Endodontic Practice US Winter 2023 Vol 16 No 4 by MedMark, LLC

Implants & Endo n 4 CE Credits Available in This Issue*

1.25“

1“ Winter 2023 Vol 16 No 4

endopracticeus.com

Unleashing the power of teamdriven endodontics Dr. Sonia Chopra

10.875“

The lateral puff in endodontics Drs. Mahmood Reza Kalantar Motamedi & Brett E. Gilbert

Broken file retrieval in the age of minimally invasive endodontics Drs. L. Stephen Buchanan & Christophe Verbanck

Management of pre- and postoperative dental and surgical pain during the opioid crisis

Drs. Diana Bronstein & Rita Steiner

1.75“ PROMOTING EXCELLENCE IN ENDODONTICS

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INTRODUCTION

Winter 2023

Volume 16 Number 4

Editorial Advisors 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 Stephen Cohen, MS, DDS, FACD, FICD Samuel O. Dorn, DDS Josef Dovgan, DDS, MS Luiz R. Fava, DDS Robert Fleisher, DMD Marcela Fridland, DDS Gerald N. Glickman, DDS, MS Jeffrey W Hutter, DMD, MEd Syngcuk Kim, DDS, PhD Kenneth A. Koch, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI Joshua Moshonov, DMD Richard Mounce, DDS Yosef Nahmias, DDS, MS David L. Pitts, DDS, MDSD 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 West, DDS, MSD CE Quality Assurance Board Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher)

Technology and positive change

he practice of endodontics has evolved dramatically over the course of the last few decades. Many practitioners consider endodontics to be at its golden age. Technology and materials have been at the forefront of these positive changes. When I reflect back on 30+ years of practice, there are a few of these technological changes that I feel have positively influenced the practice of endodontics — nickel-titanium files, torque-controlled handpieces, and cone beam computed tomography (CBCT).

NiTi files I was first exposed to nickel-titanium files in the 1990s. At that time, most endodontic files I used were made out of stainless steel. To have a material with lower chance of separation but still remarkably flexible at larger diameters dramatically changed my endodontic preparations. I was able to reduce the types and numbers of files I was using to get the clinical result I wanted. Though I still use some stainless-steel files today, in my practice I do most of my preparations with NiTi files in a safe and efficient manner.

Torque-controlled handpieces Nickel-titanium files were a game changer, but in the early use of these files there was a problem with separation while using a rotary instrument. This forced an evolution of handpieces specifically designed for endodontic uses. One of the vast improvements was handpieces for which a practitioner could control the torque values. This allowed a much safer way to use NiTi files in handpieces without a reduced risk of file separation. By introducing a safer rotary method for instrumentation, a practitioner could debride canals with less hand files and more efficiency.

CBCT Perhaps nothing that has been developed over the course of the last few decades has profoundly changed endodontics for me personally as has CBCT. Diagnostically, a CBCT is without question the most definitive way to image the oral cavity. We diagnose far more pathologies with the CBCT than without it. Additionally, the ability to image the internal structure of a tooth slated for endodontic therapy has changed our decisions to treat a tooth and the manner of how we are going to treat a tooth. Prior to CBCT, I was a big proponent of using an operating microscope in endodontics. After using CBCT, I have found I use my operating microscope far less because I know the internal anatomy of a tooth long before I begin treating a tooth. These three technologies have had a profound impact on my practice. I am excited for the next generation of advances.

Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

© MedMark, LLC 2023. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice US or the publisher.

Brian McGue, DDS, is a fulltime practicing general dentist with a private practice in Chesterton, Indiana. Dr. McGue and his wife, Susan, lecture on the topic of sedation and run hands-on workshops for dentists interested in incorporating oral and IV sedation into their practices at The Pathway in Tempe, Arizona (www.thepathway.com) and the 3-D Dentists facility in Raleigh, North Carolina, and Nashville, Tennessee (www.3ddentists.com). Together they have authored three textbook manuals on sedation. Dr. McGue is a fellow of the Academy of General Dentistry and a member of the American Dental Society of Anesthesiology, the International Anesthesia Research Society, and an educational member of the American Society of Anesthesiologists. Dr. McGue and Susan McGue can be reached at stayintheboxsedation@gmail.com.

ISSN number 2372-6245

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Volume 16 Number 4

TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

Choose faith over fear Lisa Moler, Founder/CEO, MedMark Media............................... 6

TECHNIQUE

Broken file retrieval in the age of minimally invasive endodontics

COVER STORY

Unleashing the power of team-driven endodontics

Dr. Sonia Chopra discusses her endodontic practice’s journey of growth and excellence — and it goes beyond technology and clinical expertise Cover image of Dr. Sonia Chopra courtesy of Specialty1 Partners.

Drs. L. Stephen Buchanan and Christophe Verbanck discuss a new technique to retrieve a broken fragment with a loop ...............................................................15

ENDOSPECTIVE

Are you seeing a lot of cracked teeth lately? Dr. Judy McIntyre discusses detection and treatment of teeth with cracks or craze lines ...............................................................18

CONTINUING EDUCATION

CLINICAL

Endodontics versus implants — treatment-planning decisions

Dr. Gregori M. Kurtzman discusses treatment planning for long-term success Endodontic Practice US

Volume 16 Number 4

The lateral puff in endodontics: clinically significant or a storyteller of anatomy and etiology? — a case report series Drs. Mahmood Reza Kalantar Motamedi and Brett E. Gilbert discuss the clinical significance of sealing these lateral anatomical structures.................22

ACHIEVE UNPRECEDENTED PRACTICE GROWTH AND SUCCESS “As I begin my second year of coaching with Endo Mastery, I can honestly say my coaching investment has been the smartest thing I have done over the last 23 years for my practice growth.” Dr. L. Ricks

“My new start practice with Endo Mastery coaching has been great. I set my production goal very high, and I doubled that goal. I’m loving my practice culture and the feeling that I experience while I’m at work.” Dr. K. Sterling

“I didn’t believe it was possible to do more cases with less stress, a happy team and referrals. Best of all, I dropped down to three and a half days while profitability increased dramatically for me and my associates.” Dr. J. Bonavilla

PRACTICE COACHING

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TABLE OF CONTENTS

SMALL TALK

Using the G.R.O.W. model Drs. Joel C. Small and Edwin McDonald offer a new coaching tool..................................................33 CONTINUING EDUCATION SERVICE PROFILE

A lifetime of learning with HighFive Healthcare Dr. Christopher Cook discusses the benefits of being supported by a large group of like-minded practitioners................................ 34

PRACTICE MANAGEMENT

PRACTICE PROFILE

Dr. David Whitlock discusses the joys of practicing in a rural community................................... 38

Specialized Dental Partners brings mentorship and guidance that allows this endodontic practice to grow............................ 40

Overcoming mid-career Five benefits of practicing rural blahs and blues dentistry Dr. Albert (Ace) Goerig advises how to regain energy and passion for your work................................ 36

Dr. Mona Haghani finds work-life balance

*Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://endopracticeus.com/category/continuing-education/

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Endodontic Practice US

Volume 16 Number 4

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PUBLISHER’S PERSPECTIVE

Choose faith over fear

’m sitting at my computer on a beautiful day, writing my winter message, and Billy Joel’s song, “Keeping the Faith” started playing. It started me thinking of the past and the future and how sometimes, it seems easier to stay “lost in let’s remember” than move forward and face an often scary unknown. One of my most meaningful mantras is “faith over fear.” It is so easy to keep to the same schedule, keep the same business protocols, and the same way of doing things, in a safe comfort zone. MedMark publications are meant to help you break out of that habit. We want you to not only Lisa Moler read about the expanding opportunities for every aspect of Founder/Publisher, your practice, but also to have the foresight to bring these MedMark Media innovations into your practice for your patients and your own success. After almost 2 decades of dental publishing, I have seen many advancements revolutionize dental specialties. I remember when dentists were wary of finding a new use for their darkroom space and welcoming digital imaging into the practice. Now, not only X-rays, but a myriad of digital technologies connect every aspect of the practice, from X-rays, to practice management, to marketing, and connecting with patients. Even AI has found its way to the dental office. AI is constantly evolving, so all of you brave “early adopters” should be excited about the prospects on that topic! No matter your specialty, innovations have transformed the way dental professionals practice — choices for clear aligner materials and 3D printing for orthodontists, new implant technologies for implant-focused dentists, and files and equipment to clean the root canal space for longer-lasting endodontic results. I have a personal involvement in many important breakthroughs affecting and saving the lives of those who suffer from sleep-breathing disorders. We have been honored all these years to bring new concepts and insights to our pages to bring you all of the latest clinical and business options. In our winter issue, here are some articles that will help you to fulfill your ambitious and enlightened goals. Our Cover Story focuses on Dr. Sonia Chopra’s journey of growth and how support from Specialty1 Partners helped to take the practice’s administrative weight off her shoulders and allowed her to focus on patient care. Our CE by Drs. Mahmood Reza Kalantar Motamedi and Brett E. Gilbert explains how lateral canals and sealer puffs can be storytellers about the pulp system anatomy. The article by Drs. Diana Bronstein and Rita Steiner about the management of pre- and postoperative dental and surgical pain gives us a look at reducing patient dependence on opioids for pain management. Dr. Gregory Kurtzman writes about treatment planning decisions and the often difficult choice between endodontics and implants. We can do the research, but you have to take the leap of faith. Billy Joel’s song has the right idea about honoring the past but propelling ourselves into the future: “You can get just so much from a good thing You can linger too long in your dreams Say goodbye to the oldies but goodies ‘Cause the good ole days weren’t always good And tomorrow ain’t as bad as it seems.” Don’t linger too long while others take initiative. Choose faith over fear to flourish personally and professionally! To your best success, Lisa Moler Endodontic Practice US

Volume 16 Number 4

Published by

Publisher Lisa Moler lmoler@medmarkmedia.com Managing Editor Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com Tel: (727) 515-5118 National Account Manager Adrienne Good agood@medmarkmedia.com Tel: (623) 340-4373 Sales Assistant & Client Services Melissa Minnick melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury amzi@medmarkmedia.com eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager Felicia Vaughn felicia@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Website Support Eileen Kane webmaster@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.endopracticeus.com Subscription Rate 1 year (4 issues) $149 https://endopracticeus.com/subscribe/

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COVER STORY

Unleashing the power of team-driven endodontics Dr. Sonia Chopra discusses her endodontic practice’s journey of growth and excellence — and it goes beyond technology and clinical expertise training we have as endodontists, as part of our formal training, because we are spending our energy and time on much-needed clinical education. When I first started out, I was under the impression that leadership equaled control. I believed that, as the leader, I needed to steer every aspect of the business, and I felt responsible for every facet of the practice’s success. This isn’t because I was trying to be controlling — I was simply afraid of failing, especially after I’d put so much time, money, and training into my career. While I had the clinical skills, work ethic, and compassion for my patients that I needed to succeed, I was mystified and frustrated by the high team turnover at my office. It felt like I was always at odds with my colleagues. A few disgruntled employees could be a fluke, sure, but when it became a clear pattern, I knew I needed to look inward. During this period of introspection and growth, I realized I was the common denominator, and that my leadership style was to micromanage my team, rather than empower them — not exactly the MO of a strong leader. To unlock the practice’s full potential, I had to stop being a bottleneck, step aside, and give my team permission to soar. I also needed to accept failure as a part of work, because so long as we all learned from our failures, we’d continue to improve.

What led you to realize that endodontic success hinged on your leadership style? It probably comes as no surprise, but like most dentists, I didn’t earn an MBA or obtain leadership training while completing my DDS and endodontic residency. So, when I started my practice in 2008, I was just doing my best with the little knowledge I had of running a business. It’s wild how little of that sort of Sonia Chopra, DDS, was the first female board-certified endodontist in Charlotte, North Carolina, where she founded Ballantyne Endodontics in 2008. As a mentor and impact entrepreneur, Dr. Chopra improves endodontic education for general dentists, dental residents, and patients. She is a TEDx speaker, Dentistry Today and Forbes contributor, and the author of Tooth Wisdom, a book designed to inform and empower patients in their own oral health. She teaches endodontists how to grow their practices and improve efficiencies in their workflows so they can be more effective and profitable through her Heal Your Practice program. Dr. Chopra is also co-founder of A Night for Smiles, a gala bringing Charlotte-area dentists together to support dental health initiatives. She is an active member of the American Association of Endodontics and is a Key Opinion Leader for Sonendo, Dentsply Sirona, J Morita, and Kerr. When she’s not treating patients or teaching dentists about endodontics, she loves to travel, garden, and spend time with her family. Follow her on Instagram at @soniachopradds.

Endodontic Practice US

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COVER STORY

progressively entrusting more significant responsibilities to my team. The biggest challenge was to stay on the path, even in the face of setbacks and failures. The temptation to reclaim control of tasks was enormous. But I had finally learned that leadership wasn’t about control — it was about vision, guidance, support, and building a resilient, self-sufficient, and empowered team. Over time, I noticed that those who weren’t on board with my vision, or who weren’t willing to take on responsibility or ownership of tasks, weeded themselves out. And those who remained continued to impress me with their ingenuity and commitment. I’m grateful to have several of the same team members, who have stuck with me over the last decade-plus; they are now in leadership roles in my practice.

Deciding to trust my team was terrifying at first, but it quickly became a game-changer. I humbly acknowledged that they could perform various tasks as effectively as I could — if not better — because of their unique strengths. I also began investing time and resources in my team’s continuous development by prioritizing workflows, standard operating procedures (SOPs), and other comprehensive training for our staff, ensuring everyone was confident in their roles. I embraced the importance of vulnerability, which is extremely scary for me. However, I have learned that it is my greatest superpower when it comes to connecting meaningfully with others. For instance, I let my team in on the anxieties and fears I was experiencing while tackling a particularly hard case, and explained that, when my attention is drawn away while finding a tricky MB2 or handling a delicate obturation by a question about billing or scheduling, it’s like my brain is split into two. I lose my focus on the patient, and this causes me frustration, which makes it more likely that I will be short with my colleague. So, I asked for my team’s help in helping me create that boundary between my clinical and management time, so that I can give everyone my all, when I’m focused on them. Since changing the way I lead, I’ve been able to focus on patient care — the task that only I can do — while being fully supported by my front office and back office team. Our collective productivity improved, as has everyone’s job satisfaction. Turnover has decreased and tends to be due to life changes like moves or pregnancies rather than frustration. Best of all, our patients feel well cared for, and the practice is truly thriving.

How has taking a team-driven model impacted your professional and personal life?

