, Grandini S. Final rinse optimization: influence of different agitation protocols. J Endod.

2010;36(2):282-285.

Haapasalo M, Endal U, Zandi H, Coil JM. Eradication of endodontic infection by instrumentation and irrigation solutions. Endo Topics. 2005;10(1):77-102.

Peters OA, Barbakow F. Effect of irrigation on debris and smear layer walls prepared by two rotary techniques: a scanning electron microscopic study. J Endod. 2000;26(1):6-10.

Harrison AJ, Chivatxaranukul P, Parashos P, Messer HH. The effect of ultrasonically activated irrigation on reduction of Enterococcus faecalis in experimentally infected root canals. Int Endod J. 2010;43(11):968-977.

Volume 6 Number 4

challenge of achieving optimal disinfection in the myriad of root canals that can present.

Ultrasonics provides a very versatile adjunct at all stages of endodontic treatment and is clearly proving to be a valuable tool in increasing the chemomechanical efficacy of irrigants, in particular NaOCl. EP

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

2004;30(8):559-567.

Richman RJ. The use of ultrasonics in root canal therapy and root resection. Dent Med J. 1957;12:12-18 Ricucci D, Bergenholtz G. Bacterial status in root-filled teeth exposed to the oral environment by loss of restoration and fracture or caries – a histobacteriological study of treated cases. Int Endod J. 2003;36(11): 787-802.

Rödig T, Döllmann S, Konietschke F, Drebenstedt S, Hülsmann M. Effectiveness of different irrigant agitation techniques on debris and smear layer removal in curved root canals: a scanning electron microscopy study. J Endod. 2010;36(12):1983-1987.

Roy RA, Ahmad M, Crum LA. Physical mechanisms governing the hydrodynamic response of an oscillating ultrasonic file. Int Endod J. 1994;27(4):197-207.

Ruddle CJ. Endodontic disinfection: tsunami irrigation.

Endo Practice. 2008;11(1):7-15.

Sabins RA, Johnson JD, Hellstein JW. A comparison of the cleaning efficacy of short-term sonic and ultrasonic passive irrigation after hand instrumentation in molar root canals. J Endod. 2003;29(10):674-678.

Siqueira JF Jr, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod. 2008;34(11):1291-1301.

Stamos DG, Haasch GC, Chenail B, Gerstein H. Endosonics: clinical impressions. J Endod.

1985;11(4):181-187.

Stamos DE, Sadeghi EM, Haasch GC, Gerstein H. An in vitro comparison study to quantitate the debridement ability of hand, sonic, and ultrasonic instrumentation. J Endod. 1987;13(9):434-440.

Stojicic S, Zivkovic S, Qian W, Zhang H, Haapasalo M. Tissue dissolution by sodium hypochlorite: effect of concentration, temperature, agitation, and surfactant. J Endod. 2010;36(9):1558-1562.

Walmsley AD, Williams AR. Effects of constraint on the oscillatory pattern of endosonic files. J Endod.

1989;15(5):189-194.

Walmsley AD. Ultrasound and root canal treatment: the need for scientific evaluation. Int Endod J. 1987;20(3): 105-111.

Walmsley AD, lumley PJ, Laird WR. Oscillatory pattern of sonically powered endodontic files. Int Endod J. 1989;22(3):125-132. van der Sluis LW, Versluis M, Wu MK, Wesselink PR. Passive ultrasonic irrigation of the root canal: a review of the literature. Int Endod J. 2007;40(6):415-426. van der Sluis LW, Wu M, Wesselink P. The efficacy of ultrasonic irrigation to remove artificially placed dentine debris from human root canals prepared using instruments of varying taper. Int Endod J. 2005;38(10):764-768.

Zehnder M. Root canal irrigants. J Endod.

2006;32(5):389-398.

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generated “thermoplastizes” the material to flow (Figure 16). The warm gutta-percha void that is created is then widened with a finger spreader, a matching accessory gutta-percha cone is fitted, and the process repeated until the canal is completely obturated. As the ultrasonic condensing instrument can be inserted to within 2 mm

CONTINUING EDUCATION

Intraosseous biocompatibility of an MTA-based and a zinc oxide and eugenol root canal sealer Drs. Osvaldo Zmener, Ricardo Martinez Lalis, Cornelis Pameijer, Carolina Chaves, and Gabriel Kokubu evaluate the biocompatibility of FLPX when implanted in bone tissue of the rat tibia and compare it to Grossman sealer

S

ealers or cements are widely used in clinical endodontics. Since these materials frequently come into contact with periapical tissues, they must be biocompatible in order to avoid damage to the periapical tissues (Geurtsen, Leyhausen, 1997; Sousa, et al., 2004; Siqueira, 2005). Mineral trioxide aggregate (MTA), a calcium silicate-based material, has been used in endodontics as a rootend filling material (Regan, et al., 2002; Economides, et al., 2003) for pulp capping (Faraco, Holland, 2001; Main, et al., 2004; Iwamoto, et al., 2006; Accorinte, et al., 2008; Min, et al., 2008; Nair, et al., 2008) and to repair root perforations (Main, et al., 2004).

Previous reports showed that MTA is biocompatible (Torabinejad, et al., 1995a; Saidon, et al., 2003; de Morais, et al., 2006; Torabinejad and Parirokh, 2010) and revealed good sealing properties and Parirokh, 2010; (Torabinejad Torabinejad, et al., 1993). In addition, MTA is non-cytotoxic (Torabinejad, et al., 1995b; Keiser, et al., 2000), non-mutagenic, and

Osvaldo Zmener, DDS, Dr Odont, is a head professor of the postgraduate program in specialized endodontics at the Faculty of Medical Sciences, School of Dentistry, University of El Salvador, Buenos Aires, Argentina.

Ricardo Martinez Lalis, DDS, Dr Odont, is a head professor of the postgraduate program in specialized endodontics at the Faculty of Medical Sciences, School of Dentistry, University of El Salvador, Buenos Aires, Argentina.

Cornelis H. Pameijer, DMD, MScD, DSc, PhD, is professor emeritus at the University of Connecticut School of Dentistry, Farmington, Connecticut.

Carolina Chaves, DDS, is associate clinical professor of the postgraduate program in specialized endodontics at the Faculty of Medical Sciences, School of Dentistry, University of El Salvador, Buenos Aires, Argentina.

Gabriel Kokubu, DDS, Dr Odont, is professor and head of the department of oral pathology, Faculty of Medical Sciences, School of Dentistry, University of El Salvador, Buenos Aires, Argentina.

32 Endodontic practice

Educational aims and objectives This clinical article aims to evaluate bone tissue reaction in rats to an MTAbased endodontic sealer (Fillapex®) and compare it to Grossman’s sealer.

Expected outcomes Correctly answering the questions on page 36, worth 2 hours of CE, will demonstrate you recognize that based on the presence of new bone formation at the end of the experiment, MTA-Fillapex was considered biocompatible, whereas Grossman’s sealer remained toxic even after 90 days.

neither genotoxic nor carcinogenic (Braz, et al., 2006; Melegari, et al., 2006; Ribeiro, et al., 2006). Based on these favorable characteristics, the use of MTA-based endodontic sealers with improved flow properties and manipulation characteristics was suggested as a suitable alternative for root canal obturation (Scarparo, et al., 2010; Massi, et al., 2011). Among these new formulations, the MTA-based sealer Fillapex (FLPX; Angelus, Londrina, PR, Brazil) has recently been introduced. According to the manufacturer, the components of FLPX are MTA, salicylate resin, natural and diluting resins, nanoparticulated resin, bismuth trioxide, nanoparticulated silica, and pigments, while the material has low solubility, good radiopacity, and easy handling characteristics, and extended working time (Angelus, 2011). The biocompatibility of FLPX was previously tested in subcutaneous connective tissues of the rat (Zmener, et al., 2012), but to the best of our knowledge, little information is available on the effect of FLPX sealer in contact with bone tissue. Therefore, the purpose of this study was to evaluate the biocompatibility of FLPX when implanted in bone tissue of the rat tibia and to compare it to Grossman sealer (GS). The latter is a well-established zinc oxide and eugenolbased sealer.

Materials and methods The protocol for this study was reviewed and approved by the Research Ethics Committee of the Argentine Dental

Association, Buenos Aires, Argentina.

Forty-eight autoclaved silicone tubes (Raholin SRL, V. Madero, Buenos Aires, Argentina) measuring 1 mm long with an outer diameter of 1.0 mm and internal diameter of 0.5 mm were allocated to two groups of 24 tubes each (n=24). In one group, the tubes were filled flush at both ends with freshly prepared FLPX, while the other group contained GS and served as positive control. The lateral walls of the silicone tubes were used as negative controls (NCs). Care was taken to keep the test materials within the tubes and to prevent contamination of the outside. The sealers were prepared according to the manufacturers’ instructions.

After filling, the tubes were immediately implanted in the tibias of 24 white male Wistar rats, weighing approximately 250g each. The husbandry and management of the animals met the requirements of the ISO 10993-1 (1992) and ISO 10993-2 (1992) standards as well as the International Regulatory Requirements for the care and use of laboratory animals (Bayne, 1998).

Every effort was made to minimize animal discomfort and limit the total number of animals used. All operative procedures were done under strict aseptic conditions.

The surgical procedures were as follows.

General anesthesia was administered through intraperitoneal injection of ketamine chloride (14mg/kg body weight) and acepromazine (10mg/kg body weight).

The implantation technique was performed according to the procedures Volume 6 Number 4

and staining with haematoxylin and eosin (H&E).

To evaluate the tissue response in the areas of tissue/material contact, three sections belonging to the central areas of each specimen were analyzed and photographed at different magnifications with a light microscope equipped with a digital Canon Powershot A510 camera.

These sections were examined blind by two trained evaluators who independently rated the tissue reaction as follows: • No reaction: fibrous-capsule formation, absence of inflammatory cells and newly formed healthy bone • Mild: fibrous-capsule formation with few

inflammatory cells and slight calcified tissue development • Moderate: fibrous-capsule formation with the presence of polymorphonuclear leukocytes, lymphocytes, plasmocytes, and macrophages • Severe: absence of fibrous capsule or new bone formation with presence of polymorphonuclear leukocytes, lymphocytes, plasmocytes, macrophages, foreign-body giant cells, and congested capillaries.

Before the analysis, both evaluators were calibrated by having them twice score a set of 50 similar but unrelated slides that presented with bone inflammatory reactions

Figure 1

Figure 2

Figure 3

Table 1: Distribution of the implants and severity of tissue reaction to materials

implanted in the left side. The tubes were placed such that one end extended into the marrow space while the other end was level with the cortical bone. The wounds were closed with interrupted silk sutures.

The animals were maintained on a regular diet with water ad libitum.

After 10, 30, and 90 days, the animals were euthanized in groups of eight each using an overdose of ketamine and acepromazine. The tibias were removed and fixed in 10% neutral buffered formalin (pH 7.4). The solution was replenished after 24 hours, and the samples fixed for another 10 days.

The tibias were then decalcified in ethylenediaminetetraacetic acid (EDTA), and the implants and surrounding bone were dissected and processed for routine histology, paraffin embedding, longitudinal serial sections approximately 7μm thick, Volume 6 Number 4

FLPX

GS

NCs

Days

n

NO

MI

MO

SE

NO

MI

MO

SE

NO

MI

MO

SE

10

8

-

-

-

8

-

-

-

8

8

-

-

-

30

8

-

-

1

7

-

-

-

8

8

-

-

-

90

8

7

1

-

-

-

-

-

8

8

-

-

-

NO: No reaction; MI: Mild reaction; MO: Moderate reaction; SE: Severe reaction Endodontic practice 33

CONTINUING EDUCATION

described in a previous report (Zmener, et al., 2005). Briefly, a 1.5 cm longitudinal incision was made with a scalpel lateral from the anterior border of the tibias. After the incision, muscles and ligaments, and the periosteum were displaced by blunt dissection, thus exposing the underlying bone.

