Endodontic Practice US September 2012 Vol. 5 No. 5

PROMOTING EXCELLENCE IN ENDODONTICS

!"#$"%&"'()*$+&"',-./-,0,1+2,3,,4+,3

!"#$%&'()*(+,$*-,('-",%'./'+0%1$%)$%&'-2)+"1$0%'+,-2$1('!-,'#-",3

!""#$%&#'()*%*+"#&#+%,*-&./*0'"*.(1'1'(&#+*-2++.--3"4*3%(#.,*5,6((

7#'+."%8#+-*#(*.(1'1'(&#+*-2"$."6)*%*+,#(#+%,*".9#.:3"-4*3.((#-*7"%9.;*<.((.&=*<'+=*%(1*>,,.(*>,#*?%--.=

@'/*&.(*&#/-)

@#/*(28A."*B*C*D%1#'$"%/=63"4*@'(6*3"2&&8%(

E"%+&#+.*/"'0#,.3"-4*F%8.-*%(1*G2-%(*H',+'&&)*%*16(%8#+*12'*#(*.(1'1'(&#+*/"%+&#+.

Volume 5 Number 5 Endodontic practice 1

Introduction

Perspective on pain controland positive rapport

Helping people through comfortable, professional, and caring endodontic therapy providing IV sedation, oral sedation, and nitrous oxide analgesia

The glossy photos of happy people that grace dental magazine advertising are attractive, but less than representative of the patients that face dental professionals in the chair, especially

with regard to their endodontic needs. One of the challenges we face on a daily basis is the anxious patient. Such anxiety ranges from so mild that it is often unspoken, all the way to patients who cannot have treatment without deep sedation. For both patient and doctor, having a good endodontic experience is a function of both adequate pain control (from a pharmacological standpoint) and a positive rapport, especially with anxious patients. Patients may behave and say things under dental stress that they might never do in more casual surroundings. For the endodontist, this is tough because we meet multiple patients per day with the same issues with whom we must build trust, while often having only met the patient once and having a limited amount of time to both make the patient comfortable and perform the treatment. It’s easy to get burned out. Over the years, I came to appreciate that patients do the best they can in the dental environment given their personal histories, and I do not take things personally when they are uncooperative. Being personally frustrated at patients or the situation is unproductive. With time, I gained perspective and developed several strategies for dealing with this common challenge, and some of them are shared below:

1) My staff and I spend a lot of time listening. While we may hear the same story again and again – how past traumas have made patients fearful, we let patients tell us their stories. It is our goal to let them feel heard. 2) Our informed consent is comprehensive; there is rarely a surprise, clinical or financial. 3) I assure patients that they are going to get profoundly numb, or we will not treat them – end of story. And we keep our promise. We never operate in the netherland of partial anesthesia, regardless of the clinical situation. Using the STA device (Milestone Scientific) and the X-tip (Dentsply Tulsa Dental Specialties) have been very helpful in this regard. We routinely use the STA device for PDL injections along with block and infiltration anesthesia. The X-tip is used less frequently, but when indicated, it settles the issue once and for all. 4) In March of 2011, I took my IV sedation training at the Medical College of Georgia. I have found IV sedation to be predictable, safe, and provide peace of mind. In my hands, having provided oral sedation and IV sedation, I prefer IV because the level of sedation can be titrated if the technique is performed correctly. One other benefit to providing IV sedation is the additional training in medical assessment and risk as well as algorithms for medical emergencies. Personally and for the staff, while we make every effort to avoid such emergencies, should one occur, whether the patient is sedated or not, our response is well rehearsed.

Regardless of how plush our offices are, whether we use heat-treated nickel titanium or standard nickel titanium, have a cone beam or lack one, how patients feel about their experience with us is essential for the prosperity of our practices. This “prosperity” has many components, only one of which is financial. A happy patient is priceless. A happy patient also makes a happy referring doctor and makes the experience of treating patients much smoother and more fulfilling for the endodontist (and all clinicians) providing the service.

Rich Mounce, DDS

Dr. Mounce is in full-time practice as an endodontist in Rapid City, South Dakota. He is the owner of MounceEndo, LLC, an endodontic supply company specializing in bulk purchases of rotary nickel titanium and stainless steel hand files, opening November 1, 2012. [email protected]. www.MounceEndo.com.