The process of letting go didn’t happen overnight. All the years of education, cross-country moves, and risk-taking to build my own practice in the shadow of the Great Recession had molded me into a self-proclaimed control freak. Any failing of my practice felt like a personal failure, so I had convinced myself it was necessary to oversee every detail. So, as you can imagine, it took time to unlearn those habits. I started by delegating small tasks, assessing outcomes, and

My practice has become a well-oiled machine, which has led to more benefits than I ever could have imagined. Our production has improved and, as a result, my business partner and I were able to bring on an associate and hire more team members. It’s extremely gratifying to create jobs and see the impact of my practice growth. We’ve also seen improved operational efficiencies since Specialty1 Partners began providing administrative support services to our practice at the end of 2021. A team-driven model has enhanced our company culture, too. We have traded micromanagement and competition for empowerment, trust, and collaboration. My colleagues, including the team providing business support services at Specialty1 Partners, understand that our practice will really thrive when the doctors are able to focus on the patients, and doing the work only we can do. This leads them to share all sorts of creative, problem-solving ideas. It’s exciting that my colleagues not only understand my vision for the practice, but they embrace it as their own. They take ownership over certain key performance indicators (KPIs) and proactively take steps to course-correct when we aren’t hitting our goals. With this shift in how my practice-level team functions coupled with the business and administrative support provided by

Dr. Chopra treating one of her patients

Dr. Chopra with her Ballantyne Endodontics team members

What hurdles did you face in your transition to a team-driven model?

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COVER STORY

Specialty1 Partners, the weight of the practice’s performance is no longer solely on my shoulders. That means that I have been able to work fewer days in the practice, so I can grow my endodontic education platform, spend more quality time with my family, and take on projects and adventures that excite me — like traveling, gardening, and creating business development courses for dentists and endodontists. Not only is my quality of life greatly improved, my team is happier. Turnover has decreased, and they feel more supported, empowered, and proud of their work than ever.

What else has led to your practice’s success? I can’t overstate how important technology has been to my practice’s evolution. Clinical technology has made the biggest difference in my outcomes, production, and confidence. My favorite pieces of technology are my GentleWave® System, dental operating microscope, cone beam, and Fotona® laser. While all of these innovations have changed the game, training my team to support me with modern endodontic technology has been crucial. My dental assistants, for example, are fully trained on operating the CBCT — a skill that even many dentists don’t have. When I invest in my team by educating them about the technology we use, it empowers them and makes them feel valued. Plus, it gives me the opportunity to be productive in another operatory or get some work done that I would otherwise have to take home with me. Not only does this streamline our operations, it improves team communication because my back office team understands the why behind their actions — they aren’t just following a workflow for its own sake. All of this leads to a superior patient experience and greater team collaboration and patient management. Everyone on my team knows that we all share the responsibility of patient care. We’re all invested in our work and dedicated to elevating the practice’s capabilities and success.

Ballantyne Endodontics’ technologically advanced operatory

Dr. Chopra reviewing a radiograph with her patient

What guidance would you give other endodontists looking to follow a similar journey? If you want to elevate your practice’s production, outcomes, and workplace culture, taking a team-driven approach is key. Like me, you may find it extremely fulfilling to focus on what you do best while trusting that everything else is in capable hands. At the end of the day, this isn’t an excuse to drop responsibility onto others. You still need to embody leadership, which means you’ll need to thoroughly define your practice’s vision, clearly communicate expectations and at times, have hard conversations. The buck ultimately stops with you, as your practice’s leader. However, you can still give your team members specific outcomes, tasks, and areas of responsibility to take ownership over. Those who are ready for the challenge and aligned with your vision will impress you every time! Endodontic Practice US

Never underestimate the power of a workflow or a highly documented standard operating procedure. This not only provides a step-by-step approach to tasks, but it keeps you from having to re-solve the same problems over and over. Even better, it gives you and your team an opportunity to create better worklife balance, since no one’s ever the only person who knows how to do something. Hello, vacation time! Remember, the goal in a team-led endodontic practice is to cultivate a cohesive unit, where each member’s contribution is recognized and integral to the collective success. This unity creates a ripple effect, as both your team and your patients feel highly valued. From there, your satisfied patients become your practice’s ambassadors, spreading the word to their families and dentists about their positive experiences. Ultimately, transitioning to a team-driven approach is not about relinquishing control but rather broadening the leadership spectrum. It’s about building a robust foundation where every team member is a pillar, contributing to the practice’s stability and prosperity. EP

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CLINICAL

Endodontics versus implants — treatment-planning decisions Dr. Gregori M. Kurtzman discusses treatment planning for long-term success

ndodontic therapy provides preservation Treatment planning decisions need to focus of the natural dentition, which is a primary goal of dentistry. Yet endodontic success is on the restorability of the tooth when deciding closely linked to the restorability of the coronal what treatment will provide reasonable longaspect of the tooth. Being able to identify, instrument, and obturate the canals is important, but term success.” if the tooth cannot be predictably restored, then treatment will not provide clinical success. A lack of sufficient coronal structure to retain a restoration returning the tooth to natural the endodontically treated tooth and provide resistance to disanatomy often leads to dislodgement of the restoration during placement of the fixed restoration.1-5 Today with improvements function, failure of the coronal seal of the canal system, and in adhesive dentistry, the emphasis has drifted away from the subsequent failure of the endodontic obturation. principle of restorative ferrule. Practitioners may be relying too When a patient presents with significant coronal breakdown heavily on adhesive bond strength to retain fixed prosthetic resof a tooth, this presents clinical challenges with regard to treattoration margins sealed. Thus, thought should be given to how ment planning decisions. If the practitioner performs endodontic much coronal structure remains when deciding if a tooth should treatment in their practice, do they treat the tooth and augment be treated endodontically or replaced with an implant. Those that treatment with crown lengthening to permit sufficient ferrestorative decisions need to be made prior to the initiation of rule (a band of natural tooth that is circumferentially grasped by endodontic treatment. The practitioner must determine which the crown that prevents lateral displacement of the crown from additional procedures will be necessary to achieve the required the tooth) of the remaining root structure to allow restoration, or restorative goals and how those procedures will affect the tooth is it more prudent to extract the tooth and place an implant? If being treated and adjacent teeth. the practitioner is an endodontist, and the patient was referred for treatment, has the referring general dentist determined that Raise the bridge or lower the water? sufficient tooth structure is present to restore the tooth predictWhen a patient presents with a broken-down tooth that has ably following endodontic treatment? We have to understand pulpal issues or would require intentional endodontics to allow that endodontics is a restorative treatment with an endodontic restoration, the restorability of that affected tooth needs to be component, and evaluation in that regard needs to be accomthe first consideration in deciding how and what treatment is plished prior to initiating any endodontic treatment. required for long-term predictability. When analyzing how that With regard to indirect restorations such as full coverage tooth may be restored following endodontic treatment, one has crowns and onlays, the literature has suggested that a 1.5-mm to determine if sufficient root length remains to allow stability to 2-mm ferrule is minimally necessary to prevent fracture of of the tooth once it is restored. Is adequate supracrestal tooth structure present to provide a restorative ferrule? What ancillary procedures may help increase supracrestal tooth structure to Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FIADFE, ferrule? DICOI, DADIA, DIDIA, in private general dental practice in Silver Spring, Maryland, was a former Assistant Clinical Professor at University of Maryland in the department of Restorative Dentistry and Endodontics, and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of restorative dentistry, endodontics and implant surgery, removable and fixed prosthetics, and periodontics and has over 850 published articles globally, several ebooks, and textbook chapters. He has earned Fellowship in the AGD, American College of Dentists (ACD), International Congress of Oral Implantology (ICOI), Pierre Fauchard, ADI, International Academy for Dental Facial Esthetics (IADFE), Mastership in the AGD and ICOI, and Diplomat status in the ICOI, American Dental Implant Association (ADIA), and International Dental Implant Association (IDIA).

Endodontic Practice US

Osseous crown lengthening to improve restorative ferrule Traditionally, when insufficient tooth structure presents supracrestally, osseous crown-lengthening procedures have been employed to increase the available coronal tooth structure to achieve a restorative ferrule.6,7 This presents challenges in treatment with regard to adjacent teeth. Osseous crown lengthening will require the removal of crestal bone on the adjacent teeth to create osseous slopes that will allow soft tissue maintenance. One cannot just remove bone around an individual tooth which

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CLINICAL

leads to isolated pocketing and abrupt slopes in the bone. This then leads to adjacent bone loss as the body attempts to create gentle crestal osseous slopes that it can maintain over time. So, to create adequate coronal tooth structure for restorative purposes the periodontal structures adjacent to that tooth may have to be compromised. The removal of crestal bone additionally may expose furcations on posterior teeth that can complicate home care — exposing areas that may be difficult to maintain over the long-term by the patient. This may also be a factor in the maxillary first premolars, which typically have a mesial root concavity that can create restorative challenges. When the tooth being treated has a short cervical trunk, or the furcation is already at or just coronal to the crestal margin, removal of additional bone may be contraindicated, and extraction of the tooth and subsequent replacement with an implant may be a more prudent treatment option. Some studies have reported lower long-term survival in those endodontically treated teeth that underwent osseous crown lengthening, and this should be a consideration in decisions that may incorporate that into the treatment plan.8-10

Figure 1: A single-rooted tooth that has lost coronal structure to the crestal margin of bone with insufficient tooth structure coronal to the crestal bone has a lack of tooth structure to achieve ferrule

Forced orthodontic eruption An alternative to osseous crown lengthening when additional tooth structure is needed restoratively is the use of forced orthodontic eruption.11,12 Following completion of endodontic treatment, orthodontic forces are used to erupt the tooth coronally, exposing more root structure upon which a ferrule may be placed.13-15 When this option is considered, one needs to assess how much root length will remain within the osseous housing following forced orthodontic eruption and whether this allows an adequate crown-to-root ratio to maintain tooth stability over time. This approach is more ideally suited for single rooted teeth than multi-rooted teeth.16,17 As with crown lengthening, forced eruption of multi-rooted teeth may create furcation issues and may be a contraindication to this treatment modality. Orthodontic extrusion involves slow forces of low intensity that are exerted on the tooth and as the tooth extrudes, the crestal bone and gingival apparatus move together coronally. When heavier traction forces are exerted, as seen in rapid extrusion, coronal migration of the tissues supporting the tooth is less pronounced. As rapid movement exceeds the capacity for physiologic adaptation, the tooth erupts coronally beyond the crestal bone.18,19 Following rapid extrusion, an extended period of retention is needed to allow remodeling and adaptation of the periodontium to the new tooth position.20,21

Figure 2: To achieve a restorative ferrule, osseous crown lengthening may be performed, but this requires removal of bone from the adjacent teeth to create the proper contours that compromise the adjacent teeth periodontally

Clinical decisions for single-rooted teeth If a patient presents with coronal breakdown of a single-rooted tooth that is at or close to the crestal bone margin (Figure 1), the length of the root subcrestally must be determined. Is there sufficient root length so that movement of the crestal margin in relation to the coronal of the remaining tooth structure will not compromise the crown-to-root ratio of the restored tooth? If the answer is “yes,” then two options should be considered: clinical crown lengthening (Figure 2) or orthodontic extrusion (Figure 3). Should the answer be “no,” then extraction and replacement with an implant is the treatment that is indicated. endopracticeus.com

Figure 3: An alternate treatment to achieve a restorative ferrule without affecting the adjacent teeth periodontally is orthodontic forced eruption of the affected tooth

13 Volume 16 Number 4

CLINICAL

Figure 4: A multi-rooted tooth with coronal breakdown close to the osseous crest would require endodontic treatment but lacks sufficient restorative ferrule in its current state

Figure 5: Osseous crown lengthening may be performed to achieve a restorative ferrule which requires recontouring of the bone on the adjacent teeth, possibly leading to furcation exposure on the affected or adjacent teeth

on restoration resistance and distribution of stress within a root. Int Endod J. 2006 Jun;39(6):443-452.

Clinical decisions for multi-rooted teeth A common clinical occurrence involves the presentation of a molar with significant coronal breakdown either because of fracture or decay (Figure 4). The presence of a furcation presents unique variables compared to single-rooted teeth. When analyzing the restorability of a molar, practitioners need to consider: repositioning the crestal bone margin either through osseous crown lengthening (Figure 5) or extrusion (Figure 6) to expose the furcation and complicate long-term patient home care and tooth maintenance. Teeth with short cervical areas (portion of the tooth superior to the start of the furcation) limit what treatments may be performed to provide restorative ferrules. Teeth with long cervical areas or fused roots may be better suited to those procedures, providing clinical outcomes that can be maintained over the long-term by the patient. When these objectives cannot be met, extraction and implant placement offer a better prognosis.

Conclusion Dentistry is restoratively-driven, supplemented by endodontic and surgical components. When a tooth cannot be restored, then it does not matter whether endodontic treatment can be or is rendered — long-term survival of that tooth cannot be predictably achieved. Treatment planning decisions need to focus on the restorability of the tooth when deciding what treatment will provide reasonable long-term success. The patient’s age plays a factor in those treatment-planning decisions. A patient in their 80s with the same lack of restorative ferrule presents less long-term considerations than a similar tooth on a patient who is 70 years old or younger in better health. If the tooth can be restored, then pursuing endodontic treatment is the best treatment decision. But when this cannot be accomplished or the restorative prognosis cannot provide reasonable long-term success, then extraction and implant placement is the more prudent treatment option. EP REFERENCES 1.

Libman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodont. 1995 Mar-Apr;8(2):155-161.

Tan PL, Aquilino SA, Gratton DG, Stanford CM, Tan SC, Johnson WT, Dawson D. In vitro fracture resistance of endodontically treated central incisors with varying ferrule heights and configurations. J Prosthet Dent. 2005 Apr;93(4):331-336.

Ichim I, Kuzmanovic DV, Love RM. A finite element analysis of ferrule design

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Figure 6: An alternative treatment is forced orthodontic eruption of the multi-rooted teeth which can lead to exposure of the furcation and complicate patient home care and long-term survivability of the tooth

Juloski J, Radovic I, Goracci C, Vulicevic ZR, Ferrari M. Ferrule effect: a literature review. J Endod. 2012 Jan;38(1):11-19.

Meng Q, Chen Y, Ni K, Li Y, Li X, Meng J, Chen L, Mei ML. The effect of different ferrule heights and crown-to-root ratios on fracture resistance of endodontically-treated mandibular premolars restored with fiber post or cast metal post system: an in vitro study. BMC Oral Health. 2023 Jun 3;23(1):360.

Planciunas L, Puriene A, Mackeviciene G. Surgical lengthening of the clinical tooth crown. Stomatologija. 2006;8(3):88-95.

Marzadori M, Stefanini M, Sangiorgi M, Mounssif I, Monaco C, Zucchelli G. Crown lengthening and restorative procedures in the esthetic zone. Periodontol 2000. 2018 Jun;77(1):84-92.

Camargo PM, Melnick PR, Camargo LM. Clinical crown lengthening in the esthetic zone. J Calif Dent Assoc. 2007 Jul;35(7):487-498.