An opening 1 mm in diameter and 1 mm deep was prepared with a low-speed, end-cutting bur under constant sterile saline cooling in the area of the diaphyseal bone of each tibia approximately 8 mm from the lateral external side. Two implants were placed in each rat, one containing FLPX in the right tibia, while GS was

CONTINUING EDUCATION to different endodontic sealers. If there was a disagreement between the evaluators, the sample under discussion was analyzed jointly until a consensus was reached. Data was analyzed by the Wilcoxon Signed Rank test to determine if there was a statistically significant difference between FLPX, GS, and NCs at each observation period. The total effect of time and material upon the tissue reaction was calculated by the Kruskal-Wallis and the Dunnâ&#x20AC;&#x2122;s test. The significance level was set at p<0.05. At the end of the experiment, the sealers were considered biologically acceptable when the tissue reaction was recorded as none to mild.

Results Clinical examination of the implantation sites revealed that all implants remained in situ and that wound healing was satisfactory. The number and distribution of the implants as well as the severity of tissue reaction are presented in Table 1.

Negative controls In all specimens, tissue reaction to the lateral walls of the silicone tubes was rated as none for all observation periods. The tubes were surrounded by thin fibrous connective tissue without inflammatory cells. It could easily be distinguished from the tissues at the sites where the experimental materials were in direct contact with bone.

Experimental FLPX and Grossman sealer positive control samples After 10 days, the inflammatory tissue reaction to FLPX and GS were rated severe (Figures 1A-F). A granulomatous tissue invagination into the lumen of the tubes was observed in direct contact for both materials. Newly formed vessels and randomly dispersed dark particles, which appeared to have been released from the materials, were detected in the surrounding areas. These particles were observed being phagocytized by numerous macrophages and some multinucleated foreign body giant cells. Incipient development of bone trabeculae from the opposite cortical bone could be observed in five FLPX specimens.

After 30 days, both FLPX and GS showed persistent granulomatous tissues invaginated into the lumen of the tubes.

The intensity of the inflammatory reaction to FLPX was rated moderate to severe, albeit that newly formed bone trabeculae and calcified precipitations were seen in the majority of the samples (Figures 2A-C).

34 Endodontic practice

The tissue reaction in contact with GS was rated severe with three specimens showing a few calcified precipitations (Figures 2D-F). GS revealed the presence of a fibrogranulomatous tissue containing many dispersed material particles, which were surrounded by macrophages and multinucleated giant cells. Localized accumulations of chronic inflammatory cells, mainly composed of lymphocytes, plasmocytes, and macrophages were also seen in the surrounding areas.

After 90 days, the tissue reaction to FLPX was rated as none to mild. A mixed hard and soft fibrous tissue invagination free of inflammatory cells could be seen within the lumen of the tubes in almost all FLPX samples. The surrounding areas showed active osteogenesis composed of healthy juvenile bone trabeculae, containing occasional remnants of material particles (Figures 3A-C).

In direct contact with all GS samples, the tissue reaction was still rated severe with chronic inflammatory cells and the formation of a thin layer of connective tissue interposing between the material and the granulomatous tissue invagination. Below this connective tissue layer, numerous inflammatory cells, mainly lymphocytes, plasmocytes, and macrophages containing phagocytized particles, were seen in the surrounding tissues (Figures 3D-F).

The Wilcoxon Signed Rank test demonstrated no statistically significant differences between FLPX and GS after 10 and 30 days (p>0.05), while both materials significantly differed (p<0.05) from the NC. After 90 days, FLPX did not significantly differ from the NC (p>0.05), but significant differences (p<0.05) were found between both FLPX and NCs and GS. The total effect of time for FLPX revealed that the results obtained after 10 and 30 days were significantly different from those obtained after 90 days. Furthermore, no significant differences were demonstrated for GS as well as the NCs for the three observation periods (p>0.05).

Discussion Based on previous findings (Zmener, et al., 1998; Zmener, et al., 2005), the intraosseous implantation of endodontic filling materials in the diaphyseal areas of the rat tibias constitutes a suitable model for the study of biocompatibility.

The implantation periods used in this study were within the short- and longterm time intervals of the recommended

standards practices for biological evaluation of dental materials (FĂŠderation Dentaire Internationale, 1980).

The explanation for the long-term retention of the implants throughout the entire experiment (90 days) may be based on their exact fit in the cortical bone of the tibias (Zmener, et al., 1989a). GS was used as positive control as the toxicity of ZOE-based materials has been previously determined in ex vivo (Rodrigues, et al., 1975; Zmener, et al., 1989b) and in vivo experiments (Tagger, Tagger, 1986; Yesilsoy, et al., 1988; Sousa, et al., 2004).

The lateral walls of the silicone tubes were used as negative control since the material by itself has been proven to be biocompatible (Zmener, et al., 1988; Zmener, et al., 1989a; Zmener, et al., 2005), a finding that was confirmed in the current study.

The results of FLPX after 10 days of implantation in bone of rat tibias showed similar results to a previous experiment in which FLPX was implanted in subcutaneous connective tissues (Zmener, et al., 2012). In this study, the irritation of FLPX in the short observation period was attributed to displacement of components from the freshly mixed material into the surrounding tissues during the setting period. Nevertheless, the severity of the tissue reaction persisted or was slightly reduced after 30 days with incipient reactive bone formation along with calcified precipitations.

According to Holland, et al., 1999, the presence of calcified precipitations originates from the calcium oxide in MTA, which is also present in FLPX. Calcium oxide can react with tissue fluids thus forming calcium hydroxide, which dissociates in calcium and hydroxyl ions.

The combination of calcium ions and carbon dioxide results in the formation of calcite, which will stimulate the deposition of new hard tissues (Holland, et al., 1999; Gomes-Filho, et al., 2009). In this respect, our observations are in agreement with those of Gomes-Filho, et al., 2009, who showed Von Kossa positive calcified structures in close contact with Endo-CPM sealer, another MTA-based sealer.

At the end of the experiment, no significant differences were found between FLPX and the NCs. These results tend to confirm the ones of Torabinejad, et al., 1998, who tested an MTA-based material in the tibias and mandibles of guinea pigs and reported its biocompatibility.

Volume 6 Number 4

that the intraosseous behavior of FLPX is comparable to that of MTA (Torabinejad, et al., 1995; Moreton, et al., 2000).

Acknowledgements This research was supported by a grant from the Argentine Dental Association (No AO377- 2011). EP

References Accorinte M de L, Holland R, Reis A, Bortoluzzi MC, Murata SS, Dezan E Jr, Souza V, Alessandro LD. Evaluation of mineral trioxide aggregate and calcium hydroxide cement as pulp-capping agents in human teeth. J Endod. 2008;34(1):1-6.

Massi S, Tanomaru-Filho M, Silva GF, Duarte MA, Grizzo LT, Buzalaf MA, Guerreiro-Tanomaru JM. pH, calcium ion release, and setting time of an experimental mineral trioxide aggregate – based root canal sealer. J Endod. 2011;37(6):844-846.

Angelus®. Manual for users. Angelus Science and Technology Web site. www.angelus.ind.br. Accessed December 29, 2011.

Melegari KK, Botero TM, Holland GR. Prostaglandin E production and viability of cells cultured in contact with freshly mixed endodontic materials. Int Endod J. 2006;39(5):357-362.

Bayne K. Developing guidelines of the care and use of animals. Ann N Y Acad Sci. 1998;30(862):105-110.

Braz MG, Camargo EA, Salvadori DM, Marques ME, Ribeiro DA. Evaluation of genetic damage in human peripheral lymphocytes exposed to mineral trioxide aggregate and Portland cements. J Oral Rehabil.

2006;33(3):234-239. de Morais CA, Bernardineli N, Garcia RB, Duarte MA, Guerisoli DM. Evaluation of tissue response to MTA and Portland cement with iodoform. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(3):417-421.

Economides N, Pantelidou O, Kokkas A, Tziafas D. Short-term periradicular tissue response to mineral trioxide aggregate (MTA) as root-end filling material. Int Endod J. 2003;36(1):44-48.

Faraco IM Jr, Holland R. Response of the pulp of dogs to capping with mineral trioxide aggregate or a calcium hydroxide cement. Dent Traumatol. 2001;17(4):163-166.

No authors. Recommended standard practices for biological evaluation of dental materials. Fédération Dentaire International, Commission of Dental Materials, Instruments, Equipment and Therapeutics. Int Dent J. 1980;30(2):140-188.

Geurtsen W, Leyhausen G. Biological aspects of root canal filling materials – histocompatibility, cytotoxicity and mutagenicity. Clin Oral Investig. 1997;1(1):5-11.

Gomes-Filho JE, Watanabe S, Bernabé PF, de Moraes Costa MT. A mineral trioxide aggregate sealer stimulated mineralization. J Endod. 2009;35(2):256-260.

Min KS, Park HJ, Lee SK, Park SH, Hong CU, Kim HW, Lee HH, Kim EC. Effect of mineral trioxide aggregate on dentin bridge formation and expression of dentin sialoprotein and heme oxygenase-1 in human dental pulp. J Endod. 2008;34(6):666-670.

Moretton TR, Brown CE Jr, Legan JJ, Kafrawy AH. Tissue reactions after subcutaneous and intraosseous implantation of mineral trioxide aggregate and ethoxybenzoic acid cement. J Biomed Mat Res. 2000;52(3):528-533.

Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. Int Endod J. 2008;41(2):128-150.

Parirokh M, Asgary S, Eghbal MJ, Stowe S, Eslami B, Eskandarizade A, Shabahang S. A comparative study of white and gray mineral trioxide aggregate as pulp capping agents in dog’s teeth. Dent Traumatol.

2005;21(3):150-154.

Regan JD, Gutmann JL, Witherspoon DE. Comparison of Diaket and MTA when used as root-end filling materials to support regeneration of the periradicular tissues. Int Endod J. 2002;35(10):840-847.

Ribeiro DA, Sugui MM, Matsumoto MA, Duarte MA, Marques ME, Salvadori DM. Genotoxicity and cytotoxicity of mineral trioxide aggregate and regular and white Portland cements on Chinese hamster ovary (CHO) cells in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(2):258-261.

Holland R, de Souza V, Nery MJ, Otoboni Filho JA, Bernabé PF, Dezan Júnior E. Reaction of rat connective tissue to implanted dentin tubes filled with mineral trioxide aggregate or calcium hydroxide. J Endod.

1999;25(3):161-166.

Rodrigues H, Spångberg L, Langeland K. Biologic effects of dental materials. 9. Effect of zinc-oxide eugenol cements on HeLa cells in vitro. Estomat Cult.

1975;9(2):191-194.

International Organization for Standardization. ISO 10993-1:1992. Biological evaluation of medical devices-- Part 1: Guidance on selection of tests.

Geneva, Switzerland: ISO; 1992.

Saidon J, He J, Zhu Q, Safavi K, Spångberg LS. Cell and tissue reactions to mineral trioxide aggregate and Portland cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(4):483-489.

International Organization for Standardization. ISO 10993-2:1992. Biological evaluation of medical devices -- Part 2: Animal welfare requirements. Geneva, Switzerland: ISO; 1992.