ASSOCIATE EDITORSJulian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICDRichard Mounce DDSClifford J Ruddle DDS

EDITORIAL ADVISORSPaul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCDProfessor Michael A Baumann Dennis G Brave DDSDavid C Brown BDS, MDS, MSDL Stephen Buchanan DDS, FICD, FACDGary B Carr DDSArnaldo Castellucci MD, DDSGordon J Christensen DDS, MSD, PhDB David Cohen PhD, MSc, BDS, DGDP, LDS RCSStephen Cohen MS, DDS, FACD, FICDSimon Cunnington BDS, LDS RCS, MSSamuel O Dorn DDSJosef Dovgan DDS, MSTony Druttman MSc, BSc, BChDChris Emery BDS, MSc. MRD, MDGDSLuiz R Fava DDSRobert Fleisher DMDStephen Frais BDS, MScMarcela Fridland DDSGerald N Glickman DDS, MSKishor Gulabivala BDS, MSc, FDS, PhDAnthony E Hoskinson BDS, MScJeffrey W Hutter DMD, MEdSyngcuk Kim DDS, PhDKenneth A Koch DMDPeter F Kurer LDS, MGDS, RCSGregori M. Kurtzman DDS, MAGD, FPFA, FACD, DICOIHoward Lloyd BDS, MSc, FDS RCS, MRD RCSStephen Manning BDS, MDSc, FRACDSJoshua Moshonov DMDCarlos Murgel CDYosef Nahmias DDS, MSGarry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFAWilhelm Pertot DCSD, DEA, PhDDavid L Pitts DDS, MDSDAlison Qualtrough BChD, MSc, PhD, FDS, MRD RCSJohn Regan BDentSc, MSC, DGDPJeremy Rees BDS, MScD, FDS RCS, PhDLouis E. Rossman DMDStephen F Schwartz DDS, MSKen Serota DDS, MMScE Steve Senia DDS, MS, BSMichael Tagger DMD, MSMartin Trope, BDS, DMDPeter Velvart DMDRick Walton DMD, MSFranklin S Weine DDS, MSDJohn Whitworth BchD, PhD, FDS RCS

Contents

!"#$%&$'()"*+&,'Through the keyholeDrs. James and Susan Wolcott: A dynamic duo in endodontic practice

-*")*"#%'()"*+&,'GendexImaging excellence since 1893

-,&.&$#,Irrigation: a critical step for endodontic successDr. Daniel Flynn discusses the role of irrigation and its importance during endodontic treatment

A novel endodontic cleaning and shaping approachDr. James Prichard explains his preferred cleaning and shaping methods

/.0*0*.%&$1(&.(+*$21Top ten tips: Tip number 3 – RadiographyIn his third article of the series, Dr. Tony Druttman discusses imaging methods

-*.%&.2&.3('02$#%&*.Bioceramics in endodontic surgery: a clinical reviewDrs. Dennis Brave, Kenneth Koch andAllen Ali Nasseh illustrate the benefits of bioceramics

The effectiveness of four irrigating solutions in root canal cleaning after rotary instrumentationDrs. Jorge Paredes Vieyra, Jiménez Enríquez Francisco Javier, Gaspar Núñez Ortiz, and Alejandro Alcantar Enríquez evaluate the debris removal ability of four irrigating solutions during root canal instrumentation

13

2 Endodontic practice Volume 5 Number 5

8

8

13

16

16

20

22

26

32

September/October 2012 - Volume 5 Number 5

MISSION STATEMENTTo be a practical journal promoting excellence inendodontics by providing a full range of clinical,continuing education, practice management, andtechnology articles written by leading specialists.

PUBLISHERLisa Moler Email: [email protected]: (480) 403-1505

MANAGING EDITORMali Schantz-FeldEmail: [email protected]: (727) 515-5118

ASSISTANT EDITORKay Harwell FernándezEmail: [email protected]

PRODUCTION MANAGER/CLIENT RELATIONSKim MurphyEmail: [email protected]

NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: [email protected] Tel: (619) 459-9595

E-MEDIA MANAGER/GRAPHIC DESIGNER Deidra Cole Email: [email protected]

PRODUCTION ASST./ SUBSCRIPTION COORDINATOR Lauren Peyton Email: [email protected]

CONTRIBUTORSJulian Webber (Editor-In-Chief/UK Edition) Email: [email protected]

Richard Mounce Email: [email protected]

Cliff Ruddle DDS Email: [email protected]

Pierre Machtou DDS, FICD

POSTAL ADDRESSMedMark, LLC15720 N. Greenway-Hayden Loop #9Scottsdale, AZ 85260Tel: (480) 621-8955Toll-free: (866) 579-9496Fax: (480) 629-4002

SUBSCRIPTION RATESIndividual subscription1 year (6 issues) $99 3 years (18 issues) $239

Toll-free: (866) 579-9496Email: [email protected]: www.endopracticeus.com

© FMC, Ltd 2012. All rights reserved. FMC is part of the specialist publishing

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

Contents

PROMOTING EXCELLENCE IN ENDODONTICS

!"#$"%&"'()*$+&"',-./-,0,1+2,3,,4+,3

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

!""#$%&#'()*%*+"#&#+%,*-&./*0'"*.(1'1'(&#+*-2++.--3"4*3%(#.,*5,6((

7#'+."%8#+-*#(*.(1'1'(&#+*-2"$."6)*%*+,#(#+%,*".9#.:3"-4*3.((#-*7"%9.;*<.((.&=*<'+=*%(1*>,,.(*>,#*?%--.=

@'/*&.(*&#/-)

@#/*(28A."*B*C*D%1#'$"%/=63"4*@'(6*3"2&&8%(

E"%+&#+.*/"'0#,.3"-4*F%8.-*%(1*G2-%(*H',+'&&)*%*16(%8#+*12'*#(*.(1'1'(&#+*/"%+&#+.