Patil K, Khalighinejad N, El-Refai N, Williams K, Mickel A. The Effect of Crown Lengthening on the Outcome of Endodontically Treated Posterior Teeth: 10-year Survival Analysis. J Endod. 2019 Jun;45(6):696-700.

10. Brignardello-Petersen R. There is probably a higher risk of undergoing tooth extraction in teeth that received crown-lengthening procedures. J Am Dent Assoc. 2019 Oct;150(10):e163. 11. Huang G, Yang M, Qali M, Wang TJ, Li C, Chang YC. Clinical Considerations in Orthodontically Forced Eruption for Restorative Purposes. J Clin Med. 2021 Dec 18; 10(24):5950. 12. Bruhnke M, Krastl G, Neumeyer S, Beuer F, Herklotz I, Naumann M. Forced Orthodontic Extrusion to Restore the Unrestorable: A Proof of Concept. Int J Periodontics Restorative Dent. 2023 Sep-Oct;43(5):560-569. 13. Bajaj P, Chordiya R, Rudagi K, Patil N. Multidisciplinary approach to the management of complicated crown-root fracture: a case report. J Int Oral Health. 2015 Apr;7(4): 88-91. 14. Cordaro M, Staderini E, Torsello F, Grande NM, Turchi M, Cordaro M. Orthodontic Extrusion vs. Surgical Extrusion to Rehabilitate Severely Damaged Teeth: A Literature Review. Int J Environ Res Public Health. 2021 Sep 10;18(18):9530. 15. Kocadereli I, Taşman F, Güner SB. Combined endodontic-orthodontic and prosthodontic treatment of fractured teeth. Case report. Aust Dent J. 1998 Feb;43(1):28-31. 16. Pedullà E, Valentino J, Rapisarda S. Endodontic Surgery of a Deviated Premolar Root in the Surgical Orthodontic Management of an Impacted Maxillary Canine. J Endod. 2015 Oct;41(10):1730-1734. 17. Delivanis P, Delivanis H, Kuftinec MM. Endodontic-orthodontic management of fractured anterior teeth. J Am Dent Assoc. 1978 Sep;97(3):483-485. 18. Bach N, Baylard JF, Voyer R. Orthodontic extrusion: periodontal considerations and applications. J Can Dent Assoc. 2004 Dec;70(11):775-780. 19. Faria LP, Almeida MM, Amaral MF, Pellizzer EP, Okamoto R, Mendonça MR. Orthodontic Extrusion as Treatment Option for Crown-Root Fracture: Literature Review with Systematic Criteria. J Contemp Dent Pract. 2015 Sep 1;16(9):758-762. 20. Antrim DD. Vertical extrusion of endodontically treated teeth. US Navy Med. 1981; 72:23-28. 21. González-Martín O, Solano-Hernandez B, González-Martín A, Avila-Ortiz G. Orthodontic Extrusion: Guidelines for Contemporary Clinical Practice. Int J Periodontics Restorative Dent. 2020 Sep/Oct;40(5):667-676.

14 Volume 16 Number 4

TECHNIQUE

Broken file retrieval in the age of minimally invasive endodontics Drs. L. Stephen Buchanan and Christophe Verbanck discuss a new technique to retrieve a broken fragment with a loop

f it can be broke, then it can be fixed — Bloc Party, The Pioneers. Although files and instruments nowadays are meticulously well-designed and have an unmatched metallurgy in comparison to a decade ago, instrument separation still occurs during root canal shaping and hinders completion of treatment. Reasons for instrument separation are: improper use, limited flexibility and strength in a certain curvature, excessive force, and overuse.1 Torsional stress (55.7%) and cyclic fatigue (44.3%) are the main causes for fracture during these events.2 Prevention is better than cure, and the best clinical advice to avert instrument separation is to change the instrument the moment the thought crosses your mind that the file in use might come apart. With the advent of MIE-oriented treatments, the size and location of the broken fragment will dictate the choice for removal, bypass, or leaving it untouched and entombed. Careful bypassing should be a first choice, if feasible, but in the unlikely event a broken fragment blocks the entire canal lumen, removal is the only way forward. Removal can be done solely by dislodging it with the aid of various instruments and raising it to the surface or by looping it and pulling out, especially in cases where the file fragments exceed a length of 4.5 millimeters. L. Stephen Buchanan, DDS, FICD, FACD, Dipl. ABE, has been lecturing and teaching hands-on endodontic continuing education courses for over 30 years, both in his state-of-the-art training facility in Santa Barbara, California, as well as in dental schools and at meetings around the world. He currently serves as a part-time faculty member in the endodontic departments at the University of the Pacific’s Arthur Dugoni School of Dentistry and the University of California at Los Angeles as well as being the Endodontic Advisory Board Member to the Academy of General Dentistry. Dr. Buchanan is nationally and internationally known for his 50-plus endodontic procedural articles as well as his expertise in the research and development of new endodontic technology, instruments, and techniques. He is a Diplomate of the American Board of Endodontists and a Fellow of the International and American College of Dentists. Dr. Buchanan also maintains a private practice limited to Endodontics in Santa Barbara, California. Christophe L.M. Verbanck, DDS, MSc, obtained his Master of Dentistry at Gent University in 2009. He specialized in endodontics, graduating after a 3-year postgraduate training program from the same university. Since 2010 he has worked in several multi-disciplinary and endodontic referral practices all over Flanders. In January 2016, together with his wife, he started his own referral practice for endodontics, Lovendo, in Lovendegem (Belgium). He regularly teaches endodontics to general dentists and holds workshops on the application of endodontic techniques. Disclosures: Dr. L. Stephen Buchanan is a co-founder of PlanB Dental.

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This article will go more in depth on how to retrieve a broken fragment with a loop. Older systems, like various ultrasonic tips, are used in a counter-clockwise movement around the separated instrument after the creation of a staging platform with modified Gates Glidden burs. The ultrasonic energy of the tips is used first to create space between dentin and the file fragment and then to vibrate the file to displace it from the canal. The CCW-movement is intended to get the file rotating in a way that would unscrew it from its entrapment.This time-consuming therapy usually leads to the removal of the instrument but could easily create a new problem — perforation or a future root fracture. Extractors can also be used to grasp a loose or loosened fragment. But since they are stiff in nature, a straight line path with unhindered sight is necessary to get to the fragment. Another

Figure 1: Severely decayed lower first molar with broken fragment in the distal root canal.The fragment was blocking further apical preparation so retrieval was chosen instead of bypassing. (Case by Dr. Christophe Verbanck, 2023)

Figure 2: Tooth referred for emergency retrieval since the patient did not want a surgical intervention for personal reasons. The accessible portion of the broken fragment was 2 mm, and only with the aid of the U/S- tips and EDTA, the fragment was out in only seconds. (Case by Dr. Benjamin Boublil)

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TECHNIQUE

drawback of these systems was that the rubber handle came loose, making the device unworkable.

If it can be lost, then it can be won

The TFRK-kit contains a box loaded with all the tools needed for a smooth (and almost pleasant) file removal treatFigure 3: A 9-mm fragment blocking an S-shaped mesial canal in lower second molar. Straight-line access was created with a modified GG drill followed by ment. The instruments are based on the previously described troughing a third of file length with a 6 o’clock U/S micro-spoon. Once moving, the principles of older systems but without its weaknesses or the Loop + was used to remove it. (Case by Dr. Benjamin Boublil) risk of over-enlarging the root canal space to get the job done. A modified Gates Glidden and micro-trephine bur are used to create sufficient space around the coronal part of the broken instrument, and together with the newly designed 6 and 12 o’clock U/S micro-spoons, it is now possible to work further on the inside of the curve and gently create space only where it’s needed. In this way, a trough can be made next to the instrument to free it from its engagement in dentin. Figure 4: Lower molar with broken indirect restoration. During initial attempt by Both the 6 and 12 o’clock tips make it possible to anguGP, an instrument broke in the ML canal. A .45 rotary instrument was used to reach late the tip to the correct side of the root canal of different the coronal part of the instrument followed with a semi-circular preparation on the inside of the curve upon removal with the loop. (Case by Dr. Benjamin Boublil) root canals. If no movement can be obtained, the Straight tip (S-tip) can always be used for troughing deeper apically and laterA witty design in the tip of the cannula makes it impossible to ally to loosen it. “pull in” the wire and make the device unusable but also makes Working on the inside curvature of the root canal has two it safe to put a bend of 45° in the loop with the tip of an explorer major benefits: in relation to the long axis of the cannula. The 45° angle will • It can shift the fragment coronally or can even completely easily drive the loop over the fragment. free the instrument. The loop should be facing towards the outside of the curve, • In this way, the dentinal wall on the outside of the curve making the cannula almost wedge between the instrument and is retained to support the fragment and eliminates the the canal wall. Once the coronal part is “looped,” the lasso can likelihood of fracture along the length of the separated 3 be tightened by pulling the tensioning button. While maintainfragment due to excessive ultrasonic forces. ing this tension, the fragment can be pulled out of the canal Letting the U/S-tips work on the outside of the curvature sometimes with a gentle push-pull and CCW-movement to get it increases the curvature on that side of the canal and can also completely loose. drive the fragment deeper into the canal, making the situation The intention of the loop is to gain time during a challengmore precarious than it already was. ing job. In the past, ultrasound was our only option to remove An important clinical tip is that all of the U/S-tips should be broken file segments — often a very time-consuming procedure used in bursts, by tapping the foot pedal repeatedly, and not in especially for file fragments longer than 4.5 mm. The micro-lasso a constant way to avoid breakage by heat build-up and cyclic offers an elegant and efficient solution to that problem. fatigue since they are used dry. The straight tip should also be used in a pecking/push-pull motion to avoid breaking of the fine ultrasonic tip. Once the file fragment is loose, EDTA is added, and the Spear tip is used to vibrate and potentially displace the broken file segment. File fragments longer than 4.5 mm typically require the use of a loop. In this case, an extra space of 0.4 mm-plus the diameter of the broken file segment is required to complete staging. A simple way to measure the diameter of the broken file segment is the use of vertical condensation pluggers as a gauging device.

All you need is time? The “Loop +”4 is an instrument made out of a 0.005 mm SS wire secured in the form of a micro-lasso so it can be placed around the coronal part of the broken instrument. The 0.005 wire is an update of the older 0.003 wire and tends to be 148% tougher than the 0.003 wire. The extra space created around the instrument is necessary to have sufficient room for the TFRK-L+ cannula because it’s not only the wire but also the flexible cannula holding the wire that needs to be positioned next to the fragment. Endodontic Practice US

It’s all under control

Once you get the hang of it, the Loop + can be used at all depths in the root canal. For instance, a silver point at or beyond the apex of a root canal, Thermafil® carriers that have broken mid-root, etc. It is obvious that the use of the ultrasonic tips, together with the aid of the TFRK-Loop+, make it possible to safely stage adequate space without over-enlarging and weakening root structure. Acknowledgement: Authors wish to thank Dr. Benjamin Boublil, Endodontist (Paris, France) for his case work. EP REFERENCES 1.

Sandhu MK. Techniques for removal of intracranial separated instruments (part 2). Int J App Dent Sci. 2021;7(4):38-46.

Sattapan B, Nervo GJ, Palamara JE, Messer HH. Defects in rotary nickel-titanium files after clinical use. J Endod. 2000 Mar;26(3):161-165.

Suter B, Lussi A, Sequeira P. Probability of removing fractured instruments from root canals. Int Endod J. 2005 Feb;38(2):112-123.

The Original TFRK™ (The file retrieval kit), Instructions for use. Plan B Dental Engineering Laboratories, LLC. https://planbdental.com/product/tfrk-kit/

16 Volume 16 Number 4

The Number 1 Selling Loop in the World! The Original TFRK is fully registered and available NOW

Autoclavable cassette includes all the tools required (all available as refills) with either Satelec* or EMS* compatibility 1 – Micro-Explorer Hand Instrument 1 – Gutta-Percha Removal Hand Instrument 1 – Modified #3 Gates Glidden Bur 1 – Micro-Trephine bur 2 – TFRK Ultrasonic Straight Tips 1 – TFRK Ultrasonic 6 o’clock Tip 1 – TFRK Ultrasonic 12 o’clock Tip 2 – TFRK Loop+ 2 – Maxillary Central Incisor TrueTooth Replicas with 2 broken file segments TFRK™ is a Trademark of Dental Engineering Laboratories *Satelec is a trademark of Satelec. *EMS is a trademark of EMS.

www.planbdental.com

ENDOSPECTIVE

Are you seeing a lot of cracked teeth lately? Dr. Judy McIntyre discusses detection and treatment of teeth with cracks or craze lines

cclusal forces and time, especially with existing restorations, can cause craze lines and microfractures in the dentition, much like the one in Figure 1. When these small craze lines and infractions propagate with continued use and wear, cracks can develop in teeth. Older amalgam restorations that have been in patients’ mouths for several decades are giving way after years of use. This can be clinically evident often with stained craze lines or marginal ridge cracks. When these craze lines propagate farther — below the CEJ — the term crack is appropriately coined, and often, the tooth may become symptomatic with pulpal involvement. As cracks propagate, many patients may report biting sensitivity, which may eventually lead to cold sensitivity: often the first sign and symptom of pulpal involvement. Once cold symptoms are reported, patients are often referred to endodontists. As an endodontist, especially when a crack is suspected, a 3D scan is typically warranted. Why? What if I enter the tooth and see a crack extending far below the canal orifices? The patient could be disappointed with wasting their time and resources. A CBCT scan allows me to better inform the patient about the likelihood of saving the tooth, the prognosis, and better informs them with the information to make a decision regarding how to proceed. In Figures 2 and 3, the patient had a visible craze line as well as an angular defect on 3D imaging but the angular distal defect, along with the probing was favorable so that this symptomatic upper premolar could be saved with endodontic treatment and a full coverage restoration. Even with this small “crack” the pulp was necrotic on this virgin tooth! In Figures 4 and 5, cracks are clinically visible on this lower first molar. Figures 6-8 show a D angular defect on the CBCT

Judy McIntyre, DMD, MS, experienced dental trauma as a young child. Despite this, she had positive experiences at the dentist, and her passion to become a dentist developed. She attended the Harvard School of Dental Medicine, where she performed research on dental unit waterline biofilms. After graduation, Dr. McIntyre attended the University of North Carolina at Chapel Hill for her endodontic residency. Alongside renowned researchers in the field of endodontics, traumatology, and pediatric dentistry, her thesis and research regarding traumatic dental injuries has been published in numerous professional journals. Dr. McIntyre opened her own office in 2016 and has been active in organized dentistry. She is passionate about sharing her love for dentistry, trauma, radiology/imaging, and endodontics.

Endodontic Practice US

Figure 1

Figures 2 and 3: 2. First premolar – D angular defect. 3. Visibly quite concerning, and clinically, the explorer “catches” in the M and D marginal ridges

screenshots in all planes. Once again, the angular defect along with the probing was favorable, and this molar also could be saved with endodontic treatment and a full coverage restoration.