Scarparo RK, Haddad D, Acasigua GA, Fossati AC, Fachin EV, Grecca FS. Mineral trioxide aggregate – based sealer: analysis of tissue reactions to a new endodontic material. J Endod. 2010;36(7):1174-1178.

Iwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, Jefferies S. Clinical and histological evaluation of white ProRoot MTA in direct pulp capping.

Am J Dent. 2006;19(2):85-90.

Siqueira JF Jr. Reaction of periradicular tissues to root canal treatment: benefits and drawbacks. Endod Topics. 2005;10(1):123-147.

Keiser K, Johnson CC, Tipton DA. Cytotoxicity of mineral trioxide aggregate using human periodontal ligament fibroblasts. J Endod. 2000;26(5):288-291.

Sousa CJ, Loyola AM, Versiani MA, Biffi JC, Oliveira RP, Pascon EA. A comparative histological evaluation of the biocompatibility of materials used in apical surgery.

Int Endod J. 2004;37(11):738-748.

Main C, Mirzayan N, Shabahang S, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: a long-term study. J Endod. 2004;30(2):8083.

Tagger M, Tagger E. Subcutaneous reactions to implantation of tubes with AH26 and Grossman’s sealer. Oral Surg Oral Med Oral Pathol. 1986;62(4):434440.

Volume 6 Number 4

Torabinejad M, Hong CU, Pitt Ford TR, Kaiyawasam SP. Tissue reaction to implanted super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: a preliminary report. J Endod. 1995;21(11):569-571.

Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Cytotoxicity of four root end filling materials. J Endod.

1995;21(10):489-492.

Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review – part II: leakage and biocompatibility investigations. J Endod.

2010;36(2):190-202.

Torabinejad M, Ford TR, Abedi HR, Kariyawasam SP, Tang HM. Tissue reaction to implanted root-end filling materials in the tibia and mandible of guinea pigs. J Endod. 1998;24(7):468-471.

Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod. 1993;19(12):591-595.

Yesilsoy C, Koren LZ, Morse DR, Kobayashi C. A comparative tissue toxicity evaluation of established and newer root canal sealers. Oral Surg Oral Med Oral Pathol. 1988;65(4):459-467.

Zmener O, Goldberg F, Cabrini RL. Effects of two guttapercha formulations and one zinc oxide-eugenol and Canada balsam mixture on human blood monocytes and lymphocytes. Endod Dent Traumatol. 1989;5(2):7377.

Zmener O, Guglielmotti MB, Cabrini RL. Biocompatibility of two calcium hydroxide-based endodontic sealers: a quantitative study in the subcutaneous connective tissue of the rat. J Endod.

1988;14(5):229-235.

Zmener O, Guglielmotti MB, Cabrini RL. A radiographic, histological and histometric study of endodontic materials. J Endod. 1989;15(1):1-5.

Zmener O, Martinez Lalis R, Pameijer CH, Chaves C, Kokubu G, Grana D. Reaction of rat subcutaneous connective tissue to a mineral trioxide aggregatebased and a zinc oxide and eugenol sealer. J Endod.

2012;38(9):1233-1238.

Zmener O, Banegas G, Pameijer CH. Bone tissue response to a methacrylate-based endodontic sealer: a histological and histometric study. J Endod.

2005;31(6):457-459.

Endodontic practice 35

CONTINUING EDUCATION

Based on these findings, we conclude that, after 90 days of implantation, FLPX sealer is biocompatible and appeared to stimulate new bone formation. It appears

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Ultrasonics in orthograde endodontics

Intraosseous biocompatibility of an MTA-based and a zinc oxide and eugenol root canal sealer

BHANDERI

ZMENER

1. The key to restoring the health of periodontium around all the portals of exit from the pulp space is __________. a. the judicious removal of infected pulp tissue b. securing a seal from apex to crown c. magnetostriction d. both a and b 2. Piezoelectric ultrasonic devices utilize a/an ________exposed to an electrical charge; this causes deformation and produces mechanical vibration in a more linear back-and-forth fashion and at higher frequencies of 30-40kHz. a. diamond-coated tip b. aqueous fluid c. quartz crystal d. plastic cap

6. Unlike an ultrasonic instrument that is characterized by a multiple oscillations along its length (a sinusoidal wave pattern of nodes and antinodes), a sonic instrument produces just a single waveform with _______ along its entire length. a. one node and antinode b. PUI c. NaOCl d. intense pressure 7. With a lower frequency (up to 10kHz) but high amplitude, the novel sonic device ______ hydrodynamic agitation of an irrigant when immersed. a. minimizes b. maximizes c. eliminates d. none of the above

3. One of the dangers of access cavity preparation with a high-speed bur is the ______for the clinician. a. excessive vibration b. lack of tactile feedback c. wrist stress d. buffering effect

8. It has also been shown that ______ of an energized instrument can affect performance. a. the amplitude b. oscillation c. the taper d. wavelength

4. (In post-core removal) For cast metal post-cores, the key is to reduce the bulk of the metal core, leaving just _______ above the cervical level and a diameter continuous with the radicular part of the post. a. .5 mm b. 1 mm c. 2 to 4 mm d. 5 mm

9. One of the features of ultrasonic instruments is the transfer of this energy form into ______when an activated instrument contacts and “dampens” against another material surface. a. cold b. heat c. water d. thermoplastic

5. ________ go hand-in-hand to remove the microorganisms and organic tissue to favor the host’s immune response. a. Instrumentation and shearing forces b. Positive pressure and irrigation c. Energy and frequency d. Instrumentation and irrigation

10. As the ultrasonic condensing instrument can be inserted to within _____of working length for the first couple of activations, this may provide a predictable and economical alternative to currently available warm vertical condensation obturation devices. a. 1 mm b. 2 mm c. 3 mm d. 4 mm

36 Endodontic practice

1. Since these materials (sealers or cements) frequently come into contact with periapical tissues, they must _______ in order to avoid damage to the periapical tissues. a. contain only natural resins b. be biocompatible c. be nanoparticulated d. have high solubility

6. The ______ demonstrated no statistically significant differences between FLPX and GS after 10 and 30 days (p>0.05), while both materials significantly differed (p<0.05) from the NC. a. Kruskal-Wallis test b. Dunn’s test c. Wilcoxon Signed Rank test d. Yesilsoy test

2. Previous reports showed that MTA is biocompatible and revealed good sealing properties. In addition, MTA is _______. a. non-cytotoxic b. non-mutagenic c. neither genotoxic nor carcinogenic d. all of the above

7. According to Holland, et al., 1999, the presence of calcified precipitations originates from the _____in MTA, which is also present in FLPX. a. calcium oxide b. ketamine chloride c. acepromazine d. buffered formalin

3. The tissue reaction in contact with GS was rated _____with three specimens showing a few calcified precipitations. a. none to mild b. moderate c. mixed d. severe

8. The combination of calcium ions and carbon dioxide results in the formation of calcite, which will _____the deposition of new hard tissues. a. inhibit b. stimulate c. stop d. slow

4. GS revealed the presence of a fibrogranulomatous tissue containing many dispersed material particles, which were surrounded by _______. a. subcutaneous connective tissues b. macrophages c. multinucleated giant cells d. both b and c

9. Based on these findings, we conclude that, after ______ of implantation, FLPX sealer is biocompatible and appeared to stimulate new bone formation. a. 30 days b. 60 days c. 90 days d. 120 days

5. After 90 days, the tissue reaction to FLPX was rated as ______. a. none to mild b. moderate c. severe d. atypical

10. It appears that the intraosseous behavior of FLPX is _______ to that of MTA. a. very different b. comparable c. opposite d. more intense

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UniCore Drill The ultrasafe UniCore drill features a patented, diamond-coated collar to prevent binding in access openings. Each drill and post is color matched according to size — simplifying chairside use. The UniCore drill’s uniquely designed flutes ensure rapid and consistent removal of obturators from the canal, and the heatgenerating tip facilitates rapid removal of stubborn obturators, gutta percha, and fiber posts.

IMPORTANT NOTE: Sterilize drills and posts before use.

Step 1: Position the Unicore tip in the pilot hole. Using light pressure, follow the obturation material to the length indicated by the rubber stop. Keeping the drill at full speed, withdraw from the canal. Rinse debris, and blow out excess water with TriAway™ Adapter.

Step 2: Verify post size by placing the corresponding UniCore post and seat to length. Trim post to appropriate length using a diamond disc.

Step 3: Etch space for 20 seconds with Ultra-Etch®, using the Endo-Eze® 22ga tip. Suction excess etchant with Luer Vacuum Adapter and Endo-Eze 22ga tip. Use TriAway Adapter to rinse thoroughly with water, then lightly air dry, leaving the post space slightly damp.

38 Endodontic practice

Volume 6 Number 4

SIDE-BY-SIDE

Step 4: Use the NaviTip速 FX tip to place Peak速 Universal Bond in the canal for 10 seconds. Dry using TriAway Adapter, then light cure the space for 20 seconds. Using the UniCore post or paper point, ensure post space is not obstructed with Peak Universal Bond.

Step 5: Attach the Intraoral tip to PermaFlo速 DC syringe, mix, then deliver PermaFlo DC into the post space, beginning from the bottom. Insert post and seat.

Step 6: Light cure PermaFlo DC in the canal for 20 seconds.

Deliver PermaFlo DC around the post for core buildup.

If the fill starts to slump, light cure for 2 to 3 seconds.

Repeat for each additional layer, followed by a final cure of 20 to 40 seconds (40 seconds if using a curing light with less than 600mW/cm2). Proceed with crown preparation or restorative procedure. EP This information was provided by Ultradent Products, Inc.

Volume 6 Number 4

Endodontic practice 39

RESEARCH

Comparison of isthmus debris removal using three different irrigation techniques Drs. Kathryn L. Aasen, Brian E. Bergeron, Mark D. Roberts, Van T. Himel, Thomas E. Lallier, and Kent A. Sabey evaluate the effectiveness of debris removal in mesial roots of mandibular molars Abstract Introduction: The purpose of this study was to evaluate the effectiveness of debris removal in mesial roots of mandibular molars using Max-i-Probe® (Dentsply Rinn) conventional positive pressure needle, EndoVac® Negative Pressure Irrigation System (SybronEndo), or Photon Induced Photoacoustic Streaming (PIPS) irrigation.

Methodology: Forty-five extracted mandibular molars were match paired for curvatures and randomly assigned to each irrigation technique group (n=15).

Mesial canals were prepared to a size 20/.04 at working length using rotary NiTi files and sterile water irrigation. Teeth were mounted in resin using a custom-designed Bramante style K-Kube and sectioned at 3 and 5 mm from the apex. Specimens were reassembled in the K-Kube, and mesial canals only were cleaned and shaped using rotary instrumentation and 6% NaOCl. Protocols for final preparation size of the mesial canals, irrigation sequence between instruments, and final irrigation followed manufacturers’ recommendations. Images of canals and isthmuses were taken prior to and following instrumentation/irrigation to evaluate presence of debris. Comparisons of cleanliness were made using paired t-tests, and the groups were compared with ANOVA (P < 0.001).

Kathryn L. Aasen, DDS, Brian E. Bergeron, DMD, and Mark D. Roberts, DMD, are from the Keesler Medical Center USAF, Biloxi, Mississippi.

Van T. Himel, DDS, Thomas E. Lallier, PhD, and Kent A. Sabey, DDS, are from the Louisiana State University Health Sciences Center School of Dentistry, New Orleans, Louisiana.