Cover image courtesy of Dr. Daniel Flynn

38

51


46

!"#$%&'&()Cone beam CT and endodonticsDr. Richard Kahan

Three smart ways to upgrade your radiography in today’s economyBryan Delano discusses creative techniques for investing in innovative technologies

*"+,-#"./+&0-'"Alternatives to third party financingDentalBanc discusses its payment model that can improve case acceptance and increase profits by 10% or more by providing flexible, no-interest payment options

1+&23#4./+&0-'"A closer look at Seiler microscopes and LED illumination

Redefining endodontics: Bioceramic technologyEndoSequence® BC Sealer™ and Root Repair Material (RRM™)

RVG sensor technologyCarestream Dental celebrates 30 years of RVG digital radiography

1+5#4-#".65%5("6"%4Hiring the right peopleDr. Rick Steedle

Materials & equipmentDiaryRuddle on the radarEndo restorative considerations

38

44

46

48

50

42

51

54

5655


Practice profile

!"#$%&#'%()*%$+,,%*-%#.)*$%()*/%.#&01/)*'23!"#$%&'We took very different paths to get here. I grew up in Albuquerque. My mom, an RN and a certified clinical research coordinator and my dad, an analytical spectroscopist who worked in Nuclear Weapons Surety at Sandia National Laboratories, impressed upon me, at an early age, the importance of education and a strong work ethic. This led me to start dental school at the age of 20, and while my clinical skills were evident, the lack of maturity impacted my academics. Subsequently, I found myself in the bottom half of the class and unable to secure a spot in an endodontic program upon graduating. Instead, I spent the next 4 years proving my mettle doing a year in private practice, a 2-year general practice residency (where I was invited back to be chief the second year) and a year teaching full time at the University of Tennessee before finally getting the call to become an endodontic resident at Albert Einstein Medical Center in Philadelphia. In hindsight, having to climb out of this proverbial “hole” I had dug for myself is probably one of the best things that ever happened to me. Spending the next 4 years not being able to do what I really wanted to do steeled my resolve to become an endodontist. Having learned the importance of commitment, my fellow resident Dr. Patrick Dahlkemper and I became one of the most decorated endodontic classes AEMC ever produced, including winning the AAE’s top resident award for an oral presentation. ()%"*& I grew up in a small beach town on the east coast of Florida and am the oldest of three children. After attending college in Florida, I took 5 years off to race mountain bikes professionally. Although I was a sponsored professional rider, I also worked as a dental assistant in various offices in Colorado, one of them limited to the practice of endodontics. My father passed away in the late 1990s, and before he did, I made a promise to him, as well as myself, that I would fulfill my original dream of becoming a dentist. I returned to academics to pursue my DDS at the University of Colorado, and in contrast to James, was one of the “older” students in my class. At the time, the only post-doctorate program that Colorado offered was a GPR, so the dental students were afforded an overabundance of procedures and experiences, including endodontic procedures. After performing my first root canal

treatment on a real patient at the end of my second year of dental school, I knew that endodontics was my calling. Fortunately, I was lucky and was accepted into an endodontic residency immediately following completion of dental school and attended the Boston University Goldman School of Dental Medicine’s post-doctorate program.

4-%()*/%5/#&$6&+%,676$+2%$)%+'2)2)'$6&-3()%"*& Yes, we are both board-certified endodontists. In our previous community, some of the endodontists also placed implants, including us. However, this is not the norm in our new community. Thus, while we don’t currently place implants, we do offer our patients extractions, socket preservation grafts, etc., which can save them an additional surgical procedure, especially when non-restorability is determined mid-procedure.