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ENDOSPECTIVE

Figure 4

Even with these more significant and visible “cracks,” the pulp was vital but very inflamed and symptomatic. Clinically, as we progressed to the endodontic access, we can appreciate the crack’s propagation apically in Figure 5. The 3D axial image shows a black semi-circle lucent defect (like a Mickey Mouse ear) on the distal aspect of the tooth, reflecting the crack propagation and the lack of bone around that crack (Figure 6). The 3D coronal slice (Figure 7), however, shows the interproximal defect across the horizontal bone aspect. The 3D sagittal slice shows the D angular defect in Figure 8. Comparatively, the referring doctor’s 2D periapical film (Figure 9) does not clearly reflect the crack or the true angular defect. This diagnosis can be easily missed because of the 2D radiographic limitations. A patient may present in pain, and without the appropriate diagnostic imaging, the severity of their situation may be easily overlooked. Eventually, without the appropriate treatment, a true completely cracked tooth may result, leaving extraction as the only option. In this lower molar case, the patient had gone to the emergency room over a long weekend due to severe pain. The referring dentist had long-suspected it might be cracked, and a 6-mm periodontal probing depth (PPD) measurement was recorded.

Figure 6

Figure 5

“Based on the best available evidence to date, retaining this tooth with endodontic treatment and a full coverage restoration would have provided a predictable option.”1 Although I am biased, I personally would have elected to save this tooth if it were my own with a root canal (and a crown). With both, this tooth very likely could be functional for many years to come, and even possibly even with no further crack propagation or bone loss (with full crown coverage). However, after much discussion, the patient shared they had already lost the same lower second molar on the opposite side due to a crack, so they elected for extraction. Had the patient presented earlier with a smaller probing measurement and no pulpal symptoms, a root canal could have likely been avoided completely, and the tooth could’ve been saved simply with a full coverage restoration — a crown. All cracks, if caught and treated early, can be saved! I am often asked how deep can the crack go (PPD and be visualized on 3D) and still proceed prudently with (endo/resto) saving the tooth.

Figure 7: Dips at point of crack

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19 Volume 16 Number 4

Figure 8

ENDOSPECTIVE

Figure 9 Figures 10-12: Sagittal CBCT showing the distal angular defect extending more than 2/3 length of the root; this reflects a crack having extending apically, likely for years

This is a complex and interdisciplinary answer. But to answer, I need more information, and I start with pulp testing. Sometimes there are endodontic symptoms — to varying degrees. Often, there is a probing defect, but sometimes there is not. Sometimes there is a bridge over the probing defect so the PPD could be inaccurate. Next is CBCT/3D-imaging, which brings things to light as it is a great Figures 13 and 14: The axial image of the circumferential bone loss on this tooth; the 3D volume rendering representation of our 3D patient! Altoshowing the very clear distal aspect of the lower second molar, because there is no bone attached there gether, I then reflect on all of the information gathered — probing, the pulp vitality testing results, transillumination, To avoid the above scenario, the conversations we should the clinical exam and the patient’s chief complaint, and then be having are the incipient cracks and smaller PPDs that we their imaging: periapicals, bite wings, and 3D scan. encounter and visualize, especially during yearly prevention As a specialist, I defer and follow the lead of my quarterand prophy visits. Starting these crack conversations with discusback, my referring dentist, before or after a conversation with the sion about occlusal guards and also full coverage restorations patient. In these cases, no matter the crack’s extent, I must conto avoid the propagation of these cracks when craze lines, with nect with the patient’s general dentist. Often, the dentist decides and without probing are visualized, is the best starting point for that usually about 3 mms below the crestal horizontal bone, the our patients. prognosis is poor, and recommends extraction or an implant. My “Pro Tip” is that the team process can start in hygiene — If symptomatic and urgent, then conversations are attempted to inform the dentists of any outlying periodontal measurements in real time when possible. so that when these increased PPDs are visibly consistent with A small subset of patients will still want to try to save the a craze line or crack, we can begin these conversations earlier tooth even after knowing the guarded long-term prognosis. than after when symptoms are present or cusps fracture. Very Understandably, if I had a cracked tooth, I would want to save often a full coverage crown will prevent crack propagation and it. I inform and stress the importance of follow-up to moniavoid endodontic symptoms from developing. tor for radiographic bone loss and any changes in probing If you are visualizing cracks and/or a 4/5 mm probing, please measurements. consider obtaining a CBCT scan, as the 3D scan will show the With a borderline prognosis and knowing that the tooth may true extent of a crack while most 2D X-rays may not show the only last a few years, this conversation also gets documented in extent of these cracks — even after it’s too late. the patient’s chart. Usually, the long-term prognosis is dismal, Let’s save some teeth! EP most especially because we’re sadly catching them too late. The last case shares a patient with a very deep angular defect (Figures 10-14). This could not be saved, and in this case, there was no conversation about saving. I advised extraction as I felt REFERENCE any dentistry/endodontics would be a waste of everyone’s time 1. Davis MC, Shariff SS. Success and Survival of Endodontically Treated Cracked and the patient’s resources to attempt further dentistry on this Teeth with Radicular Extensions: A 2- to 4-year Prospective Cohort. J Endod. 2019 Jul;45(7):848-855. tooth. Endodontic Practice US

20 Volume 16 Number 4

AUTHOR GUIDELINES

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

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Journals: (Print) White LW. Pearls from Dr. Larry White. Int J Orthod Milwaukee. 2016;27(1):7-8.

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 2,400 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 endodontics. 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

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n modern endodontic practice, the focus has shifted from traditional methods of cleaning, shaping, and filling to prioritizing conservative canal shaping first, to open the canals, and the use of advanced disinfection protocols with irrigation which enables more effective cleaning before three-dimensional filling.2 In an effort to be more accurate and descriptive of root canal anatomy, it is recommended to use the term “root canal system” instead of simply referring to a “root canal.” The path from the coronal orifice to the apical terminus is not a straight and single route, and there are various accessory pathways throughout the system.2 Ramifications and accessory anatomy are found in different parts of the root, with 73.5% in the apical third, 11% in the middle third, and 15% in the coronal third.3 The complex structure of the root canal system makes it impossible for any known technique, whether chemical or mechanical, to completely sterilize it. Therefore, the objective of treatment should be to remove biological tissues and reduce microbial contamination as much as possible followed by creation of an effective three-dimensional seal to encapsulate any remaining microorganisms.1 Lateral canals leading to portals of exit along the root surface at various locations serve as potential pathways for bacteria or their byproducts to reach the periodontal ligament (PDL) and

Educational aims and objectives

This self-instructional course for dentists aims to discuss the clinical significance of sealing lateral anatomical structures with sealer and explore the correlation between the presence of a lateral canal filling with sealer and the overall healing of the accompanying periradicular lesion.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions by taking the quiz online at endopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the complexity of the root canal system and complexity in completely sterilizing it. • Recognizing that disinfecting the root canal structures is important, especially in cases of pulp necrosis and apical and/or lateral periodontitis. • Realize the value of the presence of a filled lateral canal or lateral sealer puff on the final image. • Observe show how lateral canal fills and sealer puffs are able to tell a story about the pulp system anatomy and the etiology of lateral lesions. • Identity how lateral canal fills and sealer puffs can confirm the effective debridement and three dimensional sealing of the root canal system.

2 CE CREDITS

Mahmood Reza Kalantar Motamedi, DDS, MSc, received his dental degree from the Isfahan University of Medical Sciences in Isfahan, Iran in 2014. He completed his postgraduate program in endodontics at Azad University in Isfahan, Iran in 2020. He regularly teaches endodontics to general dentists and holds hands-on courses. In addition, he operates a private endodontics practice in Isfahan, Iran. Brett E. Gilbert, DDS, FICD graduated from the University of Maryland Dental School (DDS 2001, Endo, 2003). He is a professor in the Department of Endodontics at the University of Illinois at Chicago. He is a Diplomate of the American Board of Endodontics and founder of Access Endo and the Access Endo Impact Academy. He is a partner in Specialized Dental Partners and serves on the EPIC Clinical Advisory Board. He has a private practice, King Endodontics PLLC, in Niles, Illinois. Disclosure: Drs Motamedi and Gilbert have not received financial compensation for writing this article.

Endodontic Practice US

cause disease. Similarly, bacteria from periodontal pockets can reach the pulp from the outside in.4 Cleaning, disinfecting, and filling lateral canals and apical ramifications during treatment can be challenging and unpredictable. The clinical significance of sealing these lateral anatomical structures with sealer has long been a topic of debate among clinicians and researchers who ponder whether there is a correlation with the presence of a lateral canal filling with sealer and the overall healing of the accompanying periradicular lesion.

Is it necessary to clean and fill lateral canals? Verification of the sealing of lateral canals and their portals of exit with sealer on imaging is a desirable objective of treatment by clinicians. The presence of the sealer in these spaces

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confirms that enough cleansing of the intracanal dentinal walls was accomplished during the root canal procedure. In reality, the only main significance of sealing these canal structures is when there is a chance that bacterial contamination from the inside of the canal system travels to the PDL, often resulting in a lateral lesion positioned at the portal of exit.4 However, clinical experience shows that latA. B. eral lesions can heal even without filling the lateral canals.4,5 A cadaver study by Barthel, et al., reported no relationship between unfilled lateral canals and inflammation in the surrounding tissues.6 However, it must be stated that lateral canals and apical ramifications have been implicated with endodontic treatment failure when they are sufficiently large enough to harbor significant numbers of bacteria and to provide these bacteria with unimpeded access to the periradicular tissues.4 Therefore, C. D. disinfecting these structures is important in cases of pulp necrosis and apical and/or lateral periodontitis. Figures 1A-1D: Case 1 by Dr. Mahmood Reza Kalantar Motamedi. (Restoration by Dr. Pardis Doosti) Efforts should be made to incorporate therapeutic strategies that target these areas during the disinfection process. Lateral canal fills and sealer puffs are able to In clinical practice, while filling lateral canals may not always be necessary for success, the prestell a story about the pulp system anatomy, ence of a filled lateral canal or lateral sealer puff on the final image can provide valuable confirmation the etiology of lateral lesions, and to confirm that a lesion is a lesion of endodontic origin. This the effective debridement and three dimenphenomenon indicates that the canal system walls have been debrided well enough to expose the latsional sealing of the root canal system. eral canal opening inside of the root wall and allow for sealer to flow into and through the lateral canal portal of exit reaching the lateral lesion. The presence of a sealed lateral canal can be valuable in terms of providing with the patient, it was decided to proceed with non-surgical a more accurate prognosis for a given case. In essence, we can orthograde retreatment. During the procedure, no crack was extrapolate that the sealer extrusion through the lateral canal to observed in the pulp chamber floor, so treatment continued. The the coincident lesion serves as a storyteller to confirm a lesion previous root filling materials were removed, and 5% NaOCl is of endodontic origin and that sufficient cleaning was accomwas ultrasonically activated using UltraX (Eighteeth, Changzhou, plished to allow for the flow of sealer into this space. China) to improve irrigation quality. The canals were then obtuIn this study, we present some interesting case reports of latrated using the warm vertical condensation technique and AH eral canals that were filled with sealer which extends into the Plus® sealer (Dentsply DeTrey, Konstanz, Germany; Dentsply lateral lesions. Our purpose is to show how these lateral canal Sirona). This case was completed in a single visit. Immediately fills and sealer puffs are able to tell a story about the pulp sysafter obturation, a lateral sealer puff was observed in the area tem anatomy, the etiology of lateral lesions, and to confirm the previously traced with GP (Figure 1C). This may indicate the orieffective debridement and three dimensional sealing of the root gin of the endodontic lesion and the reason for the failure of the canal system. previous treatment. One-year postoperative radiograph shows a normal periapical appearance, and the tooth is functional and asymptomatic (Figure 1D). Case report 1 A 31-year-old male presented with a chronic abscess of tooth No. 18. Five years prior, primary root canal treatment was perCase report 2 formed by author MM on this tooth, but it presented with post A 64-year-old female patient presented with pain to biting treatment disease. The coronal seal appears to be intact. There tooth No. 5. An enlarged apical lesion was noted extending corare no radiographic signs of periapical radiolucency or widenonally to the mid-root level on the distal (Figures 2A and 2B). ing of the PDL (Figure 1A). However, there is a buccal sinus Diagnosis for tooth No. 5 was pulp necrosis with symptomatic tract that was traced with gutta percha (GP) and extends towards apical periodontitis. Root canal treatment was completed using the furcation (Figure 1B). This raised the suspicion of a crack, rotary instruments to a final canal preparation size of 18/.04 in the buccal and palatal canals with ExactTaperH DC™ (SS White but probing depths were within normal limits. After discussing endopracticeus.com

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Figures 2A-2C: Case 2 by Dr. Brett E. Gilbert

Dental, Lakewood, New Jersey). Copious irrigation was achieved with Triton® (Brasseler USA, Savannah, Georgia) and activation with laser-assisted endodontic irrigation protocol using the EdgePro™ laser (EdgeEndo, Albuquerque, New Mexico). Obturation was accomplished with GP and BC HiFlow™ sealer (Brasseler USA, Savannah, Georgia) using a single cone hydraulic condensation technique. A permanent access filling was placed. This case was completed in a single visit. Two portals of exit are noted curving toward the distal aspect, and a third lateral portal of exit is visible more coronally and is visible with a sealer fill (Figure 2C). The visual confirmation of the lateral canal portal of exit tells a story of anatomy and etiology providing context and understanding as to the etiology of the large lesion as a manifestation of the intracanal pulpal necrosis extruding into the PDL space via the lateral canal on the distal side of the root.