First author biography: Kathryn L. Aasen earned her DDS from the University of Iowa in 1996. She completed her 2-year Advanced Education in General Dentistry Residency at the Naval Postgraduate Dental School and received her Masters in Oral Biology from George Washington University in 2006. She is currently a second year resident in Endodontics at Keesler Medical Center USAF.

40 Endodontic practice

Results: In the mesial canals and isthmuses, there were no significant differences between the overall cleaning ability of the three irrigation techniques at 3 and 5 mm from the apex. Final cleanliness of the uninstrumented distal canals was significantly greater in the PIPS group when compared to the other two groups (P < 0.001). Conclusion: Within the limitations of this study, Max-i-Probe, EndoVac, and PIPS irrigation techniques demonstrated similar ability to clean mandibular molar mesial canals and isthmuses at 3 and 5 mm from the root apex.

Introduction It has been well established that microorganisms are responsible for the development and progression of apical periodontitis.1-2 Overall success rate of initial nonsurgical root canal therapy has been quoted as high as 96%.3 Multiple in vivo studies have shown significantly lower success rates when there is evidence of pretreatment periapical pathology.4-5

Further in vivo studies have also shown decreased success rates when cultivable bacteria are detectable immediately prior to obturation.6-7 Sjogren, et al., found viable bacteria in 40% of infected canals after cleaning and shaping using 0.5% NaOCl irrigation. Although 68% of these teeth were successful, this rate was much lower than the 94% success rate in teeth with negative cultures prior to obturation.6 The number and type of microorganisms that must be eliminated from a canal system to prevent endodontic failure is unknown.

Therefore, the quest to improve overall success rates of initial endodontic therapy should begin with the elimination of all microorganisms from the canal system.

Cleaning and shaping a root canal system to render it void of organic debris and microorganisms is challenging.8 Chemomechanical procedures have been shown to significantly decrease the numbers of bacteria left in canals but have not achieved total elimination of bacteria and debris in all canals.9-10 This, in part, is

due to the complex anatomy found in many root canal systems.11-12 Bacteria can reside in canal isthmuses, accessory canals, dentinal tubules, and canal recesses.13 Microorganisms may survive the process of cleaning and shaping simply due to the irrigant’s inability to penetrate these areas.14-15 Conventional positive pressure needle irrigation with NaOCl has been the gold standard to which many other systems have been compared. One of the drawbacks of this technique is its inability to express irrigant greater than 1 mm past the needle tip.16 Since the reduction of debris in the apical one-third of the canal is partially dependent on the volume of NaOCl irrigation directly contacting it, the apical preparation size must be large enough to accommodate placement of the irrigation needle.17-18 Klyn, et al., showed conventional positive pressure irrigation was least effective at removing canal isthmus debris 1 mm from the working length when compared to debris removal at 3 and 5 mm from the working length.19 An additional concern of conventional positive pressure irrigation is its safety.20 Desai and Himel demonstrated apical extrusion of NaOCl when using a positive pressure irrigation technique.21 A number of irrigation devices have been developed in attempts to improve the safety and effectiveness of irrigation delivery into all areas of the canal system. The EndoVac Negative Pressure Irrigation System draws irrigant apically by way of evacuation. The manufacturer’s recommended minimal apical prep size is 35/.04. This allows the placement of the microcannula to working length during final irrigation. The EndoVac’s negative apical pressure decreases the potential for apical irrigant extrusion. In a study evaluating safety, the EndoVac had the lowest frequency of irrigation extrusion when compared to the EndoActivator® (Dentsply Tulsa Dental Specialties, Tulsa, OK), passive ultrasonic irrigation, and syringe irrigation with a side-vented needle.22 Volume 6 Number 4

Materials and Methods Specimen preparation This study followed a similar protocol used by Klyn, et al., and Howard, et al.19,27 Forty-five extracted mandibular molars were evaluated for the presence of mesial canal isthmuses in the apical 5 mm using cone beam computed tomography (i-CAT, Imaging Sciences International). Teeth were stored in 0.1% thymol before use. The occlusal surface of each tooth was flattened Volume 6 Number 4

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Figures 1A-1D: A. K-Kube unassembled B. K-Kube assembled with tooth mounted in resin block C. Resin block reassembled in K-Kube after sectioning, front wall removed for visualization D. K-Kube and resin block disassembled

so that a reproducible working length (WL) reference point was established. A standard access was performed and a #10 C-File (Dentsply Maillefer) was placed into the mesial and distal canals until the tip of the file was visible at the apical foramen. Working length was determined by subtracting 1 millimeter from the above

www.engineeredendo.com

measurement. A size #20/.04 glide path was accomplished in the mesial canals using stainless steel K-files (Miltex, Inc.) and Hyflex® CM™ NiTi files (Coltène/Whaledent Inc.). The glide path allowed for easier file placement into the canals after sectioning.

The mesial canals were irrigated with 1 mL sterile saline between files. The distal canals were not instrumented. Access openings were covered with a moist cotton pellet and Cavit™ (3M™ ESPE™). Triad® gel (Dentsply Trubyte) was used to seal the mesial and distal foramen to prevent mounting resin from entering canals. The roots were covered with two coats of nail polish prior to mounting.

Each tooth was embedded into a custom-made metal cube (K-Kube), filled with EpoxiCure® resin (Buehler) up to the level of the cementoenamel junction.

The K-Kube (Figure 1) is based on the Bramante technique with the addition of a compression component.28 Compression eliminates the 0.3 mm gap created by each saw blade cut. The K-Kube facilitates the disassembly and reassembly of each tooth Endodontic practice 41

RESEARCH

THE FUTURE HAS RETURNED. Photon Induced Photoacoustic Streaming is an innovative irrigation system that uses the Fotona LightWalker Er:YAG laser (Technology4Medicine) at sub-ablative power levels in conjunction with a patented tip that is effective when placed exclusively into the coronal access cavity. This technique allows all canals to be irrigated at the same time. The cleaning ability of PIPS appears to be associated with rapid irrigant motion caused by expansion and implosion of laser-induced bubbles.23 Using single canal premolars, Peters, et al., demonstrated significantly less bacteria at the 1 mm level after PIPS activation when compared to ultrasonically activated irrigation and conventional irrigation.24 In evaluating the effectiveness of irrigation devices, previous studies have either measured debris removal or elimination of bacteria. Debris removal measurement allows visualization of the extent of irrigation penetration into canal intricacies. The complex canal anatomy of mesial molars with isthmuses makes irrigation and debris removal more challenging. Von Arx, using endoscopic inspection during periradicular surgery, noted mesial canal isthmuses in 83% of mandibular first molars.25 Mannocci also evaluated mesial roots of mandibular molars and found isthmuses were present 17%, 37%, and 50% at 1, 2, and 3 mm from the apex, respectively.26 There are a number of studies evaluating debris removal in mesial root isthmuses of mandibular molars using the EndoVac, passive sonics, ultrasonics, and conventional positive pressure irrigation. These studies have not demonstrated complete removal of debris in the apical 6 mm. The PIPS laser technique has yet to be evaluated in this manner. The aim of this study was to compare the cleaning effectiveness of conventional Max-i-Probe needle irrigation, the EndoVac system, and PIPS laser technique using mesial canal isthmuses of mandibular molars.

RESEARCH so that canal and isthmus debris can be evaluated prior to and after instrumentation and irrigation. In this technique, each root canal system serves as its own control.

After setting, the embedded specimens were removed from the K-Kube and stored in 100% humidity.

Specimen sectioning The resin-mounted specimens were sectioned at right angles to the root canal at 3 and 5 mm from the mesial root apex using an Accutom 50 precision saw (Struers) equipped with a 0.30-mmthick, high concentration diamond blade (Precision Surfaces International). The coronal surface of each section was used for evaluation and scoring.

Group assignment Each specimen served as its own control.

The teeth were match paired for curvatures and randomly placed into one of the following three groups: • Irrigation with conventional 30 gauge Max-i-Probe (n=15) • Irrigation with PIPS (n=15) • Irrigation with the EndoVac system (n=15) Initial evaluation Images of each section were made using a digital camera (Nikon CoolPix 5400, Nikon Inc.) attached to a stereomicroscope (Nikon SMZ-2T, Nikon Instruments Inc.) at the highest magnification to allow complete visualization of canals and isthmus. The color images were viewed on a highresolution iMac® monitor (Apple) and the outer surfaces of the ML, MF, D root canals, and isthmus were traced. The debris present in the canals and isthmuses was also outlined. Image J software (National Institutes of Health, v1.39a) was used to calculate the surface area of the root canal, isthmus, and the debris present. This data was used to calculate a cleanliness percentage for each canal and isthmus prior to instrumentation and after final irrigation.

Canal preparation and irrigation Each sample was reassembled into the K-Kube. The Cavit and cotton pellet were removed, and a #20/.04 file was placed at WL to verify proper reassembly. After coronal flaring with Gates Glidden drills (Dentsply) sizes #2-4, the canals in the EndoVac and conventional Max-i-Probe irrigation group were prepared with .04 42 Endodontic practice

Mesial Canals

Mesial Isthmuses

Distal Canals

Maxi-iProbe

94%

93%

50%

EndoVac

99%

95%

41%

PIPS

97%

90%

87%

Table 1. Percent cleanliness of all sections combined after final irrigation

Figure 2: Comparison of EndoVac, Max-i-Probe and PIPS using percent cleanliness of all sections combined after final irrigation

A)

B)

Figure 3: Comparison within groups of canal and isthmus cleanliness at 3 and 5 mm from mesial root apex after final irrigation

Hyflex rotary files to a master apical file size #35 using a crown-down technique. The canals in the PIPS group were prepared with .04 and .06 Hyflex rotary files using a crown-down technique to a master apical file size #25/.06 per manufacturer’s recommendations. Irrigation was as follows: Groups A/B: Conventional Max-i-Probe and PIPS laser A 30-gauge Max-i-Probe irrigation needle was placed into the canal 1 mm from binding and no further than 1 mm coronal

to the WL. One ml 6% NaOCl irrigation was used between each file size to irrigate the canal. Time per irrigation cycle was 30 seconds.

Group C: EndoVac Per manufacturer’s recommendations, between each file the EndoVac master delivery tip (MDT) was placed above the access opening, and 6% NaOCl was simultaneously delivered and evacuated keeping the canal and chamber replenished with irrigant. The macrocannula was inserted into each canal while the MDT Volume 6 Number 4

RESEARCH

continually replenished the canal and chamber with 6% NaOCl. Insertion of the macrocannula was to a point just short of binding, and it was slowly moved up and down in the canal for 30 seconds.

Final Irrigation Group A: Conventional Max-i-Probe The Max-i-Probe delivered 1.0 mL of 6% NaOCl over 30 seconds in each canal, and the NaOCl was allowed to remain passively in the canals for an additional 30 seconds.

In each canal, 0.5 mL 17% EDTA was delivered over 10 seconds and allowed to remain passively for 50 seconds. Finally 1.0 mL 6% NaOCl was delivered over 30 seconds to each canal and then allowed to remain passively for 30 seconds.

Group B: PIPS laser The irrigation technique followed manufacturerâ&#x20AC;&#x2122;s recommendations for final irrigation. The 2940 nm Er:Yag LightWalker laser at 20 mJ (15 Hz, 50 microsecond pulse duration) was equipped with a 600 micron stripped tip. In each cycle, the PIPS laser tip was placed exclusively into the pulp chamber, short of any canal orifice.