!"(%262%()*%2+&62+%$)%8)&*-%)'%+'2)2)'$6&-3!"#$%& It was my sophomore year of dental school in the endodontic pre-clinic lab where the class was working on extracted teeth. Any dental student who has had to find good extracted teeth knows how difficult this can be; suffice it to say I showed up with a particularly curvaceous molar, to which one of the faculty predicted I would “screw it up.” Well, I’m a tad competitive, and to make a long story short, it turned out nicely. At this point, it occurred to me that I may have found my calling. Beyond that however, being a specialist with its commensurate pros and cons appeals to me. I am driven to try to be the best at something, even if it is only one thing. ()%"*& As for me, as I already mentioned, I assisted in an endodontic group practice before beginning dental school. Witnessing a patient’s demeanor change from fear and anxiety to happiness because his/her pain was alleviated by having root canal therapy intrigued me. Of course, the question remained, “Could I do it when I was the one on the other side of the chair who was responsible for rendering treatment?” Luckily, that first root canal in dental school went smoothly enough (as few things rarely go smoothly in dental school) to solidify my desire to become an endodontist. Everyone knows root canals get a bad rap. It is

+,-.)/,'0,$'1$2,.'$3-%4'!"#$%'"*5'()%"*'6.78.00!"#$%&'()"#*+"(%",%#+#+%-()"./&)-(),"


Practice profile

so gratifying for me to be able to ease patients’ fears about their treatment and help them save their natural teeth. I want to do my part to make root canal treatment a positive dental experience!

!"#$ %"&'$ ()*+$ ,"-$ .++&$ /0)12313&'4$ )&5$ #()2$6,62+76$5"$,"-$-6+8!"#$%& Well, I’ve been a dentist for 20 years now, limited to endodontics for the last 16 years. Meanwhile, Susan graduated from dental school in 2003 and went directly to her specialty training, and has done only endodontics since. I was a partner in a large specialty practice, and upon completing her training, Susan joined the same practice. However, in 2009, we were blessed with a wonderful surprise, our son, Oliver. Shortly thereafter, it became obvious that a large group practice is not right for everyone, and we decided that it was time for a change. We chose New Mexico because obviously, it is my home, but it is also much closer to a set of grandparents! This also allowed us to start our own business where we could practice at the highest level of our specialty and not under group-setting restraints. The rotary method that we use the most is the ProTaper® Universal system. We were both trained using the operating microscope, so Zeiss plays a large role in our day-to-day operating system. We are a paperless office so all of our charting and radiographs are digital. We are very fortunate in that in our community most of the referring doctors would prefer their endodontist to place the necessary restoration after the root canal therapy is complete. Our favorite fiber post and core system is a new system that we are beta testing for Dentsply Caulk.

9()2$20)3&3&'$()*+$,"-$-&5+02):+&8'(%")& Again, we are both Diplomates of the American Board of Endodontics, which is to say we are committed to continuing education. Aside from accumulating our own CEUs beyond local requirements, we also periodically offer half-day courses to our referring doctors on a variety of topics. We are invited occasionally to lecture in academic settings. This year, James gave two lectures at the AAE’s Annual Session, as well. Furthermore, while the majority of our CE hours are endodontic specific, there are a fair number of hours gleaned from other disciplines such as periodontics, surgery, prosthodontics, etc., to make sure we maintain a functional awareness of what others on the team are doing. In fact, a few years ago, both of us completed, and continue to maintain, implant certification from our liability carrier (an additional 64 hours of rigorous implant-specific CE) so that we are better positioned to help our patients

faced with choosing between root canal treatment and implant treatment. Our commitment to lifelong learning enables us to collaborate with our dental colleagues to provide the best treatment plans in the best interests of our patients.

9("$()6$3&6/30+5$,"-8!"#$%& I have been blessed with many exceptional mentors. Taking the circuitous route in my dental education afforded me the opportunity to form relationships with many exceptional dental educators. Each was a mentor with a different story to tell, including Drs. McCoy, Wilson, Averbach, Kleier, Himel, Rossman, and Hicks. Each one of them encouraged me to develop my skills as a teacher and a clinician, as well as give back to my profession. I wanted to be just like them. Also, while I didn’t have the same personal relationship, there were three others I feel fortunate to have as part of my endodontic program: Drs. Bender, Seltzer and Trowbridge. However, the person that pushes me every day to be the best endodontist I can is my wife. '(%")& I too, was fortunate enough to have Drs. Don Kleier and Bob Averbach as mentors at a very early stage in my career, dental school. In fact, these two were so encouraging, that from a small graduating class of 37, they inspired six of us to become endodontists! I also owe a great deal to Dr. Jeff Hutter for accepting me into BU’s endodontic program and to Dr. Lou Rossman who helped me numerous times along the journey. Of course, I would be remiss if I did not mention my husband. He was already an endodontist by the time we met, and his reassurance and support were invaluable to me while I was in my program. He still inspires me today. He is one of the most passionate, knowledgeable, and adept clinical endodontists that I have ever had the good fortune to know, and I am lucky that I get to call him my partner!

9()2$36$2(+$7"62$6)236;,3&'$)6/+12$";$,"-0$/0)1231+8!"#$%& Being able to pursue my profession with my spouse by my side and having the autonomy to be able to choose to do it right. '(%")& How do I say it any better than that?