Case report 3

An 80-year-old female presented with a chronic apical abscess. Tracing of the sinus tract revealed the responsible tooth was tooth No. 30 (Figure 3A). However, both adjacent teeth, Nos. 29 and 31, were also necrotic with asymptomatic apical periodontitis. Unfortunately, tooth D. C. No. 31 was not salvageable due to heavy destruction of the crown, and it was referred for extraction. Figures 3A-3D: Case 3 by Dr. Mahmood Reza Kalantar Motamedi. (Restoration by Dr. After administering local anesthesia and isolating Pardis Doosti) with a dental dam, access cavities were prepared for both teeth Nos. 29 and 30 at the same time (in this Case report 4 case report, we are only focusing on tooth No. 29). ThroughA 72-year-old female patient presents for pain in the upper out the root canal instrumentation, the irrigant of choice was right quadrant for 1 week, which was exacerbated by biting 5% NaOCl. A crown-down approach was performed with pressure. The diagnosis was tooth No. 3 pulp necrosis with T-Pro rotary files (Shenzhen Perfect Medical Instruments Co. symptomatic apical periodontitis. An enlarged apical lesion Ltd., Guangdong, China). The final preparation size of the root was noted on the palatal root extending coronally within the canal for tooth No. 29 was 40/.04. NaOCl was activated with apical third of the palatal root on the distal (Figures 3A and 3B). UltraX for a few minutes before obturation. Due to the close RCT was completed using rotary instruments to a final canal proximity of the apex of tooth No. 29 to the mental foramen, preparation size of 18/.04 in the mesiobuccal and distobuccal the master GP cone was placed 1 mm short of the working canals (no second mesiobuccal canal was present) and to a length along with the least amount of AH Plus sealer. Warm size 30/.04 in the palatal canal with ExactTaperHDC. Copious vertical obturation technique was carried out. Post-obturation irrigation was done with Triton and activation with a laser-asradiograph revealed a small amount of sealer extrusion from a lateral canal toward the lateral lesion. The tooth was temposisted endodontic irrigation protocol using the EdgePro laser rized and referred for permanent restoration. A follow-up of 3 and obturation with GP and BC Hi Flow sealer using a single months shows a favorable healing of periradicular lesion and cone hydraulic condensation technique. A permanent access complete resolution of the sinus tract. filling was placed. Endodontic Practice US

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This case was completed in a single visit. The primary portal of exit on the palatal canal was directed toward the distal and a lateral portal of exit on the distal aspect of the palatal root in the apical third was noted on the final image (Figure 4C). The visual confirmation of the lateral canal tells the story of the reality of the pulp system anatomy, and etiology providing context and confirmation that this is a lesion of endodontic origin, and its position on the distal aspect of the palatal root was directed by the location of the lateral portal of exit of the necrotic canal.

Discussion

Lateral canals are typically not visible in preoperative radiographs, except in cases where there is localized thickening of the PDL on the root’s lateral surface or the presence of a lateral periodontal lesion.4 Use of cone beam computed tomography can help to identify these structures in some cases. Lateral canal anatomy can be visualized on radiographs after root canal obturation when root filling material is forced into the ramifications, a phenomenon that B. C. we consider a “storyteller,” highlighting pulpal system anatomy and verification of the etiology of lateral perFigures 4A-4C: Case 4 by Dr. Brett E. Gilbert iradicular lesions. practice, when we observe the final image and see the sealer The complete cleaning of these ramifications, without leaving protruding into the lateral lesion, it indicates and confirms that any tissue residue or infected debris, is a challenge. Complete 7 the lesion originated from extrusion of necrotic debris from the cleaning of accessory or lateral canals is not likely feasible. lateral canal. This also suggests that the lateral canal has been However, in endodontic practice, the goal is to minimize the cleaned to a significant enough extent for the sealer to pass intracanal bacterial load as much as possible, and visual evithrough. It is more likely that sealer travels through a lateral canal dence of lateral sealer puffs helps to confirm this has occurred that has been cleaned rather than a non-cleaned one. This tells during treatment. the clinician a story confirming the presence of lateral anatomy If the pulpal tissue in these accessory innervations is necrotic and the likelihood that in necrotic cases, a periradicular lesion and infected, leading to apical and lateral periodontitis, it laterally adjacent to the root is of endodontic origin. EP becomes crucial to thoroughly clean and disinfect these lateral canals rather than simply filling them with an inert material. REFERENCES The shaping phase alone cannot reach these spaces, highlight1. Carrotte P. Endodontics: Part 1. The modern concept of root canal treatment. Br Dent ing the importance of irrigation in three-dimensional cleaning. J. 2004 Aug 28;197(4):181-183. After shaping, the use of irrigants such as sodium hypochlorite 2. Teja KV, Ramesh S. Is a filled lateral canal - A sign of superiority? J Dent Sci. 2020 Dec;15(4):562-563. and ethylenediaminetetraacetic acid (EDTA), along with various Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral surgery, oral 3. activation techniques like subsonic activation, sonic activation, medicine, oral pathology 1984;58(5):589-99. Vertucci FJ. Root canal anatomy of the ultrasonic activation, and laser-assisted and multisonic activahuman permanent teeth. Oral Surg Oral Med Oral Pathol. 1984 Nov;58(5):589-599. tion can aid in the removal of pulp tissue remnants and hard 4. Ricucci D, Siqueira JF Jr. Fate of the tissue in lateral canals and apical ramifications tissue debris. A highly effective technique that does not require in response to pathologic conditions and treatment procedures. J Endod. 2010 Jan;36(1):1-15. expensive devices for activation of irrigation is the ultrasonic 8 Camps J, Lambruschini GM. L’obturation des canaux latéraux: nécessité thérapeutique 5. activation technique. ou satisfaction radiologique? [Obturation of lateral canals: necessary therapy or radioOnce the main root canal is adequately cleaned, it is ready logical satisfaction?]. Rev Fr Endod. 1991 Jun;10(2):19-26. French. for obturation. Based on some studies, warm obturation tech6. Barthel CR, Zimmer S, Trope M. Relationship of radiologic and histologic signs of inflammation in human root-filled teeth. J Endod. 2004 Feb;30(2):75-79. niques can effectively fill the previously cleaned lateral canals.9,10 Siqueira JF Jr, Araújo MC, Garcia PF, Fraga RC, Dantas CJ. Histological evaluation of 7. Moreover, high-flow sealers can be helpful to fill lateral canals. the effectiveness of five instrumentation techniques for cleaning the apical third of root In the cases presented in this study, BC sealer with single-cone canals. J Endod. 1997 Aug;23(8):499-502. hydraulic condensation technique or AH-plus sealer with warm 8. Retsas A, Boutsioukis C. An update on ultrasonic irrigant activation. ENDO: Endodontic Practice Today. 2019;13(2):115-129. vertical condensation technique were utilized for obturation. 9.

Summary Based on the literature, it appears that cleaning the lateral canals is more important than filling them. However, in clinical endopracticeus.com

DuLac KA, Nielsen CJ, Tomazic TJ, Ferrillo PJ Jr, Hatton JF. Comparison of the obturation of lateral canals by six techniques. J Endod. 1999 May;25(5):376-380.

10. Carvalho-Sousa B, Almeida-Gomes F, Carvalho PR, Maníglia-Ferreira C, Gurgel-Filho ED, Albuquerque DS. Filling lateral canals: evaluation of different filling techniques. Eur J Dent. 2010 Jul;4(3):251-256.

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Continuing Education Quiz The lateral puff in endodontics: clinically significant or a storyteller of anatomy and etiology? — a case report series MOTAMEDI-GILBERT

Ramifications and accessory anatomy are found in different parts of the root, with __________ in the apical third, 11% in the middle third, and 15% in the coronal third. a. 13% b. 24% c. 73.5% d. 83.5%

The objective of endodontic treatment should be to _________. a. remove biological tissues b. reduce microbial contamination as much as possible c. create an effective three-dimensional seal to encapsulate any remaining microorganisms d. all of the above

AGD Code: 070

Date Published: December 21, 2023 Expiration Date: December 21, 2026

Lateral canals and apical ramifications have been implicated with endodontic treatment failure when they are sufficiently large enough to harbor significant numbers of bacteria and to provide these bacteria with unimpeded access to the periradicular tissues. a. True b. False In clinical practice, while filling lateral canals may not always be necessary for success, the presence of a filled lateral canal or lateral sealer puff on the final image can provide valuable confirmation that __________. a. the canal system walls have been inadequately debrided b. a lesion is a lesion of endodontic origin c. the sealer will be blocked from flowing d. the area has been infected with bacteria

5. Lateral canals are typically not visible in preoperative radiographs, except ________. a. where there is localized thickening of the PDL on the root’s lateral surface b. when there is presence of a lateral periodontal lesion c. when there is no tissue debris d. both a and b 6.

n To receive credit: Go online to https://endopracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers.

Use of ________ can help to identify these structures in some cases. a. preoperative radiographs b. cone beam computed tomography c. intraoral photographs d. transillumination If the pulpal tissue in these accessory innervations is _______, leading to

2 CE CREDITS

apical and lateral periodontitis, it becomes crucial to thoroughly clean and disinfect these lateral canals rather than simply filling them with an inert material. a. necrotic and infected b. removed c. fragmented d. none of the above 8. After shaping, the use of irrigants such as sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA), along with various activation techniques like _________ and laser-assisted and multisonic activation can aid in the removal of pulp tissue remnants and hard tissue debris. a. subsonic activation b. sonic activation c. ultrasonic activation d. all of the above 9.

Based on some studies, warm obturation techniques can effectively fill the previously cleaned lateral canals. Moreover, ________ can be helpful to fill lateral canals. a. water b. flushing chemicals c. high-flow sealers d. bicarbonate soda solution

10. It is more likely that sealer travels through a lateral canal that has been cleaned rather than a non-cleaned one. a. True b. False

To provide feedback on CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

Endodontic Practice US

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Management of pre- and postoperative dental and surgical pain during the opioid crisis Drs. Diana Bronstein and Rita Steiner discuss protocols to reduce patient dependence on opioids for pain management Introduction and background The opioid crisis is a well-documented and reported current event which deserves attention and consideration when practicing daily patient care. With over 9.5 million Americans abusing prescription opioids in 2020 and over 2.7 million with an opioid use disorder, the U.S. Department of Health and Human Services has declared the misuse of opioids a public health emergency.2 Today’s clinicians are aware that the amount of peri- and postoperative opioid use for pain management and their intake duration following surgery are positively associated with chronic opioid use and addiction subsequently. It is one of the top contributors to this epidemic.3-5 The challenge is to reduce opioid use while maintaining adequate pain control. This article will examine surgical procedures known to increase patients’ risk of developing chronic opioid use and propose protocols for better patient outcomes including reduction of dosage and duration of surgical procedure-related opioid use.

Diana Bronstein, DDS, MS, MS, MS, has been a Clinical Professor, Associate Program Director and Faculty in the Department of Periodontology and at the Advanced Education of General Dentistry Department at Nova Southeastern University, College of Dental Medicine. She is double boarded as Diplomate by the American Board of Periodontology and Implant Dentistry (ABP) in Periodontology and Dental Implant Surgery, and she is a Diplomate and Fellow of the International Congress of Oral Implantologists (ICOI). She co-authored the third and fourth edition of Misch’s and Resnik’s Contemporary Implant Dentistry volumes. Dr. Bronstein has a Diploma in Clinical Homeopathy which she practices upon patient request adjunctively to standard of care during her periodontal and surgical dental practice. Rita Steiner, DMD, has been a dentist since 1994 and an endodontist since 2004. She has been teaching at the VA Medical Center in Miami, Florida and is an adjunct clinical assistant professor at Nova Southeastern University (NSU) College of Dental Medicine (CDM) since 2012. She currently serves as faculty at the Department of Advanced Education in General Dentistry (AEGD). Dr. Steiner was also president of the North Dade -Miami Beach Dental Association 2018-2019. Dr. Bronstein acknowledges the time and effort of Research Assistant Samuel Rabins. Disclosure: Dr. Bronstein reports that no financial or other interests exist for herself or her family members regarding StellaLife or any other brands mentioned in this article.

endopracticeus.com

Educational aims and objectives

This self-instructional course for dentists aims to discuss how to manage pre- and postoperative oral surgery/endodontic procedural pain in patients during the opioid epidemic.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions by taking the quiz online at endopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the extent of the opioid crisis in the United States. • Anticipate which cases will require analgesic intervention and to what extent. • Identify the best analgesia choices in individual patients dependent on patient history and procedure performed. • Realize a variety of systemic, local, and topical prescriptions, chairside and OTC (over-the-counter) analgesia options for the patient and the practitioner.

2 CE CREDITS

Dose increases in both the postoperative inpatient and outpatient settings independently increase the risk of prolonged opioid use,3,6 including opioid naive patients.

Pain management modalities for surgical patients Managing postoperative pain is an important part of the surgery that involves carefully weighing the risks and benefits since initial and progressive pain control plays a large role in a patient’s overall satisfaction with treatment. A patient experiencing too much pain leads to poor clinical outcomes, while providing access to more than the minimal necessary amount of opioids can initiate chronic dependency.7,8 The challenge is to judge the minimal effective dosage of opioids for adequate pain control successfully while it varies from patient to patient, making it difficult to assess their pain sensitivity objectively.9 “One potential solution to this problem is the use of peripheral nerve blocks. Their use as a replacement for at least some percentage of opioid pain control during and after medical procedures has the potential to reduce opioid use, misuse, and

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Figures 1 and 2: 1. Irrigation syringe filled with StellaLife rinse to dispense to patients to use locally on surgical site on a cotton ball or rinse postoperatively. 2. StellaLife post-op kit recommended for patients to get before procedure and bring to appointment. Contains pre-and post-op rinse, gel, and spray

dependency.” Current research suggests that using peripheral nerve block may present viable analgesia.1 According to Cardwell, et al., 2022, the use of pre-surgical peripheral nerve blocks significantly decreases opioid need not only after the procedure, but also in all facets of the surgical process. The most significant reduction in opioid consumption is seen in the first 1-3 days postop, and the patient who received peripheral nerve blocks in the study reported lower pain scores than the control group individuals. It is important to note that this reduction in opioid consumption did not negatively impact patient experience or increase their pain score levels. In fact, it has been shown that the “patients have significantly lower pain scores, higher overall satisfaction, and even prefer the use of blocks when compared to general anesthesia and opioids alone. However, utilization of peripheral nerve blocks is not ubiquitous” while this study produced evidence that peripheral nerve blocks are an effective tool for managing postoperative pain. Another painful oral surgery sequela is post-extraction dry socket occurrence most often experienced by smokers and non-compliant patients. Dry socket is one of the most common postoperative complications after mandibular tooth extraction, characterized by severe pain and exposed bone. The usual palliative is irrigation of the socket to debride any food or foreign material and packing of the socket with medicated gel or paste to provide pain relief and allow normal wound healing.10 Studies have reported that dry socket pain starts 1–3 days after tooth extraction.17,18 The time it takes for the dry socket to heal varies depending on its severity, but usually, it ranges from 5 to 10 days.19 The management of dry socket has been less controversial18 than its etiology and prevention. Many authors agree that the primary objective is pain control until normal healing occurs as suggested by Fazakerley.16 Systemic analgesics or antibiotics may be necessary or indicated.20 The use of intra-alveolar dressing materials is also suggested in the literature as local palliative treatment,21,22 although it is generally acknowledged that dressings delay the healing of the extraction socket.23 Endodontic Practice US

Figure 3: Tooth No. 7 with a perio-endo lesion presents with a preoperative probing depth of 10 mm (top). Figure 4: Adjacent No. 8 presents with postoperative probing depth buccal of 5 mm with tissue blanching indicating initiation of healing after completed root canal therapy