Cycles 1-3: 30-second continuous cycles of 6% NaOCl activated by the PIPS laser Cycle 4: 30-second continuous cycle of sterile water activated by the PIPS laser Cycle 5: 30-second continuous cycle of 17% EDTA activated by the PIPS laser Cycle 6: 30-second continuous cycle of sterile water activated by the PIPS laser Group C: EndoVac The irrigation technique followed manufacturerâ&#x20AC;&#x2122;s recommendations. Final irrigation followed the microCycle technique for two canals (purging and charging canals).

Microcycle 1: The microcannula was placed in the first canal to working length while the MDT delivered 6% NaOCl for 10 seconds.

The MDT was quickly removed, and the microcannula was allowed to suction the NaOCl from the canal (purged). The cycle was repeated. On the third cycle, after the initial 10 seconds, the microcannula was quickly withdrawn from the canal allowing the MDT to fill the canal with 6% NaOCl (charged). The NaOCl was allowed to sit in the canals for an additional 30 seconds.

During this time, the irrigation sequence was repeated on the second canal. Microcycle 2: Again using the microcannula and MDT, each canal was irrigated with 1.0 mL 17% EDTA over 10 seconds, then the canal was charged. The 17% EDTA remained Volume 6 Number 4

The amount of debris present before instrumentation and after final irrigation was compared with paired t-tests, and the groups were compared with repeated measures analysis of variance (P < 0.001).

five specimens in the conventional Maxi-Probe group were lost either during processing or lacked a detectable isthmus.

There were no statistically significant differences in mesial canal and isthmus cleanliness among all three groups at all sections prior to instrumentation or after final irrigation (Table 1, Figure 2). All canals and isthmuses were significantly cleaner after final irrigation compared to before instrumentation. Within each group, there was no statistically significant difference in canal cleanliness at 3 or 5 mm from the mesial root apex (Figure 3). The distal canals in the PIPS group post-final irrigation were significantly cleaner than the uninstrumented distal canals in the other two groups (P < 0.001). The cleanliness of the distal canals in the EndoVac and Max-iProbe conventional needle irrigation groups was not significantly different (Figure 4).

Results

Discussion

One specimen in the EndoVac group and

The results of this study demonstrated an

passively in the canals for an additional 50 seconds. Microcycle 3: 6% (NaOCl) was the same as Microcycle 1.

Final Evaluation After final irrigation, all specimens were removed from the K-Kube, and each sample slice was examined for remaining debris similar to the initial evaluation.

Percent canal cleanliness was statistically analyzed for significant differences between each group, section, canal total, isthmus total and pre-instrumentation, post-final irrigation techniques.

Data Analysis/Interpretation

Endodontic practice 43

RESEARCH A)

B)

Figures 4A and 4B: A) A sample from each group demonstrating mesial canal and isthmus cleanliness before instrumentation (upper image) and after final irrigation (lower image) at 5 mm from apex. B) A sample from each group demonstrating distal canal cleanliness before instrumentation (upper image) and after final irrigation (lower image)

overall mesial canal cleanliness of 94% in the conventional Max-i-Probe needle irrigation group. These results are similar to those of Klyn, et al., and Howard, et al., who demonstrated over 95% mesial canal cleanliness after final irrigatation.19 Overall mesial canal cleanliness for the EndoVac in this study was 99%, which is in agreement with Howard, et al., who reported over 95% mesial canal cleanliness.27 We found a 93% overall isthmus cleanliness after using conventional irrigation; this is supported by Klyn, et al., with 90% isthmus cleanliness using conventional Maxi-i-Probe needle irrigation.19 Our overall isthmus cleanliness using EndoVac irrigation was 95%; this is much higher than 55% reported by Howard, et al.27 The differences in isthmus cleanliness results may be attributed to variations in isthmus width and length.

44 Endodontic practice

In this study, there were no statistically significant differences in canal and isthmus debridement at various levels between conventional Maxi-i-Probe needle, EndoVac, and PIPS laser irrigation. This is in agreement with Howard, et al., who also found no significant differences between canal and isthmus cleanliness when comparing the EndoVac with conventional irrigation.27 Additional studies have also evaluated debris removal using conventional and EndoVac irrigation. In a study by Siu and Baumgartner, the EndoVac showed significantly better debridement at 1 mm from working length compared to needle irrigation.29 When evaluating debris removal in narrow mesial canal isthmuses of mandibular molars, Susin, et al., found the EndoVac produced considerably cleaner isthmuses when compared to manual dynamic irrigation.30

In this study we used the NaOCl and EDTA irrigation protocol recommended by the manufacturers of the PIPS laser and EndoVac systems. The volume of NaOCL irrigation and contact times were not consistent between groups. Effectiveness of NaOCl is dependent on surface contact time, volume of irrigant, and exchange of solution.31 The PIPS protocol had a final apical preparation size of 25/.06.

Therefore, there were fewer file and irrigation cycles in the PIPS group during mechanical instrumentation compared to the other two groups. Although fewer files may have produced less additional debris in the PIPS samples, decreased overall irrigation time and volume of NaOCl may have had an effect on the dissolution of organic debris. Also the PIPS final irrigation technique consisted of three 30-second intervals of continuous NaOCl irrigation, totaling 90 seconds for all canals. The final irrigation technique for the EndoVac and conventional needle irrigation had a total NaOCl irrigation time of 180 seconds.

The EndoVac also had an advantage of continuous NaOCl exchange during the cleaning and shaping process, whereas the PIPS and conventional irrigation groups were limited to 1 mL NaOCl between files.

The PIPS technique is unique in that the tip of the laser is placed exclusively within the pulp chamber and not into the canal space below the orifice level. Through acoustic streaming, irrigant activated by the LightWalker laser has the potential to flow into all of the canals. In this study, the distal roots were retained so that the effect of PIPS on debris removal in a non-instrumented canal could also be observed. Although teeth were sectioned at 3 and 5 mm from the mesial root apex, the distance of the distal root sections from the distal root apices was not controlled within or between groups. The overall cleanliness of the distal roots was significantly greater (P < 0.001) in the PIPS group when compared to the EndoVac or conventional irrigation groups. The distal canal cleanliness in the EndoVac group compared to the conventional group was not significantly different. This data can only be noted as anecdotal, and further study would be required to confirm and expand on these observations.

Conclusion The findings in this study showed no significant difference in debris removal of mandibular molar mesial canals and Volume 6 Number 4

Acknowledgement The authors wish to gratefully acknowledge Technology4Medicine for their generous donation of the PIPS laser patented tip and Dr. DiVito who personally oversaw the use of the Er:Yag laser. We would like to thank Dr. Cerniglia of Metarie, LA who graciously allowed us use his office space and Fotona LightWalker Er:Yag laser. We would also like to recognize Coltène/Whaledent for their generous donation of the Hyflex CM

NiTi rotary files to facilitate this resident research. The authors deny any conflicts of interest related to this study. This article is the work of the United States government and may be reprinted without permission.

Opinions expressed herein, unless otherwise specifically indicated, are those of the authors. They do not represent the views of the Department of the Air Force or any other department or agency of the United States government. EP

References 1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol. 1965;20:340-349.

2. Sundqvist G, Figdor D. Life as an endodontic pathogen. Ecological differences between the untreated and root-filled root canals. Endod Topics.

2003;6(1):3-28.

3. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod.

2004;30(12):846-850.

4. Friedman S, Abitbol S, Lawrence HP. Treatment outcome in endodontics: the Toronto Study. Phase I: initial treatment. J Endod. 2003;29(12):787-793.

Oral Surg Oral Med Oral Pathol. 1971;32(5):778784.

13. Haapasalo M, Orstavik D. In vitro infection and disinfection of dentinal tubules. J Dent Res. 1987;66(8):1375-1379.

14.Alves FR, Almeida BM, Neves MA, Moreno JO, Rôças IN, Siqueira JF Jr. Disinfecting ovalshaped root canals: effectiveness of different supplementary approaches.

J Endod. 2011;37(4):496-501.

15. Horiba N, Maekawa Y, Matsumoto T, Nakamura H. A study of the distribution of endotoxin in the dentinal wall of infected root canals. J Endod.

1990;16(7):331-334.

5. Seltzer S, Bender IB, Smith J, Freedman I, Nazimov H. Endodontic failures-- an analysis based on clinical, roentgenographic, and histologic findings. I. Oral Surg Oral Med Oral Pathol.

1967;23(4):500-516.

16. Boutsioukis C, Lambrianidis T, Verhaagen B, Versluis M, Kastrinakis E, Wesselink PR, van der Sluis LW. The effect of needle-insertion depth on the irrigant flow in the root canal: evaluation using an unsteady computational fluid dynamics model. J Endod. 2010;36(10):1664-1668.

6. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J.1997;30(5):297306.

17. Brunson M, Heilborn C, Johnson DJ, Cohenca N. Effect of apical preparation size and preparation taper on irrigant volume delivered by using negative pressure irrigation system. J Endod.

2010;36(4):721-724.

7. Nair PN, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after “one-visit” endodontic treatment.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2005;99(2):231-252.

18. Sedgley CM, Nagel AC, Hall D, Applegate B. Influence of irrigant needle depth in removing bioluminescent bacteria inoculated into instrumented root canals using real-time imaging in vitro. Int Endod J. 2005;38(2):97-104.

8. Schilder H. Cleaning and shaping the root canal.

Dent Clin North Am. 1974;18(2):269-296.

9. Baker NA, Eleazer PD, Averbach R, Seltzer S. Scanning electron microscopic study of the efficacy of various irrigating solutions. J Endod.

1975;1(4):127-135.

10. Siqueira JF Jr, Rôças IN, Santos SR, Lima KC, Magalhães FA, de Uzeda M. Efficacy of instrumentation techniques and irrigation regimens in reducing the bacterial population within root canals. J Endod. 2002;28(3):181-184.

11. Vertucci FJ, Williams RG. Root canal anatomy of the mandibular first molar. J N J Dent Assoc.

1974;45(3):27-28.

12. Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular first molar.

Volume 6 Number 4

19. Klyn S, Kirkpatrick TC, Rutledge RE. In vitro comparisons of debris removal of the EndoActivator system, the F file, ultrasonic irrigation, and NaOCl irrigation alone after handrotary instrumentation in human mandibular molars.

J Endod. 2010;36(8):1367-1371.

Visualization of irrigant flow and cavitation induced

by Er:YAG laser within a root canal model. J Endod.

2011;37(6):839-843.

24. Peters OA, Bardsley S, Fong J, Pandher G, Divito E. Disinfection of root canals with photoninitiated photoacoustic streaming. J Endod.

2011;37(7):1008-1012.

25. von Arx T. Frequency and type of canal isthmuses in first molars detected by endoscopic inspection during periradicular surgery. Int Endod J. 2005;38(3):160-168.

26. Mannocci F, Peru M, Sherriff M, Cook R, Pitt Ford TR. The isthmuses of the mesial root of mandibular molars: a micro-computed tomographic study. Int Endod J. 2005;38(8):558-563.

27. Howard RK, Kirkpatrick TC, Rutledge RE, Yaccino JM. Comparison of debris removal with three different irrigation techniques. J Endod.

2011;37(9):1301-1305.

28. Bramante CM, Berbert A, Borges RP. A methodology for evaluation of root canal instrumentation. J Endod. 1987;13(5):243-245.

29. Siu C, Baumgartner JC. Comparison of the debridement efficacy of the EndoVac irrigation system and conventional needle root canal irrigation in vivo.

J Endod. 2010;36(11):1782-1785.