<0";+663"&)%%,4$#()2$)0+$,"-$7"62$/0"-5$";8!"#$%& Aside from the obvious, that I have the opportunity to help others on a daily basis, I would say it’s a tossup between being board certified and my appointment to the Journal of Endodontics editorial board. Simply put, giving back to my specialty was something impressed on me by several of my mentors, and as such

Truly the practice’s strength – Annette (clinical assistant), Julie (clinical as-sistant), Lynda (financial coordinator), Veronica (seated) (office manager).

Reception area with hues, textures, and tones that reflect our community

Our attempt at the KISS principle and keeping our patient’s field of view clutter free


Practice profile

I have published, taught at both the pre- and post-doctorate level, and served on several AAE committees. In fact, I would argue that the single best way for any endodontist to give back to the specialty is become board certified. By definition, without a Board there is no specialty, and without Diplomates there is no Board. Personally though, of all these activities, the one that is arguably the hardest, most time-consuming, and by far the most rewarding is my role as one of 11 JOE associate editors worldwide. Indeed, of the entire editorial board, only a couple of us are full-time private practitioners. Thus, while all of us, clinicians, educators, researchers, students, etc., all play a vital role in the health of the specialty, I am in a unique position to help represent clinicians as it relates to our Journal (might I add, the highest ranking endodontic journal for the last 7 years and ranking in the top 10 of all dental journals for that same time period. AAE members should be proud of their journal!). !"#$%& He keeps stealing my answers. I agree with James’ assessment that the best way to give back to your specialty is to become board certified. It is a long and arduous process, but the reward is an overwhelming sense of pride. There is no monetary “payback.” Most patients and referrers do not know (or possibly care) that you are boarded…but YOU know. You have been through the process and came out alive on the other side. I cannot describe the feeling that you get when you receive that letter from the ABE letting you know you have passed, but nothing else (professionally) has given me the joy that becoming board certified did. Another thing that I am extremely proud of is our new practice. It isn’t the fanciest or the largest, but it is ours. Coming out of a residency and going straight into a group practice left me a little naïve. The “machine” was already running, and I just had to step in and start doing root canals. There was never any brain damage as to whether or not I could provide for myself and my family. All of that changes when you embark on setting up your own practice. Will there be enough patients? Do we have enough working capital? How in the world do you file insurance? The logistics behind the things that I took for granted in a group practice were a nightmare to circumnavigate! However, the reward of this is so much more than I imagined, and I applaud all of those who have done this before me!

!"#$%&'%(')%$"*+,%*-%)+*.)/%#0')$%(')1%21#3$*3/4!"#$%& It is unique that we are spouses practicing in the same office. Because there are two of us at start-up, we are able to fully book one schedule and leave the other open for emergencies. Solo practicing endodontists do not always have that luxury.

!"#$%"#-%0//+%(')1%0*55/-$%3"#66/+5/4'$()#& Starting a new practice after already carrying the mantle of an existing practice is not what most of us bargain for. Transitioning from established endodontists back to the new kids in town in such a tightly knit community is a tad humbling. Furthermore, since my wife and I practice together, when we decided to relocate to New Mexico, it meant introducing two endodontists to the community simultaneously. !"#$%& The biggest challenge I have is common to most working parents, and that is balancing my career and raising our child. The facts are simple: I love both of these, and I would not change the path that I have chosen. Women are great at multitasking!

!"#$%7')6&%(')%"#8/%0/3'9/%*:%(')%"#&%+'$%0/3'9/%#%&/+$*-$4'$()#& An architect. I’ve been told some of them get to work from home. There are days when that sounds pretty good… !"#$%& When I was very young, I thought I might go into veterinary medicine. Now we have two very rambunctious Viszlas, and I am glad I changed my mind (with much respect to veterinarians)!

!"#$%*-%$"/%:)$)1/%':%/+&'&'+$*3-%#+&%&/+$*-$1(4'$()#& While it is always hard to predict the future, the good news is that endodontics historically has not rested on its laurels. The AAE was very proactive years ago to establish the Foundation, which is now paying dividends by helping support research on the future of endodontics. Innovations such as regenerative endodontics shine bright on the horizon. So while there seem to be other treatment modalities that are perceived as being the “latest and greatest,” endodontics has not been idle. Rest assured, we do not perform root canal therapy the same way we did when we graduated from our programs. A good, albeit dated, example would be the advent of MTA, which has become commercially available since I graduated from my program. A trend that we find promising is the increasing focus on the biological aspect of endodontics not just the mechanics (i.e., just another file design).