Another treatment modality of dry socket appears to be Platelet-Rich Fibrin (PRF). PRF is characterized by the slow polymerization during its preparation in the centrifuge that generates a fibrin network very similar to the natural one that enhances cell migration and proliferation.13 Choukroun, et al.,15 in France advocated the use of PRF, which is a second-generation platelet concentrate. PRF is a stringently autologous fibrin matrix. Dohan, et al.,14 suggested that PRF addition can correct destructive reactions in the natural process of healing of wound tissues, suggesting that PRF contributes to the immune regulatory mechanism. Choukroun, et al.,15 demonstrated a clinical example in which they used the PRF as a filling material in the extraction socket. There was a significant decrease in pain and the number of socket wall exposure by the third postoperative day; the pain had completely resolved and socket fully epithelialized by the tenth postoperative day. The use of PRF yielded promising results in terms of both pain reduction and improved wound healing which was comparable to the conventional Alveogyl (Septodont) dressing. It may be concluded that PRF is an effective modality for the management of dry socket.10 The studies confirmed that neovascularization and epithelial coverage of the extraction socket can be achieved with the use of PRF. PRF is a reservoir of platelets, leukocytes, cytokines, and growth factors. It is reported to allow the slow release of cytokines, transforming growth factor, platelet-derived growth factor, vascular endothelial growth factor, and epidermal growth factor, which play a vital role for angiogenesis, tissue healing, and cicatrization.14,15 There are further modalities of postoperative morbidity control. Many innovations have made their way into mainstream standard of care. One of the main challenges after extraction, especially postsurgical extractions of impacted 3rd molars, is

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Figure 5: Tooth No. 8 presenting with perio-endo lesion preoperatively with blown out buccal plate (left). Figure 6: Tooth No. 8 presents with 9-month postoperative healing of periapical osseous defect on CBCT slides (right)

pain control, and one of the treatments for pain control is lowlevel laser therapy (LLLT). The study by Santos, et al., 2020, aimed to assess the effectiveness of LLLT for pain control after extraction of lower third molars11 and concluded that LLLT within the parameters determined was effective in reducing the intensity of postoperative pain in third molar surgery, presenting the best results 48 and 72 hours after the procedure. The application of LLLT can offer greater postoperative comfort and wellbeing to patients, functioning as both an inhibitor of the inflammatory process and a modulator. The working mechanism is by interference of the laser in biochemical and molecular levels, promoting the improvement of clinical signs and symptoms, considering that it stimulates endorphin release, inhibits nociceptive signals, and reduces pain proception. In addition, LLLT may reduce edema and hyperemia, accelerate the wound-healing process, and stimulate bone repair.51,52 With new modalities of pain management, there are also improved conventional pain medication protocols to provide today’s practitioners with evidence-based prescription framework. Since the efficacy and rapid onset of postsurgical oral pain relief are critical to improve clinical outcomes and reduce the risk of excessive dosing with analgesic drugs, another study by Cristalli, et al., 2021, compared analgesic effects of preoperative administration of paracetamol 500 mg plus codeine 30 mg in single-tablet and effervescent formulation to ibuprofen 400 mg, and placebo in the management of moderate-to-severe postoperative pain after mandibular third molar surgery.12 Within the limits of that study, over postoperative 3 days, a statistically significant intensity pain reduction and decreased rescue therapy consumption were recorded in the paracetamol-codeine group than to ibuprofen group. Nevertheless, lower pain intensity at 2 hours post-dose and longer time using rescue therapy was found in the ibuprofen group without statistical significance and without adverse events over the studied period.12,53 A critical property of antiseptic solutions is pain management, especially in terms of trying to limit opioid use. The U.S. opioid public health crisis due to over-prescribing, has subsequently created a drug overuse problem mostly affecting teenendopracticeus.com

Figure 7: Pre-op teeth Nos. 7 and 8 with bone loss and periapical radiolucency, increased mobility, and probing depth (left). Figure 8: Teeth Nos. 7 and 8 with root canal therapy completed and No. 8 with intentional sealer puff. Tooth No. 8 was managed surgically with incision, drainage, and curettage (right)

Figure 9: Teeth Nos. 7 and 8 after I&D and curettage, sealant is removed. Mesial No. 7 calculus was removed after this X-ray was taken (left). Figure 10: Healing at 9 months post endodontic therapy and periodontal treatment with some bone regeneration and periapical healing (right)

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agers, leading to a dramatic increase in fatal overdoses.25 It has been more than 5 years since the Food and Drug Administration (FDA), National Institute of Drug Abuse (NIDA), National Institutes of Health (NIH), Drug Enforcement Agency (DEA), the Centers for Disease Control (CDC), and medical and dental organizations such as the American Medical Association (AMA), American Dental Association (ADA),26 and the American Association of Oral and Maxillofacial Surgeons (AAOMS) collectively declared a drastic need to combat their misuse.26,27,28,29,30 Since the mid-1990s, deaths from opioid overdose has more than quadrupled, which parallels the increase in opioid prescriptions written in dental and Figure 11: Dr. Bronstein during an oral surgery procedure (left). Figure 12: Dr. Steiner using a microscope medical practices,31,32 which is why some during an endodontic procedure (right) countries have entirely banned opioid pain management due to its anti-inflammatory and anti-nociuse in dental practice. In these areas, pain control appears to be ceptive properties.44,46 The mechanism of action is associated manageable. Given that the surgical area is known prior to the with its ability to inhibit pro-inflammatory cytokines such as procedure, pre-surgical analgesia can be implemented to help TNF-Į, IL-1, IL-6 and IL-8,44 and by its COX inhibition, which reduce the amount of opioid prescriptions in a private practice 33,34 is a main mediator of nociception and inflammation.46 Chamosetting. mile (Matricaria recutita), which has been used historically as a Pain perception is initiated in the peripheral nervous systopical anesthetic, may also function as a selective cycloxegetem (PNS) before the central nervous systems (CNS) become nase (COX)-2 inhibitor.46 It may have a synergistic effect when involved, starting with nociceptors which transmit signals along employed in combination with other non-steroidal anti-inflamsmall myelinated A and unmyelinated C fibers before synapsing 35,37 matory drugs (NSAIDs), such as diclofenac.46 Chamomile has Signals are then relayed in the dorsal horn of the spinal cord. also been shown to reduce dose-dependent sodium channels, through the thalamus and cortex via the spinothalamic tract of 36 thus decreasing peripheral nerve excitability.39 The anxiolytic the spinal cord. and anti-nociceptive mechanism of Aconitum works via blockActivity in the dorsal horn can be modulated by psycholog49 35 ing voltage-dependent sodium channels. It was used in ancient ical factors. Active ingredients in StellaLife such as Aconitum, 38 40,42,43 Chinese and Japanese medicine as an analgesic. In summary, Gelsemium, and Ignatia have shown anxiolytic properties. many of the active ingredients in StellaLife exhibit known and Anxiolysis is critically important in dental pain management, proven anti-inflammatory and anti-nociceptive properties that since patients with anxiety or depression experience more pain 48 aid in pain management. Pathways involved include the reducfrom surgery. Postoperative pain occurs in two phases: an inition of pro-inflammatory cytokines, COX inhibition, anxiolytics, tial phase with acute pain at the point of noxious stimuli (or and the blockade of neuronal sodium currents. While many of incision), and a second phase of prolonged, dull pain around 35 our patients report a soothing effect when using the StellaLife the surgical area. The pain stimulus is initiated by inflamma41,35 rinse and gel, more research is necessary to evaluate how these The objective tory mediators released at the site of surgery. ingredients work synergistically to control pain by pre- and postof pre- and postoperative analgesia is to decrease inflammatory 35,45 operative applications. mediators post-surgery. Unlike conventional pain manage® Figures 3-10 illustrate the perio-endo case of a 51-year-old ment regiments, minimizing postoperative pain with StellaLife ® male MMA fighter. Following trauma to his teeth Nos. 7 and 8 starts 3 days before the procedure. VEGA Oral Care Recovery which was treated conservatively with root canal therapy and Kit by StellaLife has 16 active homeopathic ingredients includscaling and root planing, surgical management with incision, ing Arnica, chamomile, and Aconitum. In a study evaluating the drainage and curettage were also performed, and consequently, mechanisms of Arnica montana flower methanol extract (AMME) 47 postoperative pain management needed to be applied. EP in an arthritic rat model, the authors proved that AMME significantly reduced the amount of oxygen free-radicals and pro-inflammatory cytokines such as TNF-Į, IL-1, and IL-6, without the REFERENCES host exhibiting toxic side effects. Interestingly, when compared 1. Cardwell TW, Zabala V, Mineo J, Ochner CN. The Effects of Perioperative Peripheral to the commonly utilized corticosteroid dexamethasone, AMME Nerve Blocks on Peri- and Postoperative Opioid Use and Pain Management. Am Surg. 50 showed greater therapeutic efficacy in the study. Another ingre2022;88(12):2842–2850. dient in StellaLife is chamomile, which is commonly utilized for 2. Substance Abuse and Mental Health Services Administration. Key substance use and Endodontic Practice US

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mental health indicators in the United States: Results from the 2020 national survey on drug use and health. Published October 2021. https://www.samhsa.gov/data/sites/ default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf. Accessed January 6, 2023. 3.

Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017 Jun 21;152(6):e170504.

Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014 Feb 11;348:g1251.

Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293.

Ruddell JH, Reid DBC, Shah KN, Shapiro BH, Akelman E, Cohen EM, Daniels AH. Larger Initial Opioid Prescriptions Following Total Joint Arthroplasty Are Associated with Greater Risk of Prolonged Use. J Bone Joint Surg Am. 2021 Jan 20;103(2):106-114.

Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287-2298.

Demsey D, Carr NJ, Clarke H, Vipler S. Managing opioid addiction risk in plastic surgery during the perioperative period. Plast Reconstr Surg. 2017;140(4):613e-619e.

Younger J, McCue R, Mackey S. Pain outcomes: A brief review of instruments and techniques. Curr Pain Headache Rep. 2009;13(1):39-43.

10. Keshini MP, Shetty SK, Sundar S, Chandan SN, Manjula S. Assessment of Healing Using Alvogyl and Platelet Rich Fibrin in Patients with Dry Socket - An Evaluative Study. Ann Maxillofac Surg. 2020 Jul-Dec;10(2):320-324. 11. Santos PL, Marotto, AP, Zatta da Silva T, Bottura MP, Valencise M, Marques DO, Queiroz TP. Is Low-Level Laser Therapy Effective for Pain Control After the Surgical Removal of Unerupted Third Molars? A Randomized Trial. J Oral Maxillofac Surg. 2020 Feb;78(2): 184–189. 12. La Monaca G, Pranno N, Annibali S, Polimeni A, Pompa G, Vozza I, Cristalli MP. Comparative Analgesic Effects Of Single-Dose Preoperative Administration Of Paracetamol (Acetaminophen) 500 Mg Plus Codeine 30 Mg And Ibuprofen 400 Mg On Pain After Third Molar Surgery. J Evid Based Dent Pract. 2021 Dec;21(4):101611. 13. Al-Hamed FS, Tawfik MA, Abdelfadil E. Clinical effects of platelet rich fibrin (PRF) following surgical extraction of lower third molar. Saudi J Dent Res. 2017;8(1,2):19-25. 14. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part II: platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Mar;101(3):e45-50. 15. Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, Dohan AJ, Mouhyi J, Dohan DM. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Mar;101(3):e56-60. 16. Fazakerley M, Field EA. Dry socket: a painful post-extraction complication (a review). Dent Update. 1991 Jan-Feb;18(1):31-34. 17. Fridrich KL, Olson RA. Alveolar osteitis following surgical removal of mandibular third molars. Anesth Prog. 1990 Jan-Feb;37(1):32-41. 18. Nitzan DW. On the genesis of “dry socket”. J Oral Maxillofac Surg. 1983 Nov;41(11): 706-710. 19. Blum IR. Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. Int J Oral Maxillofac Surg. 2002 Jun;31(3):309-317. 20. Heasman PA, Jacobs DJ. A clinical investigation into the incidence of dry socket. Br J Oral Maxillofac Surg. 1984 Apr;22(2):115-122. 21. Vezeau PJ. Dental extraction wound management: medicating postextraction sockets. J Oral Maxillofac Surg. 2000 May;58(5):531-537. 22. Swanson AE. A double-blind study on the effectiveness of tetracycline in reducing the incidence of fibrinolytic alveolitis. J Oral Maxillofac Surg. 1989 Feb;47(2):165-167. 23. Bloomer CR. Alveolar osteitis prevention by immediate placement of medicated packing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000 Sep;90(3):282-284. 24. Estrin NE, Romanos GE, Tatch W, Pikos M, Miron RJ. Biological Characterization, Properties, and Clinical Use of a Novel Homeopathic Antiseptic Oral Recovery Kit: A Narrative Review. Oral Health Prev Dent. 2022 Nov 30;20(1):485-499. 25. Rutkow L, Vernick JS. Emergency Legal Authority and the Opioid Crisis. N Engl J Med. 2017 Dec 28;377(26):2512-2514. 26. American Dental Association (ADA). American Dental Association announces new policy to combat opioid epidemic. 2018. https://www.prnewswire.com/news-releases/american-dental-association-announces-new-policy-to-combat-opioid-epidemic-300618928.html Accessed January 9, 2023. 27. Califf RM, Woodcock J, Ostroff S. A Proactive Response to Prescription Opioid Abuse. N Engl J Med. 2016 Apr 14;374(15):1480-1485. 28. Centers for Disease Control and Prevention. Opioid overdose: Understanding the epidemic. Centers for Disease Control and Prevention, US Department of Health and