30. Susin L, Liu Y, Yoon JC, Parente JM, Loushine RJ, Ricucci D, Bryan T, Weller RN, Pashley DH, Tay FR. Canal and isthmus debridement efficacies of two irrigant agitation techniques in a closed system. Int Endod J. 2010;43(12):1077-1090.

31. Senia ES, Marshall FJ, Rosen S. The solvent action of sodium hypochlorite on pulp tissue of extracted teeth. Oral Surg Oral Med Oral Pathol.

1971;31(1):96-103.

20. Mehdipour O, Kleier DJ, Averbach RE. Anatomy of sodium hypochlorite accidents. Compend Contin Educ Dent. 2007;28(10):544-546, 548, 550.

21. Desai P, Himel V. Comparative safety of various intracanal irrigation systems. J Endod.

2009;35(4):545-549.

22. Mitchell RP, Yang SE, Baumgartner JC. Comparison of apical extrusion of NaOCl using the EndoVac or needle irrigation of root canals. J Endod. 2010;36(2):338-341.

23. Matsumoto H, Yoshimine Y, Akamine A.

Endodontic practice 45

RESEARCH

isthmuses when comparing the EndoVac, PIPS, and conventional Max-i-Probe needle irrigation. Although non-instrumented distal root cleanliness was not a controlled variable in this study, PIPS was significantly better at cleaning these uninstrumented canals when compared to the other two groups. A controlled study looking at PIPS ability to effectively clean canals with minimal instrumentation is warranted.

ENDODONTIC CONCEPTS

Dr. Julian Webber’s 10 steps to endodontic heaven 1 Concepts and Rationale

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The most important endodontic principles in 10 bullet points

C

linical endodontics has undergone a huge revolution in the last 10 years. So huge that we may be lured into thinking that if we have the right essential equipment, the treatment looks after itself.

But while endodontics is easier to do than ever before, it should never be described as easy. It is one of the most challenging dental treatments, and that is why we must

Dr. Julian Webber has been a practicing endodontist in London for more than 30 years. He was the first UK dentist to receive a Master’s degree in endodontics from a university in the U.S. (Northwestern University Dental School, Chicago) in 1978. He has lectured extensively and given many hands-on courses on endodontics worldwide. He is a fellow of the International College of Dentists and an active member of the American Association of Endodontists. Dr. Webber is the editorin-chief of Endodontic Practice.

46 Endodontic practice

always ensure we follow basic principles.

This article sets out the 10 essential steps to predictable and successful outcomes for the benefit of all our patients.

1. Concepts and rationale Because in clinical endodontics we are treating a disease process, two major considerations should be understood.

These are, firstly, the anatomy of our root canals, and secondly, the bacteria that reside within. Eradication of substrate anatomy and sterilization of the root canal with a filling technique to prevent reinfection are the primary goals.

In 1974, Herbert Schilder coined for the first time the term “root canal systems” (RCS). He also spoke about “Lesions of Endodontic Origin” (LEO), and he introduced us to the term “Portals of Exit”

(POE). LEOs arise adjacent to the POE. In order to eradicate substrate within the RCS, we need to shape the canals so that irrigants can clean and digest all substrate.

Furthermore, when the main canal is shaped correctly, we can fill the RCS with a three-dimensional root filling based on gutta percha that not only fills the main canal but also those POE at which the LEO arises.

2. Diagnosis Almost everyone these days makes a periodontal assessment of their patients’ mouths. Does anyone carry out an endodontic assessment? If every mouth has a non-vital tooth, and this is not far from the truth, there could be a lot of endodontic treatment to be carried out. Diagnosing endodontic disease in symptomatic and Volume 6 Number 4

We have at our disposal everything we need to make our patients comfortable.

Painless endodontics will ensure patients return time after time.

3. Anesthesia Nowhere in dentistry is there more frustration than the inability to anesthetize a tooth requiring endodontics, especially an inflamed or “hot” tooth. Painless and effective anesthesia is achievable especially with the use of devices such as “The Wand.” We have at our disposal everything we need to make our patients comfortable.

Painless endodontics will ensure patients return time after time.

4. Access/ultrasonics Access is the key to success. Get this wrong, and everything else will be frustrating, difficult, and ultimately lead to failure. We can all restore teeth, but we don’t always get a second chance at our root canal. Access cavity preparation is hugely important, and the access should be as large as is necessary to do the job properly. Ultrasonic techniques will help us find canals and refine our access cavities without gross destruction of coronal tooth structure commonly seen when oversized burs are used. Dentsply Maillefer Start-X™ ultrasonics tips are simply amazing for modification of access cavities and canal location.

5. Magnification “Seeing is believing.” There is no excuse to miss a canal because of inadequate magnification and illumination when so many products are available to improve vision.

Endodontists use microscopes, but there is no reason not to purchase a set of telescopic lenses to improve mag up to 2.5x – 3.5x. Once you step up your magnification, you will be astounded at what you can see and realize what you must have missed in the past.

6. Digital radiography On everyone’s wish list, DR with its obvious advantages over the smaller version will improve our diagnostic skills and help educate our patients. Over an extended period, as there are no developing costs, the system will pay for itself. Fully integrated into most patient software management packages, DR is the first giant step towards “ a paperless” office.

Volume 6 Number 4

7. Irrigation Irrigants clean our root canal systems, and files shape them. The two main standbys of irrigation are 2.5-5% sodium hypochlorite (NaOCl) and 17.5% ethylenediaminetetracetic acid (EDTA).

NaOCL digests soft tissue, and EDTA removes inorganic debris (smear layer) that builds up on the surface of the canal enhancing penetration of NaOCl into lateral canals, dentinal tubules, and POE. During the root canal shaping procedure, irrigant exchange becomes more effective, allowing for deeper and deeper positioning and effectiveness of irrigant in the RCS. Modern preparation techniques with NiTi files are so rapid nowadays that irrigation needs enhancing to compensate for the reduced time the irrigant is in the canal. Ultrasonic and sonic activation of irrigants is essential to optimize irrigation effectiveness.

8. Working length Electronic Apex Locators (EAL) with enhanced technology will indicate the position of the apical foramen in about 96% of cases even in the presence of canal fluid.

They are an indispensable tool to length control and should always be “believed” before an X-ray.

While there is huge controversy regarding final placement of instruments and filling materials, a patency technique ensures the end of the canal is not blocked with debris and that only GP root filling fills the body of the canal “flush” to the canal terminus. Check working length regularly throughout the preparation of the canal.

9. Shaping Root canals should be shaped with a continuously tapering preparation objective in mind whereby the narrowest aspect of the preparation is apical and the widest is coronal (access cavity). A tapered root canal can be irrigated effectively to clean the canal of tissue and bacteria. The tapered clean root canal can then be optimally filled with three-dimensional gutta percha.

Herbert Schilder said, “Unshaped root canals cannot be cleaned, and unshaped root canals cannot be filled.”

There are many available file systems that will achieve the tapered preparation objective. Which system you use is a matter of preference. Your assessment of what is good and bad can be acquired through some of the many courses offered by the various manufacturers. You have to try the file systems for yourself using the recommendations for use that comes with each instrument.

At present I am using Dentsply Tulsa Dental Specialties’ WaveOne® system.

A single file technique to shape a canal in a reverse reciprocating motion where the backward movement is greater than the forward movement. It’s an exciting concept.

10. Three-dimensional obturation Nearly all causes of endodontic failure are related to missed canals or unfilled POE. Filling root canals truly three-dimensionally ensures further reinfection is avoided.

Three-dimensional obturation can now easily be achieved with devices such as System B™ (SybronEndo), Thermafil® (Dentsply Tulsa Dental Specialties), the Obtura (Obtura Spartan Endodontics) heated gutta-percha delivery system, SybronEndo Elements Obturation Unit, E&Q combination unit from Meta Biomed Co. Ltd., Hot Shot and Hot Fill from B&L, and Calamus® from Dentsply Maillefer.

Filling the root canal system was once a time-consuming procedure but can now be achieved rapidly and with a level of predictability.

So, those are my 10 steps to endodontic heaven, a hit list of all that is important in endodontics and designed to improve and increase efficiency and success to the benefit of patients and clinicians alike. EP For more info and relevant literature contact: jw@julianwebber.com

Endodontic practice 47

ENDODONTIC CONCEPTS

asymptomatic teeth is the cornerstone to good practice and the building block that will ensure that patients keep on coming through the doors of our practices.

PRACTICE MANAGEMENT

Negotiating successful payment arrangements Looking for perfect payment arrangements? Janice Keller reveals four easy steps to help you succeed every time, with every patient

W

ouldn’t it be nice if every payment arrangement interaction between your practice and your patients went smoothly, with no awkwardness or misunderstandings? The bottom line is that you can make that happen. “Perfect” payment arrangements are possible if you follow these four easy steps: 1. Information gathering 2. Preparations 3. Negotiation 4. Documentation Let’s look at each step in a little more detail.

1. Information gathering Gather information before speaking with the patient. A discussion with the dentist 1 to 2 days prior to the consultation is important in the preparation process. If the negotiation process occurs on the same day as the appointment, the team will need excellent communication skills. Relaying the recommended treatment from hygienist to dentist allows the patient to hear it for the second time. Again, communication regarding recommended treatment should be communicated verbally. Ask the patient if he/she has any questions before the financial coordinator takes over. If the patient is ready, the financial coordinator can start the negotiation process.

2. Preparations Prepare where the negotiations will take place. A private, quiet area with computer access is ideal. If you do not have a consultation area or private area

Janice Keller has more than 25 years of experience in dentistry as an office manager and software trainer. Now, as a practice management consultant, she provides high-quality, customized practice development and education to clients and their teams.

Ms. Keller is certified by Bent Ericksen & Associates in employee law compliance, and also certified by the Institute of Practice Management. She is a member of the prestigious Speaking Consulting Network, and the Academy of Dental Management Consultants. She is also an independent certified Softdent trainer.

48 Endodontic practice

to hold negotiations, having the treatment coordinator address it with the patient in the treatment room, sitting eye-to-eye and knee-to-knee will work. The bottom line is – be prepared, and have all the information you need in hand (e.g., X-rays and a written treatment plan). It’s also important to prepare for resistance or discussion. Going into a negotiation situation without being prepared will almost surely lead to failure.

3. Negotiation Don’t be afraid to negotiate. Let’s say Mary, the financial coordinator, presents the first payment option to the patient. If the patient is agreeable to this option, Mary moves

If a patient has a question, or hesitates, it does not mean he/she doesn’t want the treatment.

It simply means you have not yet found the solution that makes it acceptable from a financial point of view.

on to documentation of the arrangement, gets the patient’s signature, schedules the treatment, and thanks the patient. Job well done!

But, if the first option is not acceptable to the patient, then move to the second option, according to your practice guidelines. The key here is to always stop and wait for the patient to respond. We are often uncomfortable with silence, and do not allow the patient a moment to think and respond before jumping in with the second and third options because we’re afraid he/ she will say no. It’s okay if they say no!

The goal is to negotiate until they agree. They have already agreed to the treatment – you are now negotiating how they pay for it. Remember, if a patient has a question, or hesitates, it does not mean he/

she doesn’t want the treatment. It simply means you have not yet found the solution that makes it acceptable from a financial point of view.

4. Documentation Documentation is critical. Patients should always sign consent forms that clearly define the negotiated payment arrangements.

On the off-chance the patient declines treatment, documentation is still crucial. In this case, a declined treatment form should be signed, noting the reason the patient is delaying or declining the recommended treatment. Use your software to assist with this documentation. Create reminders for follow-ups if you have discussed contacting the patient in the future to discuss scheduling treatment. EP Volume 6 Number 4

AUTHOR GUIDELINES

Endodontic Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Endodontic Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Endodontic Practice US requires original, unpublished article submissions on endodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education.

Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Endodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available.

Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to endodontic dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.

Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 6 Number 4

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text. Number tables consecutively and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style.

For example: Journals: (Print) Greenwall L. Combining bleaching techniques.

Aesthetic & Implant Dentistry. 2000;1(1):92-96.

(Online) Author(s).

Article title.

Journal Name.

Year;vol(issue#):inclusive pages. URL. Accessed [date].

Manuscript Review All manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity.

Articles should be submitted to: Greg McGuire, Production Manager greg@medmarkaz.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001.

Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011.

Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Checklist for article submissions: 3 A copy of the manuscript and figures/ captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkaz.com

Endodontic practice 49

ENDOSPECTIVE

The benefits of a “beginner’s mind” Dr. Rich Mounce focuses on regaining the excitement of dentistry

I

am often asked for clinical and practice management advice. The advice sought by endodontists is commonly related to increasing business volume, solving staff challenges, and establishing strategies for dealing with difficult patients. General dentists have similar questions, which also include technique specific inquiries such as “What is the ideal master apical diameter?” and “What do you irrigate with?” among others. Generalist or specialist, doctors are seeking answers.

In 2013, dentistry is a tough business; especially for endodontic specialty practices, depending on their location, the local economy, the volume and quality of competition, and numerous other secondary factors. For general dentists and endodontists alike, the days of hanging out one’s shingle, drilling, filling, and billing, and being busy and profitable are over. The source of the challenges are numerous, but they include too many dentists in urban areas (and not enough in rural areas), the rise of corporate dentistry and diminishing private practice opportunities, declining caries rate, a lack of business training in dental school, diminished insurance reimbursement, an uncertain national economy, the current astounding debt levels from dental school graduation, and difficult patients.

Two things strike me in my conversations with some of the people who seek advice. One is a lack of enthusiasm for dentistry, and second is a lack of appreciation that we are running a business, albeit a compassionate one, and subject to market forces. Dentistry has changed, and I am not sure this is recognized by some. We are competing with our colleagues and in a hostile

Dr. Rich Mounce is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty.

He owns MounceEndo, LLC, marketing the rotary nickel-titanium MounceFile in Controlled Memory and Standard NiTi. Dr. Mounce can be reached at: RichardMounce@MounceEndo.com MounceEndo.com Twitter: @MounceEndo

50 Endodontic practice

environment beyond them. Insurance companies, contractors, landlords, and our vendors, among other market players, are looking out for their interests first.

I have observed that the enthusiasm and excitement for practice one displays is directly proportional to the level of both clinical and financial success of the individual. Abraham Lincoln said, “People are just as happy as they make up their minds to be.” It’s true. If one is passionate about dentistry, he/she will find ways to manage all the “other stuff” to allow them to do the thing he/she loves. Their enthusiasm is contagious. Alternatively, an individual who finds fault and makes excuses without looking in the mirror is already defeated.

The resulting career dissatisfaction will

direct solutions to the aspects of the profession that created the dissatisfaction.

We can directly address our weaknesses if only we make the effort, and resources to this end abound.

It provides comfort to recognize that some issues and challenges we face, especially as specialists, are unsolvable, and therefore, they are situations we must let go of. As a specialist, it is a given some general dentists are not available as referring doctors. These doctors, for whatever reason, personal or clinical, might have referred at one time but are not interested in either referring or having any form of relationship. Seeing one’s schedule open and subsequently focusing on the doctors who don’t refer is pointless.

Abraham Lincoln said, “People are just as happy as they make up their minds to be.” It’s true. If one is passionate about dentistry, he/she will find ways to manage all the “other stuff” to allow them to do the thing he/she loves. inevitably back splash onto the non-dental side of their lives if it has not already done so.

For readers who are less than enthusiastic about endodontics or dentistry today than they were when they started, it might well be time to go back and figure out why they embarked on a dental career and seek to regain their passion. Having a beginner’s mind to regain one’s enthusiasm and belief in the possible can only help see opportunity instead of defeat.

What can be done to regain this excitement?

The answer involves introspection and examination of past and present life influencers such as family upbringing with regard to money and success, work ethic, physical and mental fitness, and interpersonal psychology for patient communication among others.

Identifying ones weaknesses clinically and in business management can provide

A much better focus is providing excellent service to those who do.

A second such issue touching both general dentists and specialists is staff management. Staff challenges are omnipresent. Any human group tasked to work together will have disagreements, conflict and be in a constant state of flux. What family gets along all the time?

Patience and leadership can go a long way toward minimizing the frustration of people underperforming. This is a neverending quest.

In summary, renewal and rediscovery of why one embarked on a career in dentistry and endodontics in particular cannot be overstated in value. A beginner’s mind can provide a new vantage point from which to start the day with more reserve, patience, and ultimately satisfaction at its end. I welcome your feedback. EP Volume 6 Number 4

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ANATOMY MATTERS

“What’s It All About?” Part 7 Dr. John West recognizes that the best education in the world is an endodontist’s own personal education

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n 1966, British actor Michael Caine was an Oscar nominee for his movie Alfie, as was the Burt Bacharach and Hal David song of the same name that begins with the lyrics: What’s it all about, Alfie? Caine has appeared in more than 150 films, plays, and television shows, and he’s not done yet. Professor Dr. Herbert Schilder passed away 5 years ago in 2008. Had he lived, like Caine, he would not have been done. In fact, at age 80, like actor Michael Caine, he would have been at the top of his game.

Dr. Schilder always asked, “What’s it all about?” In his search for the answer, he did not discover the human root canal system, but he was the first to identify the relationship of root canal system anatomy, endodontic mechanics, and endodontic predictability. He changed the endodontic landscape. He changed the language of endodontics.1,2 Schilder also did not invent the root canal system, but he was the first to refer to the root canal as a “system” versus a simple tunnel. Schilder was the first to popularize sodium hypochlorite for cleaning away “dentin mud” (dentin filings packed inadvertently into the apical zone) and digesting detached dental pulp. In fact, Schilder used to call dentin mud the “fatal flaw” of endodontics. It still is today. When I was in my third year of dental school, sodium hypochlorite was not protocol. Instead, alcohol was the preferred endodontic irrigant but did not affect detached pulp, biofilm, or necrotic pulp. Next, Schilder suggested calling

foramina portals of exit (POEs). A portal of exit could be a foramen, an iatrogenic perforation, or a resorptive perforation. All root canal system communications with the attachment apparatus are communications nonetheless, requiring a hermetic seal in order to make endodontic treatment predictable.

Schilder renamed endodontic radiolucencies (previously called abscess, granuloma, or cyst) lesions of endodontic origin (LEOs) and suggested the biologic job of the endodontic clinician is to prevent or heal LEOs. Schilder was the first to assign a finishing checklist to radicular shapes.

He was the first to be perhaps arrogant enough to suggest three-dimensional obturation was not only possible but predictable. In the 1970s, authors such as Dr. Angelo Sargenti claimed it was impossible to clean the root canal system, and that it was better to “fumigate” the anatomy with formaldehyde in the form of N2 paste. Meanwhile, teachers like Dr. Frank Weine would have legendary debates with Dr. Schilder about whether to be “short” versus “patent” at the POE sites.

Clinically, I have never seen a 3D-sealed endodontic failure.3 All endodontic failures to heal were failures to seal.

When I was in dental school at the University of Washington, endodontics originated with Dr. John Ingle who is one of the all-time quintessential teachers, educators, and visionaries of endodontics.

He was the first to understand the need for

John West, DDS, MSD, the founder and director of the Center for Endodontics, continues to be recognized as one of the premier educators in clinical and interdisciplinary endodontics. Dr. West received his DDS from the University of Washington in 1971 where he is an affiliate associate professor. He then received his MSD in endodontics at Boston University Henry M. Goldman School of Dental Medicine in 1975 where he is a clinical instructor and has been awarded the Distinguished Alumni Award. Dr. West has presented more than 400 days of continuing education in North America, South America, and Europe while maintaining a private practice in Tacoma, Washington. He co-authored “Obturation of the Radicular Space” with Dr. John Ingle in Ingle’s 1994 and 2002 editions of Endodontics and was senior author of “Cleaning and Shaping the Root Canal System” in Cohen and Burns 1994 and 1998 Pathways of the Pulp. He has authored “Endodontic Predictability” in Dr. Michael Cohen’s 2008 Quintessence text Interdisciplinary Treatment Planning: Principles, Design, Implementation, as well as Dr. Michael Cohen’s soon to be published Quintessence text Interdisciplinary Treatment Planning Volume II: Comprehensive Case Studies. Dr. West’s memberships include: 2009 president and fellow of the American Academy of Esthetic Dentistry, and 2010 president of the Academy of Microscope Enhanced Dentistry, the Northwest Network for Dental Excellence, and the International College of Dentists. He is a 2010 consultant for the ADA’s prestigious ADA Board of Trustees where he serves as a consultant to the ADA Council on Dental Practice.

Dr. West further serves on the Henry M. Goldman School of Dental Medicine’s Boston University Alumni Board. He is a Thought Leader for Kodak Digital Dental Systems, and serves on the editorial advisory boards for: The Journal of Esthetic and Restorative Dentistry, Practical Procedures and Aesthetic Dentistry, and The Journal of Microscope Enhanced Dentistry. Visit www.centerforendodontics.com, or email: johnwest@centerforendodontics.com, phone 1-800-900-7668 (ROOT), fax 253-473-6328.

52 Endodontic practice

a system-based endodontics. This idea is not new. At that time, it was thought that if the main canal were treated successfully, that a 93 to 95% endodontic success rate could be expected. However, in graduate school at Boston University Henry M. Goldman school of Dental Medicine, Dr. Schilder had a different way of thinking. He said that all root canal system anatomy was potentially significant. Simply treating the “main” canal may simply not be enough.

Who was right?

I was about to find out. As an educator, I have always taught that the best education in the world is our own personal education.4-9 So, when I was a 1-year endodontist fresh out of graduate school, a patient named Lucille presented at my office. Her diagnosis and treatment changed my endodontic life forever. Lucille represented a defining moment in my endodontic career. I have never looked back. What did Lucille teach me?

Lucille was referred by her restorative dentist for evaluation of a “lateral radiolucency” distal to her mandibular left second premolar (Figure 1A). The pulp tested nonvital using the electric pulp tester and confirmed using ice test. The pulp did not respond to either test, which suggested a necrotic pulp. The adjacent pulps and contralateral tooth tested vital to the same two tests. The gingival crevice probed within normal limits. In order to confirm necrotic pulp diagnosis, I performed a “test cavity,” which also proved negative. I, therefore, scheduled nonsurgical endodontic treatment. I cleaned and shaped both the “main” root canal and serendipitously slid into a distal midroot lateral canal (Figures 1B and 1C). Endodontic treatment was before the advent of the endodontic microscope and before NiTi rotary shaping. A cone fit was made, and the root canal system was obturated using vertical compaction of warm gutta-percha technique (Figure 1D). The main canal appeared filled, and in addition, a lateral canal was filled at the original lateral LEO site. Lucille was seen for posttreatment 18 months later, and I thought Lucille was healing satisfactorily (Figure 1E). At 24 months posttreatment, however, the LEO was increasing in size, and the tooth was Volume 6 Number 4

1A. Pretreatment image of apparent lateral lesion of endodontic origin

1B. Manually cleaning and shaping the “main” canal to the radiographic terminus

1C. Sliding through distal lateral canal with subsequent short vertical amplitude strokes

1D. Cone fit to validate the last step of successful and appropriate shaping

1E. 18-month recall suggested satisfactory healing

1F. 24-month recall showed LEO increasing in size, and symptoms were increasing

1G. A retroprep was made, and the retroseal was packed with amalgam

1H. 35-year posttreatment is an example of a long-term success, which was surgically sealing the undersealed lateral “main” canal

becoming symptomatic (Figure 1F). Since the “main” canal appeared properly sealed, and since the LEO was located exclusively lateral, my treatment plan was to attempt to locate and seal the apparent offending undersealed lateral canal. My thinking was that if the lateral LEO then healed, that for Lucille, at least, her “main” canal would have been a lateral canal. If this were true, then Dr. Schilder was right: all anatomy is potentially significant, and I would have my own clinical example to prove that even a lateral canal could be the “main” or significant canal. I would understand for the first time in my own clinical experience that the location of the POEs could influence predictability regardless of their location along the entire root surface. I surgically discovered Lucille’s lateral canal, made a retropreparation using a straight handpiece and surgical length quarter round bur, and placed a lateral retrograde seal with amalgam, which was the surgical seal of choice at the time (Figure 1G).