!"#$%#1/%(')1%$'2%$*2-%:'1%9#*+$#*+*+5%#%-)33/--:)6%21#3$*3/4'$()#& There seems to be a never-ending barrage of “experts” who are willing to share their ideas about what makes a successful practice. While some have merit (the AAE’s practice promotion resources as well as some top tier practice consultants), many are simply presented as page filler between full page ads in non-peer

Intense case discussions (i.e., whose turn is it to make dinner?)We were fortunate to be able to provide our staff a spacious sterilization room

reviewed journals. At the end of the day, all of the buzz words and catch phrases aside, it is the drive to deliver the best ethical patient care possible that helps us sleep at night and makes us want to come to work tomorrow.

!"#$%& We have been very proactive in getting our practice up and running; we know we can’t just wait for patients to walk through the

door! As James said earlier, we are the new kids in town, and we’re working hard to build partnerships and trust throughout the Santa Fe dental community. We’re readily available for patient consults and emergency treatments, and we welcome the opportunity to provide specialized care that puts patients at ease, and allows dentists to focus on the core parts of their practice they enjoy most. '$()#& With our new practice, every patient is an audition for the next patient.

!"#$%&'$#"()*+,$-",.-%.($&'$&$%/'0&+1$&+1$#*2.$-.&3$&22.4-.1$5"/($6(&4-*4.$'-57.8$'$()#& I would say Susan helps temper me. Or to put it another way, we complement each other nicely. We each have our strengths and weaknesses, and fortunately they are different. Thus, we rarely find ourselves butting heads as it relates to the practice. In fact, without specifically assigning tasks, overseeing the remodel build-out fell to me, while the staffing and equipping found its way to my wife. !"#$%& Of course, I agree with the first statement above. As I said earlier, I think James is one of the best clinical endodontists that I know. We are all aware, of course, that there is more to endodontics than seeing pretty white lines on a radiograph. If I encounter a clinical situation that leaves me perplexed, I know that I can go to James, and he will give me an educated opinion, not an empirical one. The man knows the literature!

9%&-$&1:*4.$#"/71$5"/$,*:.$-"$0/11*+,$.+1"1"+-*'-'8'$()#& Always strive to improve. Compromise and complacency are more beguiling than you think.

9%&-$&(.$5"/($%"00*.';$&+1$#%&-$1"$5"/$1"$*+$5"/($'6&(.$-*3.8'$()#& I’m a gearhead, albeit on a budget. My dad and I restore, drive, and race vintage Porsche 914s. We have several in various states of repair from a Concours winning 914-6 to a fully-caged, vintage club racer. Additionally, to get my fix of racing at the top level, I volunteer with The Racers Group in Grand-Am Rolex competition, where every year I am one of their extra driver changer specialists for the Rolex 24 at Daytona. I also volunteer for McMillin Racing, every year at the Baja 1000 as a chase crew member. The McMillins are indeed a superlative team with exceptional values. My annual trek to Baja every November is truly the high point of my year. !"#$%& Besides spending time with our son and two Viszlas, I like to shop, although with the opening of this new practice, that

Top Ten List

The following are the top ten articles that have impacted how we practice, each in its own unique way.

1. Abbott JA, Wolcott JF, Gordon G, Terlap HT. Survey of general dentists to identify characteristics associated with increased referrals to endodontists. J Endod. 2011 Sep;37(9):1191-6.An evidence-based approach should apply to all that we do, including how we interact with our fellow professionals.

2. Baumgartner JC, Xia T. Antibiotic susceptibility of bacteria associated with endodontic abscesses. J Endod. 2003 Jan;29(1):44-7.While probably dated even now due to the explosion of DNA techniques, the study was still a strong reminder that newer doesn’t necessarily mean better.

3. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone: I and II. J Am Dent Assoc 1961;62:152-60 and 708-16.While imaging continues to progress, the underlying lessons of these two articles remain valid: there are always limitations to our tools and technologies. Our best diagnostic tool remains between our ears.

4. Bender IB, Seltzer S, Soltanoff W. Endodontic success–a reappraisal of criteria. I and II. Oral Surg Oral Med Oral Pathol. 1966 Dec;22(6):780-802. More than 40 years ago, these authors proposed more pragmatic success criteria based on function more so than radiographic. Yet, this concept has been seemingly overlooked until recently when the implant literature touted its superiority to the natural dentition using survival as its mantra. Subsequently, authors, such as Iqbal and Kim (noted below), spoke to leveling the playing field as it relates to appraisal of “success.”

5. Iqbal MK, Kim S. For teeth requiring endodontic treatment, what are the differences in outcomes of restored endodontically treated teeth compared to implant-supported restorations? Int J Oral Maxillofac Implants. 2007;22 Suppl:96-116. Review. Erratum in: Int J Oral Maxillofac Implants. 2008 Jan-Feb;23(1):56.Although commissioned by the Academy of Osseointegration, this article shows the exceptional service that quality endodontics can still provide our patients.