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Human Services, 2017. Reviewed June 1, 2022. 29. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA. 2016 Apr 19;315(15):1624-1645. 30. Hupp JR. Opioids: Combating Misuse While Properly Caring for Our Patients. J Oral Maxillofac Surg. 2019 Apr;77(4):669-670. 31. National Institute on Drug Abuse. Overdose death rates. National Institute on Drug Abuse, National Institutes of Health, 2017. Updated January 20, 2022. 32. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths--United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):1378-1382. 33. Lee CYS, Suzuki JB. The efficacy of preemptive analgesia using a non-opioid alternative therapy regimen on postoperative analgesia following block bone graft surgery of the mandible: A prospective pilot study in pain management in response to the opioid epidemic. Clin J Pharmacol Pharmacother. 2019;1(2):1006. 34. Tatch W. Opioid Prescribing Can Be Reduced in Oral and Maxillofacial Surgery Practice. J Oral Maxillofac Surg. 2019 Sep;77(9):1771-1775 35. Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. Am Fam Physician. 2001 May 15;63(10):1979-1984. 36. Gupta SC, Prasad S, Reuter S, Kannappan R, Yadav VR, Ravindran J, Hema PS, Chaturvedi MM, Nair M, Aggarwal BB. Modification of cysteine 179 of IkappaBalpha kinase by nimbolide leads to down-regulation of NF-kappaB-regulated cell survival and proliferative proteins and sensitization of tumor cells to chemotherapeutic agents. J Biol Chem. 2010 Nov 12;285(46):35406-35417. 37. Pogatzki-Zahn EM, Zahn PK. From preemptive to preventive analgesia. Curr Opin Anaesthesiol. 2006 Oct;19(5):551-555. 38. Ameri A. The effects of Aconitum alkaloids on the central nervous system. Prog Neurobiol. 1998 Oct;56(2):211-235. 39. Alves Ade M, Gonçalves JC, Cruz JS, Araújo DA. Evaluation of the sesquiterpene (-)-alpha-bisabolol as a novel peripheral nervous blocker. Neurosci Lett. 2010 Mar 12;472(1):11-15. 40. Bhat NP, Sairoz DC, Shetty A, Quadros L, Krishnan H, Bakthavatchalam P. Efficacy of Aconite and Ignatia as an anxiolytic-In vivo study. Int J Res Pharmaceut Sci. 2021;12(2):1484–1489. 41. Dahl JB, Kehlet H. Preventive analgesia. Curr Opin Anaesthesiol. 2011 Jun;24(3): 331-338. 42. Magnani P, Conforti A, Zanolin E, Marzotto M, Bellavite P. Dose-effect study of Gelsemium sempervirens in high dilutions on anxiety-related responses in mice. Psychopharmacology (Berl). 2010 Jul;210(4):533-545. 43. Marzotto M, Conforti A, Magnani P, Zanolin ME, Bellavite P. Effects of Ignatia amara in mouse behavioural models. Homeopathy. 2012 Jan;101(1):57-67. 44. McKay DL, Blumberg JB. A review of the bioactivity and potential health benefits of chamomile tea (Matricaria recutita L.). Phytother Res. 2006 Jul;20(7):519-530. 45. Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesth Analg. 2005 Mar;100(3): 757-773. 46. Ortiz MI, Fernández-Martínez E, Soria-Jasso LE, Lucas-Gómez I, Villagómez-Ibarra R, González-García MP, Castañeda-Hernández G, Salinas-Caballero M. Isolation, identification and molecular docking as cyclooxygenase (COX) inhibitors of the main constituents of Matricaria chamomilla L. extract and its synergistic interaction with diclofenac on nociception and gastric damage in rats. Biomed Pharmacother. 2016 Mar;78:248-256. 47. Sharma S, Arif M, Nirala RK, Gupta R, Thakur SC. Cumulative therapeutic effects of phytochemicals in Arnica montana flower extract alleviated collagen-induced arthritis: inhibition of both pro-inflammatory mediators and oxidative stress. J Sci Food Agric. 2016 Mar 30;96(5):1500-1510. 48. Taenzer P, Melzack R, Jeans ME. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain. 1986 Mar;24(3):331-342. 49. Wang CF, Gerner P, Wang SY, Wang GK. Bulleyaconitine A isolated from aconitum plant displays long-acting local anesthetic properties in vitro and in vivo. Anesthesiology. 2007 Jul;107(1):82-90. 50. Sharma SM, Anderson M, Schoop SR, Hudson JB. Bactericidal and anti-inflammatory properties of a standardized Echinacea extract (Echinaforce): dual actions against respiratory bacteria. Phytomedicine. 2010 Jul;17(8-9):563-568. 51. Karu T. High-tech helps to estimate cellular mechanisms of low power laser therapy. Lasers Surg Med. 2004;34(4):298-299. 52. Medrado AR, Pugliese LS, Reis SR, Andrade ZA. Influence of low level laser therapy on wound healing and its biological action upon myofibroblasts. Lasers Surg Med. 2003;32(3):239-244. 53. Bronstein D, Suzuki JB. Post Operative Pain Management During the Age of Opioid Crisis. Oral Health. https://www.oralhealthgroup.com/features/post-operative-painmanagement-during-the-age-of-opioid-crisis/ Accessed January 9, 2023.

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Continuing Education Quiz Management of pre- and postoperative dental and surgical pain during the opioid crisis BRONSTEIN-STEINER

1. With over _______ Americans abusing prescription opioids in 2020 and over 2.7 million with an opioid use disorder, the U.S. Department of Health and Human Services has declared the misuse of opioids a public health emergency. a. 3 million b. 5.6 million c. 9.5 million d. 12 million 2. Dry socket is one of the most common postoperative complications after mandibular tooth extraction, characterized by ________. a. severe pain b. exposed bone c. nausea d. both a and b 3. The time it takes for the dry socket to heal varies depending on its severity, but usually, it ranges from ________. a. 1 to 3 days b. 5 to 10 days c. 2 weeks to 1 month d. 2 months to 3 months 4. ____________ is a reservoir of platelets, leukocytes, cytokines, and growth factors. a. Platelet-rich fibrin b. StellaLife c. Guided bone regeneration d. TNF-Į 5. The application of LLLT can offer greater postoperative comfort and wellbeing to patients, functioning as ________. a. an inhibitor of the inflammatory process b. a modulator c. neuronal sodium d. both and b 6. Since the mid-1990s, deaths from opioid overdose has more than ________, which parallels the increase in opioid prescriptions written in dental and medical practices, which is why some countries have entirely banned opioid use in dental practice. a. doubled b. tripled c. quadrupled d. quintupled

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496, or visit https://endopracticeus.com/subscribe/ to subscribe today. n To receive credit: Go online to https://endopracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 157 Date Published: December 21, 2023 Expiration Date: December 21, 2026

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7. Pain perception is initiated in the peripheral nervous system (PNS) before the central nervous systems (CNS) become involved, starting with nociceptors which transmit signals along small myelinated A and unmyelinated C fibers before synapsing in the dorsal horn of the spinal cord. a. True b. False 8. The initial phase of postoperative pain starts with ________. a. prolonged dull pain around the surgical area b. acute pain at the point of noxious stimuli (or incision) c. the bone graft d. guided bone regeneration site 9. The objective of pre- and postoperative analgesia is to __________ inflammatory mediators post-surgery. a. intercept b. increase c. decrease d. track 10. According to the article, _________ was used in ancient Chinese and Japanese medicine as an analgesic. a. Aconitum b. Arnica c. Diclofenac d. Matricaria recutita

Endodontic Practice US

32 Volume 16 Number 4

SMALL TALK

Using the G.R.O.W. model Drs. Joel C. Small and Edwin McDonald offer a new coaching tool

ir John Whitmore first introduced the GROW model in 1992. Since that time, coaches and corporate leadership teams throughout the world have embraced this simple and effective model. The GROW model is useful as a personal tool as well as a coaching tool for individual and team performance enhancement. GROW is an acronym for Goals, current Reality, Options, and Will. For doctors who ask, “How can I get my team to be more productive and accountable? “this model may be the answer to their prayers.

Goals Having extreme clarity regarding a goal, whether it be achieving a specific task, correcting a behavior, or creating one’s preferred future, is critical to the success of the model. Leaders create a scenario for success by supporting team members in creating their own self-defined goals. Team leaders, trained in basic coaching skills, can assist individuals or teams in identifying and clarifying goals by remaining non-directive while asking probing questions intended to assist others in identifying and clarifying their goals. *Note: Occasionally, it may be preferable to change the order of the GROW model for the sake of clarity. For example, if a team member is unaware of a specific negative behavior or attitude that requires correction, the coach/leader should share their observations regarding the current reality before addressing the goal.

Current reality As stated above, if the conversation is remedial in nature and the objective is to correct a specific behavior, we may need to introduce our perspective. If our input is required, we should address the issue in terms of how the current behavior is affecting the team, patient care, productivity, etc. and avoid making our comments a personal affront to the team member. Otherwise, the comments may be perceived as an emotional threat to the recipient. There is current research in neuroscience that supports this approach. Research has shown that the human brain releases cor-

Drs. Joel C. Small and Edwin (Mac) McDonald have a total of over 75 years of dental practice experience. Both doctors are trained and certified Executive Leadership Coaches. They have joined forces to create Line of Sight Coaching, a business dedicated to helping their fellow dentists discover a better and more enjoyable way to create and lead a highly productive clinical dental practice. Through their work, clients experience a better work/life balance, find more joy in their work, and develop a strong practice culture and brand that positively impact their bottom line. To receive their free ebook, 7 Surprising Steps to Grow Your Practice Through Leadership, go to www.lineofsightcoaching.com.

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tisol, a powerful neurotransmitter that creates the flight response when a person experiences emotional threats. When people are experiencing the flight response, they are seldom present enough to engage in a productive conversation. Furthermore, disgruntled team members may become very negative and emotional when describing a current reality. When they become highly emotional, they are experiencing a cortisol-dominated reactive state and are unable to engage in a productive conversation. This is a critical juncture that requires converting their emotions from negative (cortisol-mediated) to a more positive and calmer (dopamine-mediated) state. The best approach is to listen attentively while acknowledging their perspective and emotions as presented. Then, make this simple request; “I have heard, and I understand what you do not want. Now please tell me what you DO want.” This simple statement can shift the nature of the conversation from a negative one to a calmer, more productive, and goal oriented one. Again, neuroscience has shown that when we focus on images that are positive and desirable, our brain releases dopamine, another neurotransmitter that produces calm and enhances focus. Once we shift the person’s emotional state to a more engaged and productive one, we must remain focused on their preferred future rather than returning to the negative aspects of their current reality, keeping them in a more productive mindset. We can ask powerful, probing questions that help create deep thought and bring forth words and images that clearly define the goal they wish to accomplish. We can strengthen their resolve to achieve their goal by asking questions related to the benefits they will derive.

Options Once we have created a calm and focused mindset, and clearly defined goal, we can collaborate with our team member(s) to define various options to achieving the goal. It is best to let the team member(s) give their thoughts first, so they are not influenced by our choices and authority. Some team members who lack self-confidence must take baby steps toward achieving their goal while others can move forward rapidly. The final steps for achieving the goal must be designed with this reality in mind.

Will This final step is designed to determine the degree of commitment to achieving the goal. In general, a goal that is extremely clear and viewed as achievable, is more likely to produce a high degree of commitment. If someone expresses a moderate-to-low level of commitment to achieving the goal, we may want to ask what would need to happen to increase their level of commitment. This discussion may lead to further coaching sessions designed to identify and resolve individual blind spots and/or self-limiting beliefs. EP

33 Volume 16 Number 4

SERVICE PROFILE

A lifetime of learning with HighFive Healthcare Dr. Christopher Cook discusses the benefits of being supported by a large group of like-minded practitioners

hen I graduated from dental school in 1995, our Dean had these parting words for us: “We’ve given you enough of an education to be dangerous. Now go out there and continue to learn for life.” Twenty-eight years later, those words still ring true. Though we walk across that stage and get handed a diploma, there is no end to our education as people or as endodontists — not if we truly want to achieve success for ourselves, our families, and our patients. Learning isn’t a solo act. Even reading a book in quiet solitude involves at least two people, an author and a reader — someone with knowledge and someone to pass it on to. That’s why it’s so important to surround ourselves with people who are better than us at their craft. One thing that has always served me well was surrounding myself with people who are the best in their respective industries. Being a jack of all trades in any vocation doesn’t make sense. We can’t be experts at everything. And trying to be that person only takes us away from our calling, hampering

Dr. Christopher Cook, DMD, served 6 years active duty in the U.S. Navy as a general dentist, attaining the rank of Lieutenant Commander. He received his specialty training at the University of Louisville Graduate Endodontic Program. He practices at Louisville Endodontics and is a proud partner of HighFive Healthcare. Dr. Cook is a member of the American Association of Endodontics (AAE), the American Dental Association (ADA), the Kentucky Dental Association (KDA), the Louisville Dental Society (LDS), and the past president of the Southern Indiana Dental Association (SIDA). He lectures across the country on endodontics.

our ability to do what we were trained to do. So when I had the opportunity to join a larger group of like-minded practitioners with HighFive Healthcare, it was a no-brainer. It’s easy for most practices, including my own at the time, to end up going on autopilot after a few years and losing efficiencies along the way. Keeping up with insurance reimbursement, fee schedules, consumable prices, and credentialing, just to name a few, are burdens that take away from clinical care. By partnering with HighFive, I was able to entrust those important elements of my practice to a team of experts dedicated to just that, freeing me to focus on patient care and things I love doing. What I love doing is continuing to learn and get better at endodontics. I wish HighFive was around in 2003 when I started my practice, but now I have over 85 like-minded doctors available to meet as a group or one-on-one to learn from and get support in that endeavor. It’s a priceless comradery I can only compare to my time in the Navy. If I have a question about a case, I’m a text away from multiple perspectives from peers I know and trust. It’s the next best thing to having them standing beside me in the office. Our regular Zoom lectures bring the best and brightest in the industry to present to us and keep us all at the top of our game. I look forward to our group’s yearly, in-person get-together more than I can say. It’s in those moments of shared learning, support, and friendship that I truly realize HighFive is more than a company — it’s a family. And a family is what every endodontist needs. A diverse group of people, each bringing their unique expertise to bear, to provide the very best care for our patients. EP This article was provided by HighFive Healthcare.

Endodontic Practice US

34 Volume 16 Number 4

Most endodontists have to master multitasking. Ours just have to master root canals. Do what you do best and we’ll handle the rest. We aren’t your typical DSO. When you partner with HighFive Healthcare, you join an exclusive network of top endodontists dedicated to exceptional patient care. Our doctor-owned practices and seasoned team of experts nurture a fun and collaborative culture like no other. While we optimize and scale the business side of endodontics, clinical autonomy is left in your skilled hands. Together, we’ll help you take ownership of something bigger than a single practice and support you as you create your own tomorrow. Learn more at high5health.com

RECRUITING

SCHEDULING OPTIMIZATION

SCAL ABILIT Y

BRANDING & MARKETING

PAYROLL

IT SERVICES

AND MORE

PRACTICE MANAGEMENT

Overcoming mid-career blahs and blues Dr. Albert (Ace) Goerig advises how to regain energy and passion for your work

or many doctors, enthusiasm and passion for endodontics and their practice can drift downward over time. One day, you wake up and everything seems a bit ho-hum. This effect often shows up midcareer and can be partly attributed to familiarity. Not much happens in a day that you haven’t encountered previously dozens, hundreds, or (in the case of an RCT), thousands of times. Often nothing is particularly wrong. In fact, you may recognize that you currently have more than you’ve ever had in the past, and that by most typical measures, you are living a blessed life. And yet, something is creeping up on you, and more frequently you feel something is lacking. Here are some common signs of diminished energy and passion at work: • Feeling tired and unenthused at the start of the day. • Feeling like you’re just going through the motions. • Feeling a lack of accomplishment at the end of the day. • Feeling like you are working too hard for too little results. • Feeling worn out by managing your practice and team. • Feeling like you are spending too much time in the practice. • Feeling restless, bored, and unchallenged professionally. • Feeling the day is dragging along too slowly. • Feeling like you want to escape the profession. These are all symptoms of an unbalance in your passion. Passion is what keeps us motivated, improving, and growing, which is exciting stuff. But when passion stumbles, the first effect is often that our focus falters. Without the drive to push forward, practices (and how we feel inside them) can drift downward. Left long enough, it can become a personal crisis leading to burnout.