A subsequent 35-year posttreatment image demonstrated regeneration of the apical and lateral lamina dura and periodontal ligament (Figure 1H). Lucille’s mandibular left second premolar remained asymptomatic throughout all those years.

My lesson learned from Lucille was first that there are no POEs that we don’t want (Figures 2A-2D). I also have learned that nature is unpredictable when it comes to underfilled root canal systems that heal or don’t heal (Figures 3A-3H). My final lesson Volume 6 Number 4

Figures 2A-2D. Which POE don’t you want? We want them all!

2A. Pretreatment image of another mandibular left premolar that had become pulpitic and needed endodontic treatment in order to save the tooth and the patient!

It really hurt

2B. Downpack image. Which of the several POEs don’t you want?

2C. Perpendicular view of finished endodontic treatment. Which POE don’t you want?

2D. Oblique view of finished endodontic treatment. Which POE don’t you want? I (you) want them all. All underfilled and unfilled POEs have the potential to cause endodontic failure Endodontic practice 53

ANATOMY MATTERS

Figures 1A-1H: Lower-left necrotic second premolar is an example that all endodontic anatomy matters when measuring the determinants of endodontic predictability

ANATOMY MATTERS Figures 3A-3H: POE (foraminal) transportation often caused failure to seal, and therefore, failure to heal

3A. Endodontically underfilled maxillary left second molar treated 5 years previously. No radiolucencies or symptoms. What will it be like in 30 more years?

3E. Downpack image demonstrating apical and lateral POEs being obturated

3B. DB POE has been transported internally while the MB POE has been transported externally

3F. 29-year posttreatment recall demonstrating complete long-term nonsurgical retreatment success

3G. Perpendicular pretreatment of perforated maxillary left central incisor

Figures 4A-4F: Sealing a lateral perforation can yield the same success in endodontics as treating a previously missed canal

4A. Perpendicular image of mesial and distal post perforation of mandibular right first molar

3C. Pretreatment of maxillary left central incisor with guttapercha cone tracing lateral LEO

4B. Oblique view of A

3D. Cone fit in preparation of warming and compacting into the entire endodontic anatomy

3H. Oblique image of same tooth revealing severe nature of perforation location

in this issue of Anatomy Matters is that nature heals LEOs in the presence of both mechanical and natural POE perforations (Figures 4A-4F).

So “What’s it all about?” The answer has always been simple: anatomy matters, anatomy matters, and anatomy matters.

Measure your successes and failures during your endodontic career by having an intentional long-term treatment recall system. Then look back, see what you have learned, and then become part of the evidence that matters. EP References 1. Schilder H. Filling root canals in three-dimensions. Dent Clin North Am. 1967;723-44.

2. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2):269-96.

4C. Image after MTA repairs of mesial and distal perforations. MTA was trolled into place using micro West spatulas and then allowed to cure

4D. Oblique image of C

3. West J. The frequency of underfilled root canal systems in endodontic failures. Presented at: Boston University School of Graduate Dentistry; June 1975.

4. West J. Anatomy matters. Endodontic Practice US. 2012;5(2):14-16..

5. West J. Anatomy matters — part 2. Endodontic Practice US. 2012;5(4):26-27.

6. West J. Anatomy matters — part 3. Furcal endodontic seal heals furcal lesion of endodontic origin. Endodontic Practice US. 2012;5(6):22-24.

7. West J. Anatomy matters. Long-term case report.

Endodontic Practice US. 2013;6(1):50-51.

8. West J. Anatomy matters. Root canal system anatomy only matters when it matters. Endodontic Practice US. 2013;6(2):56-58.

4E. 8-month posttreatment with healed attachment apparatus and tooth asymptomatic 54 Endodontic practice

4F. Clinical confirming successful attachment of the gingival sulcus

9. West J. Anatomy matters — part 6. Do lateral canals really matter? Endodontic Practice US. 2013;6(3):52-53.

Volume 6 Number 4

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

Current Endodontics: A Clinical Perspective Dr. Brett Gilbert August 13, 2013 Boise, ID www.sybronendo.com

Excellent and Efficient Endodontics Dr. John Olmstead September 12, 2013 Kansas City, KS www.sybronendo.com

CDA Presents: The Art and Science of Dentistry August 15-17, 2013 San Francisco, CA www.cdapresents.com/sf2013.aspx

Current Scientific Evidence in Endodontic Therapy Dr. Michael Nimmich September 20, 2013 Charleston, WV www.tulsadentalspecialties.com

Pathways To Successful Endodontics Dr. Joseph Maggio August 23, 2013 San Francisco, CA www.sybronendo.com

Predictable Endodontics – From Access To Obturation Dr. Pierre Machtou September 21, 2013 Montreal, Canada www.tulsadentalspecialties.com

PAIN Week 2013 – The National Conference On Pain For Frontline Practitioners September 4-7, 2013 Las Vegas, NV www.painweek.org

Endodontic Techniques for Safe and Predictable Results. An Intense 2-Day Hands-On Workshop Barry Lee Musikant, DMD Allan S. Deutsch, DMD September 27-28, 2013 S. Hackensack, NJ www.essentialseminars.org

Current Scientific Evidence in Endodontic Therapy Dr. George Bruder September 27, 2013 Asheville, NC www.tulsadentalspecialties.com

Endodontic Solutions For 2013 And Beyond Dr. Gary Glassman September 28, 2013 Toronto, Canada www.sybronendo.com

AAP 99th Annual Meeting September 28 – October 1, 2013 Philadelphia, PA www.perio.org

ADEA Sections On Business & Financial Administration and Clinic Administration Mid-Year Meeting October 9-12, 2013 Washington, DC www.adea.org

Endodontic Solutions: Strategies For Performing Endodontic Treatment Predictably, Profitably, and Painlessly Dr. Gary Glassman September 6, 2013 Cherry Hill, NJ www.sybronendo.com

Volume 6 Number 4

Endodontic practice 55

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Clinician’s Choice announces expansion of endodontic line For nearly 20 years, CLINICIAN’S CHOICE Dental Products, Inc. has been providing dentists throughout North America with clinically proven esthetic and restorative products, designed to solve their every day clinical challenges. More recently, the company has expanded into endodontics by introducing a full line of products designed for both general dentists and endodontic specialists.

The company’s flagship endodontic product, TYPHOON™ Infinite Flex NiTi Files, was one of the first files on the market to offer Controlled Memory NiTi™ technology. Boasting up to 600% more resistance to fatigue stress and three times the torsional strength of traditional NiTi files, TYPHOON files dramatically reduce the risk of file separation, while offering effortless navigation in extremely curved canals.

Trusted to produce consistent results, CLINICIAN’S CHOICE can be counted on for every day endodontic essentials, such as access burs, cordless obturation and backfill units, rotary instrumentation systems, ultrasonic units and tips, gutta percha, paper points, esthetic fiber posts, and core material.

For more information, contact CLINICIAN’S CHOICE at 1-800-265-3444 or visit www.clinicianschoice.com

Essential Dental Systems introduces C-Mor™ Ultra-Bright Mouth Mirrors Essential Dental Systems new ultra-bright mouth mirror makes performing all aspects of dentistry easier by allowing dentists to seemore clinically. Essential Dental Systems, Inc. (EDS) is proud to announce a new product to its line of quality dental devices, C-Mor Ultra-Bright Front Surface Mirrors. These mirrors revolutionize the visual field of dentistry by incorporating a special hi-tech process giving the practitioner the highest reflectance, light, and definition available.

With superior reflection, sharpness, and contrast, you can literally see more without distortion or cloudiness. Imagine television without high-definition ­— now that same groundbreaking technology is available in dental mirrors, allowing for the most enhanced field of vision available with any other mirror on the market. The C-Mor Mirror, with its 113% reflection factor will change the way you practice dentistry by enhancing what you see in a way unimaginable until now.

For more information, please visit the company website at www.edsdental.com or call 201-487-9090.

56 Endodontic practice

DentalEZ® Group’s everLight® is now enhanced for brighter illumination The first true, Direct LED light in the U.S. is now new and improved.

Conversion kits are available for competitive lights as well as existing users for a simple and easy upgrade.

DentalEZ® Group, a supplier of innovative products and services for dental health professionals worldwide, is pleased to announce that its popular everLight® LED operatory light is now enhanced with brighter illumination for a more productive experience. Conversion kits are available for competitive lights as well as existing users of the original everLight for a quick and easy upgrade.

An alternative to halogen-based operatory lights, the everLight LED operatory light provides color-corrected lighting, precise light pattern, and energy efficient features simply not possible using traditional halogen lighting. The everLight encompasses a long life of 30,000-plus hours, 10 times longer than halogen; therefore, there no longer is a need for replacement of lightbulbs. Moreover, dental professionals will enjoy substantial savings on monthly energy expenses, as the everLight uses less than 35 watts of energy; 70% less than halogen-based systems.

For more information about the new and improved everLight and all DentalEZ offerings, please call 866-DTE-INFO or visit www. dentalez.com.

Long Island Periodontist establishes Interdental Brush Buyers’ Club Long Island Periodontist Dr. Paul Crane recently partnered with numerous leading interdental brush manufacturers to establish a webbased company called Interdental Brush Buyers’ Club (IBBC). IBBC utilizes innovative and easy-to-navigate custom software designed to provide dental professionals with a continuous supply of FREE top quality brand interdental brush samples while encouraging the use of interdental brushes by patients through education, incentives, and convenient availability at a discounted price.

For more information, please visit www.interdentalbrushclub. com.

Netsertive: Local patients rely on the internet Local patients rely on the Internet to find the right clinician for their needs. Practices can now increase production and attract qualified patients with Netsertive’s Digital Extend™ marketing programs that combine the power of search, display, mobile, retargeting, and other online tactics to ensure that practices and top services are highly visible to patients doing research in specific local markets. The company’s experts will review the practitioner’s marketing goals and estimate what can be achieved within budget using the firm’s patent-pending technology. For more information, visit http://netsertive.com/dental or call 800-940-4351.

Volume 6 Number 4

The Ideal 3D Imaging Systems...

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We go further to test the limits

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Sensors built to last.

Experience the durability of Carestream Dental RVG sensors.

They’re tested to support tens of thousands of torsions, and waterproof for worry-free disinfection. Choose from three sizes, all built to last with a free three-year limited warranty.

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© Carestream Health, Inc., 2013.

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