6. Penesis VA, Fitzgerald PI, Fayad MI, Wenckus CS, BeGole EA, Johnson BR. Outcome of one-visit and two-visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation. J Endod. 2008 Mar;34(3):251-7.In the face of a long-standing debate, these authors invested time and energy to develop evidence at the highest level: a CONSORT Randomized Clinical Trial.

7. Roane JB, Sabala CL, Duncanson MG Jr. The “balanced force” concept for instrumentation of curved canals. J Endod. 1985 May;11(5):203-11.For us, this concept of “balanced force” opened the door to rotary instrumentation, which has fundamentally changed how we do what we do.

8. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod. 2002 May;28(5):378-83.We believe specialists should practice the breadth and scope of their specialty, which means staying abreast of evolutionary changes with all the various techniques in our armamentarium.

9. Seltzer S, Bender IB. Cognitive dissonance in endodontics. Oral Surg Oral Med Oral Pathol. 1965 Oct;20(4):505-16.Arguably our specialties’ first call to arms for an evidence-based approach.

10. Shabahang S, Goon WW, Gluskin AH. An in vivo evaluation of Root ZX electronic apex locator. J Endod. 1996 Nov;22(11):616-8.The researcher in us considers the design of this study elegant in its simplicity. Beyond combining in vivo and ex vivo aspects, it managed to harness the best of both worlds.

has been curtailed quite a bit. I like to travel, and since my family is still in Florida, my son and I visit there several times a year. I also like to garden, and I really hope to become more active with the cultural activities in and around the Santa Fe area. EP


Practice profile

Our pride and joy!

ensure Gendex excellence — FOX™ (Focus-Optimized X-ray) technology increases the depth-of-field for optimized radiographic image clarity, and the EasyPosition system stabilizes patient for clear, consistent images in a short amount of time. With real estate prices at a premium, the GXDP-300 is a space saver that can fit in a small footprint. Gendex also has invested years in sensor technology research. The newest GXS-700™ sensors are easy to use and have advanced sensor technology that enhances image quality, elevating technical and diagnostic capabilities. With sensors in size 1 and size 2, rounded corners and smooth edges, children and adults can have a more comfortable imaging experience. Ultra-portable, the sensors have high-speed USB 2.0 connectivity and no need for USB controllers, adapters, or docking stations.

!"#$%&'%()*++*$,-".,/Filippo Impieri, Director of Marketing for Gendex, notes that staying current with various digital imaging technologies can help practices to differentiate themselves with patients in the current competitive environment. He says, “Digital radiographs and 3D scans, with their ability to be projected on a large computer monitor, give the clinician the opportunity for improved patient education and communication. Having a digital system cuts down on the time the patient spends in the chair taking x-rays, speeding up the office workflow and allowing for the doctor to spend more time chairside.” Dentists who have the additional information obtained with 3D imaging also proceed into surgery with increased confidence in a successful treatment outcome.

!0&1."1)2.,3)&)4.'.*"For nearly 120 years, dental professionals have strived to advance the quality of dental care by investing in Gendex panoramic x-ray systems. Then and now, Gendex’s mission has remained the same: to deliver reliable and innovative imaging solutions to dental professionals so that they can provide the quality of care their patients deserve.

This information was provided by Gendex.

Gendex has a great accomplishment to celebrate in 2013 – its 120th anniversary of excellence in imaging.

5.#3)3.',*$/The Gendex legacy started in the late 1800s with the Victor X-ray Corporation, which developed a device that yielded more consistent exposure, and as a result, more consistent X-rays at an affordable price point. In 1923, parent company, Victor Electric was acquired by the General Electric Company, and during those years, the GE Medical Division began to develop intraoral and panoramic imaging. Panelipse® became the early benchmark for panoramic performance. As the result of GE dividing its medical and dental lines in 1983, The Gendex Corporation was born, followed by a series of innovative products such as the GX-Pan® panoramic, and the GX-770™ intraoral, the AcuCam® camera, Orthoralix® 8500 and 9200 series of panoramic, DenOptix® PSP system, and VixWin™ imaging software. As part of the celebration of its long-standing history, Gendex is launching a program to reward its current loyal panoramic owners by offering extraordinary savings when moving up to the latest Gendex panoramic innovations. For a limited time only, owners can trade-in any Gendex panoramic x-ray system to receive exclusive savings on any new Gendex GXDP-300™ or GXDP-700™ Series.