Resetting your energy balance Every job comes with pluses and minuses. Every job has things you must do (whether you like it or not) and things that you love to do (which probably motivated you toward that job

Albert Goerig, DDS, MS, is a Diplomate of the American Board of Endodontics and a sought-after speaker who has lectured extensively on the field of endodontics and practice success throughout the United States, Canada, and abroad. He is the author of more than 100 published articles and contributing author to numerous endodontic textbooks. Dr. Goerig has a private endodontic practice in Olympia, Washington, in the top 1% nationwide for practice profitability. He has almost 40 years of experience as an endodontic educator and practice coach to over 1,000 endodontists. www.endomastery.com | 1-800-482-7563 | info@endomastery.com

Endodontic Practice US

in the first place). If you are not making progress on the things you love to do, then the things you must do will end up taking more and more space in your head. Then, you are in the situation when you feel like you are working for everyone else’s needs but not your own. The first step to restoring your energy balance is to ask yourself and understand what you love most. What excites you? Where do you feel the most motivation and least friction to push yourself to new levels? For some doctors, it is purely the clinical experience. They love to live inside the tooth. For other doctors, it’s helping their patients and referring doctors. They are very people-oriented and need to build relationships within the community. Still other doctors may regard endodontics as a great economic profession in which to experience a life that they love and enjoy with their families. Whatever the answer is for you, which could be a mixture of various things, the best way to bring passion back into your life is to pursue the things you love. Invest in yourself to go after those things enthusiastically. For example, if you are clinically focused, then who are your potential mentors? How do you get close to them? How do you put yourself on track to become the ultimate clinician? And then, how do you make your own practice and environment into one that supports you and lets you practice clinical care at that level?

Simplifying burdens At the same time as you are pursuing the things you love, simplify your life around the things you also must do. Reduce your management stress. Implement stronger systems and teamwork so there is less handholding and micromanagement needed from you. Educate and empower your team so you can delegate to them with trust and confidence.

36 Volume 16 Number 4

PRACTICE MANAGEMENT

This isn’t about giving up control. It’s Creating a new vision with updated goals for about maintaining pinpoint control while giving up the labor you’ve taken on. That practice success, team dynamics, economics, and labor is such a weight and burden that it can daily enjoyment is the key turning point to the next overwhelm even the most passionate doctor. It’s like holding up a pillow at arm’s length. stage of professional fulfillment. It’s easy to do for a short time, but as the time extends longer and longer, it becomes heavier and heavier. If you’re holding on to labors in your practice and life that are becoming heavy (even if they are instead as a sign that you have absolutely conquered everything objectively simple to do), it will eventually draw all your energy at your current level. It’s now time to up your game and start away from the things that you love and enjoy. looking at new possibilities and goals. And in that way, you always keep looking forward and prioritizing your growth and enjoyment. Recharging your vision Often, the greatest realization that the doctors I work with as The biggest challenge is admitting you need to make changes a practice coach has been that their vision was predominantly and improve, because that feels like admitting to having a probbased around getting established in endodontics — a first stage lem and failure. However, the mid-career blahs and blues typvision. Now that they’re established, it’s no longer driving them. ically affect people who are beyond the possibility of failure. On top of that, their life outside the practice has often changed. By contrast, people who are still striving to reach fundamental goals rarely suffer from a lack of passion. They’re hungry and Their family, their finances, their personal priorities, etc. have motivated to keep making progress. evolved. Creating a new vision with updated goals for practice Instead, rather than accepting that the lackluster feeling you success, team dynamics, economics, and daily enjoyment is the key turning point to the next stage of professional fulfillment. EP have is inevitable for the remainder of your career, look at it

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37 Volume 16 Number 4

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Five benefits of practicing rural dentistry Dr. David Whitlock discusses the joys of practicing in a rural community

racticing dentistry in a rural setting is my chosen way to practice in today’s dental landscape. I didn’t come to this conclusion without a lot of headache and heartache, but for me, the choice was undeniable. I have been practicing in a rural setting for almost 4 years, and I will never go back to “big- city” dentistry. First, let’s define the term “rural.” Definitions can vary depending on who you’re talking to. Fort Collins, population 150,000, was once the “smallest” place we had ever lived. By no means is Fort Collins a rural community. They have a Costco! That’s criterion number one. (If you have a Costco, you are not rural!) Most people will define rural based on population size. My current town has a population of approximately 25,000 people. Others will define rural based on geography — how isolated you are from a major city. We are 2 hours from the closest major airport and city. A third criteria would be based on the socioeconomics of the people in the area. Aspen, Colorado has a population of just under 7,000 people, and it’s almost a 4 hour drive to the closest major city, Denver. According to the U.S. Census Bureau, the median household income for Aspen from 2017-2021 was $89,625. Many would not consider Aspen as a rural community. Some stark contrasts are apparent when I compare practicing rurally and practicing in an urban/suburban setting. The following are the five main benefits to practicing in a rural community.

plan under the sun because you have to compete with every other dentist within a mile radius of your office. When patients have multiple options, more times than not, they are going to choose based on price. That’s a no-win for everyone involved. There are rural communities throughout the country that are in desperate need of providers. These are the situations that foster success not only professionally, but financially as well.

2. Lower cost of living

1. The level of competition I have practiced in heavily populated areas where there are literally five dentists on every block. There simply aren’t enough patients to go around. If you practice in an area where competition is either low or nonexistent, your ability to produce is greatly increased. This sounds so simple, yet so many dentists turn a blind eye to this fact. Personally, I previously have naively disregarded the competition level in other places I’ve practiced. I was told in dental school that you can simply decide where you want to live, practice there, and you’ll be just fine. That is absolutely not true. Competition matters. It matters if you don’t have enough people to work on. It matters if you have to drastically reduce your fees or be encumbered by every insurance

David Whitlock, DDS, graduated dental school from Virginia Commonwealth University in 2007. He has since practiced in Phoenix, Arizona; Dallas/Fort Worth, Texas; Fort Collins, Colorado; and Raleigh, North Carolina, before settling in eastern Kentucky. Dr. Whitlock has been married for over 20 years and is the proud father of three daughters and two sons. He is passionate about rural dentistry and the opportunities that exist for dentists in rural communities. You can connect with Dr. Whitlock through his website: www.ruralpractices.com.

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The largest expense of any adult/family is housing. Whether you’re renting or buying, housing is less expensive in rural areas. When I moved from Colorado to Kentucky, my house payment was cut in half while only sacrificing a few hundred square feet from my Colorado home to my Kentucky home. Gas is cheaper. Groceries are cheaper. Utilities are cheaper. Also, (and this is purely anecdotal), when one has less “shopping” options in town, you are more likely to spend less money. When all the factors are considered, you can decrease your home’s “overhead” by thousands of dollars per month by living in a rural community. The amount of stress that can be alleviated from knowing that your monthly take-home pay doesn’t have to be an astronomical number each month makes practicing dentistry a little more enjoyable. Instead of fretting over the implant patient that didn’t show up, you’re happy to have a little extra time to surf the web. That one broken appointment won’t make or break your month.

3. Work/life balance Dentistry is hard work. Dealing with the general public is difficult. Dealing with staffng issues is difficult. Even if you’re an associate with no ownership responsibilities, you still have to deal with patients and staff. We all need to find ways to get out of the office and de-stress. Working in a rural community

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gives you that opportunity. The vast majority of rural practices still operate Monday through Thursday from 8 a.m. to 5 p.m. I work on Fridays, and I’m the outlier. Evenings and weekends seldom need to be covered. Working 4 to 5 days per week provides opportunities to get out of the office and pursue passions that reinvigorate us. It provides down time to simply relax and recharge for another day/week. It provides time to spend with family at ball games, swim meets, or orchestra concerts. It provides time to work on that side hustle that you’re passionate about. Again, dentistry is hard on us physically and mentally. We all need breaks. Practicing rurally gives us those breaks.

4. Opportunity to get involved in the community where you practice This might sound like a nightmare to some of you. My biggest fear when I decided to practice in a small town was running into patients in public — that awkward exchange of me knowing who they are but them not knowing who I am is so uncomfortable to me. That being said, getting involved in the community where you practice is so very rewarding. In a big city, dentists are a dime a dozen, but in a small community, you stand out. You’re a healthcare provider. Your donation to a school sports team actually makes a difference. The board seat that you can hold for whatever local organization you are passionate about can enact real change that helps your community. A couple of decades ago, the elected mayor in our town also was a local dentist! I have enjoyed being able to contribute to the sports teams that my

kids have played on over the past few years. I have also enjoyed getting involved in community events like homecoming parades, 5k races, and community outreach that help improve our community and those who live here.

5. Career fulfillment Not only do you have the opportunity to do more dentistry, but you have the ability to choose the type of dentistry you want to do. You can narrow your scope of practice and focus solely on placing implants, treating children, or treating sleep apnea. More importantly, you can also eliminate procedures that might cause you more stress than you want to deal with. Personally, I have never been proficient at molar endo. In the past I’ve done it, mostly because I “needed” the production, but it was never very profitable to me because I wasn’t very fast at it. Plus, I always felt guilty if one I did failed. When I transitioned to a rural practice, I decided I would refer out all my molar endo to the specialist. It has made my life so much easier. I love seeing a crown on my schedule where the endo was done by someone else. Not only can you narrow your focus, but you can extend your career in a rural environment. Less wear and tear from working long hours can extend your career by years, if not close to a decade. Rural dentistry has been ignored for far too long. The benefits of practicing in a rural area far outweigh the drawbacks, in my opinion. You can practice the way you want with little/no competition in an environment that is cheaper to live in. Sounds like a win-win to me. EP

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39 Volume 16 Number 4

PRACTICE SPOTLIGHT

Dr. Mona Haghani finds work-life balance Specialized Dental Partners brings mentorship and guidance that allows this endodontic practice to grow

r. Mona Haghani is a smart, driven, and highly accomplished endodontist. And she’s quick to attribute her success to knowing the right time to lean on others for help and guidance. Dr. Haghani is a partner at the Endodontic Center in Stoughton, Massachusetts, just outside of Boston. A native of Iran, she moved to Canada at 17 and stayed until she completed her undergraduate studies. Dr. Haghani then moved to the states to attend dental school and complete her endodontic residency at Boston University. During her residency at BU, Dr. Haghani was fortunate to work under the guidance of a faculty endodontist, Dr. Barry Jaye. He took her under his wing, partially because they shared a unique bond — both are left-handed. He recognized Dr. Haghani’s potential and mentored her extensively. “He used to come to my bay and say, ‘Let me teach you how to do this right!’” Dr. Haghani recalls with a laugh. As luck would have it, Dr. Jaye was also the original owner of the Endodontic Center. “By the time I was ready to graduate, he was saying, ‘I taught you everything you know, so come and work with us.’ He brought me to this practice in 2017 and I’ve been here ever since.” The young associate joined the Endodontic Center family and found that, not only could she lean on Dr. Jaye for help, but she could also count on established clinicians, Dr. Jose Hoyo and Dr. Maria Hoyo as teachers and mentors. “It was a true private surgery course for me,” Dr. Haghani says. “I would get into cases and have trouble, so I would pick their brains, and Maria sat next to me and assisted with surgery. It gave me confidence, and I grew exponentially that first year.” Just 2 short years later, in 2019, Dr. Haghani took charge as the third owner of the 40-year-old practice, determined to protect Mona Haghani, DMD, graduated cum laude from Boston University School of Dental Medicine (BU). She then pursued post-doctoral training and received her Certificate of Specialty in Endodontics as well as Master of Science in Endodontics from BU. Dr. Haghani was named a Diplomate of the American Board of Endodontics in 2019 and is also a Fellow at Royal College of Dentists of Canada. Her research was awarded from the American Association of Endodontists, where she studied cone beam computed tomography use in endodontics. Dr. Haghani is a member of the American Dental Association, a Specialist Member of the American Association of Endodontists, and the Massachusetts Dental Society. Outside of endodontics, Dr. Haghani’s passions include yoga, skiing, and above all, spending time with her family. Disclosure: Dr. Mona Haghani is a partner of Specialized Dental Partners.

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Above: Dr. Mona Haghani puts a patient at ease before a root canal. Left: Dr. Mona Haghani (L) with her practice partner and teacher, Dr. Maria Hoyo (R).

its stellar reputation and maintain its legacy in the community. Dr. Haghani says their practice is unique due to their unwavering commitment to patient needs and their referring offices. They prioritize comfort and security, ensuring that patients leave with a positive experience. To that end, the Endodontic Center added a periodontist to their team roster in 2020. “It makes the process really easy and streamlined for the patient,” Dr. Haghani says. “If a patient is in my chair, numb, and the tooth needs to come out, we don’t refer them out and give them more hoops to jump through.” Looking ahead, Dr. Haghani envisions a fully integrated practice with several specialties under one roof and believes adding an oral surgeon is the next logical step. Dr. Haghani is more than just an accomplished, forward-thinking endodontist — she’s a mother to two children, ages 6 and 3, which has played a key role in her recent professional decisions. “This is a very large practice. I have two little kids, and for me to manage both life and the practice, I needed to find a balance — I needed help,” Dr. Haghani remembers. Help came in the form of joining Specialized Dental Partners, a Specialty Dental Service Organization that champions endodontists, periodontists, and oral and maxillofacial surgeons, and believes wholeheartedly in the integrated care philosophy, in 2021. “The difference in my personal life is huge — my stress level has completely changed,” she says. “I’m home early enough to spend time with my kids.” “I have a real balance now. I can be a professional; I can be endodontist and a great clinician, but I’m a mother first right now. I could not have that without Specialized Dental.” EP

40 Volume 16 Number 4

Specialized is energized. Dr. Tyler Peterson, Metropolitan Endodontics Partner and believer since 2021 Dr. Mark Palo & Dr. Vince Penesis Oakbrook Endodontics Associates Partners and believers since 2021

Welcome to the future of oral health care. Energized care.

Elevate patient experiences with unparalleled support.

We were the first specialty DSO to champion endodontists and remain committed to the specialty—now, we’re expanding our impact and welcoming periodontists and oral surgeons to our community to revolutionize oral health care. Together, we’re delivering world-class patient experiences and creating brighter tomorrows for all.

Learn more about the partnership opportunity for Endodontists at specializeddental.com

Energized excellence.

Advance oral health care with innovative technologies.

Energized connection. Thrive in a community of growth-minded peers.

Energized future. Secure your legacy while doing what you love.

The Champion of Specialists