6-&7.,/)+$*(-#,'The Gendex GXDP-700 brings the power of 3D to endodontic treatment planning. Gendex is proud to note that the GXDP-700 offers a 4 cm x 6 cm scan size (along with its larger 6 cm x 8 cm size) that is ideal as a diagnostic tool for endodontic procedures. EasyPosition™ and PerfectScout™ features help operators to concentrate on the exact location when scanning, while the 3D software helps doctors zero in on such conditions as fractures, perforations, and resorption from all angles. The benefits of cone beam imaging have reached the endodontic specialty. Recently, the American Academy of Oral and Maxillofacial Radiography (AAOMR) and the American Association of Endodontists (AAE) released a Joint Position Statement that says, “The advent of CBCT has made it possible to visualize the dentition, the maxillofacial skeleton, and the relationship of anatomic structures in three dimensions.” The statement lists many complex endodontic conditions that are appropriate for 3D cone beam imaging. The GXDP-700 Series is a three-in-one system that has the ability to transform from 2D panoramics to cephalometrics to 3D. These images are integral to better diagnosis and treatment planning of caries, root investigation, orthodontics, implants, and other surgical procedures, as well as patient education. Besides 3D, this flexible unit offers 33 panoramic options — 11 projections for three patient sizes, two 3D volume sizes plus a dose-saving scout view, and the ability to add cephalometrics. The GXDP-300 incorporates the most commonly used imaging modes; a simple, three-step process; and a durable, sleek, compact body design. Quality panoramic images are captured by a simple three-step operation through a large LCD touchscreen interface. The image is obtained by choosing the projection, selecting the patient size, and taking the pan. Exclusive technologies

EP

Corporate profile


!"#$"%&'()*+#*&"%,"--"#,"&.+#,"&/012


Clinical

The goal of endodontic treatment is the prevention or treatment of diseases of the dental pulp and the periapical tissues.

Endodontic treatment is a predictable modality. Clinicians can enjoy success rates of up to 96% when sound biological approaches are followed. Once the correct diagnosis has been made, and root canal treatment has been initiated, irrigation is the key to success. In vital cases, i.e., elective cases or where a diagnosis of reversible or irreversible pulpitis has been made, the role of irrigation is to:

In vital cases, the canal system is not infected; therefore, it is imperative to use a rubber dam so that contaminants are not introduced into the canal. Ideally, a four-walled chamber is created so that the irrigant may be contained in the canal system. E. faecalis is one of the most common isolates found in retreatment cases. This bacterium is resistant to killing when present in very large numbers, although it is easily killed in small numbers. It is possible that many vital cases fail due to the introduction of bacteria during treatment. Saliva has millions of bacteria which, when introduced to the root canal system, can become pathogenic. If you are obturating and can see saliva seeping into the canal system, this means bacteria are contaminating the area despite your best efforts

essential for the success of endodontic treatment.

!"#$%&'$()(Sodium hypochlorite (NaOCl) is the irrigant of choice for vital cases due to its tissue-dissolving ability. The higher the concentration, the greater the dissolution capacity. For vital cases, use 3% hypochlorite. You can also heat the hypochlorite to 60°C or use ultrasonics to activate it to increase its activity. In infected cases, the role of irrigation includes the above, plus:

When using hypochlorite, it is vital to respect this chemical.

rapidly. It has a foul taste if it leaks into the patient’s mouth. The irrigating needle should never be bound in the canal, which forces solution towards the apical tissues. This can cause a hypochlorite accident leading to immediate severe pain and swelling, followed by facial bruising. The idea that bacteria, causing apical disease are free floating in the canal has been superseded by the realization that, in reality, the bacteria are attached to the canal walls in a thick

an image of the bacteria lining the canal walls. Studies have shown endodontic instruments touch only around 50% of the walls. Therefore, if 50% of the walls are not touched by the instruments, it is only the irrigants that can disinfect these areas. Canals are not round in cross section, and the preparation should be viewed as a means of getting access for the irrigation to the source of infection. I will open the canals to at least a size 25 apically before gauging to

determine the optimum apical size. Sizes smaller than 25 do not allow an adequate flow of irrigant to the apical areas. The wider the taper, the better the flow of irrigant. This must be balanced

Following preparation, I spend at least 20 minutes irrigating the canals. I also use ultrasonics and the gutta-percha cones to

not touched by instrumentation. Ultrasonics work by acoustic streaming and cavitation, crashing the irrigant against the walls where the bacteria are attached, like waves beating a coastline. This has been shown to be more effective at bacterial removal than passive irrigation alone. One should always realize that the irrigant also only passes 1 mm beyond the tip of the needle. So, if the tip

into the depths of the canal. I have never understood why some

compared to sodium hypochlorite. It only works as an anesthetic agent if it is applied under pressure, and the needle needs to be

a 0.5% concentration, is effective at killing bacteria. Studies have suggested that it is equally effective at removing bacteria at this concentration as at higher concentrations. The tissue-dissolving

!""#$%&#'()*%*+"#&#+%,*-&./*0'"*.(1'1'(&#+*-2++.--3"4*3%(#.,*5,6((*1#-+2--.-*&7.*"',.*'0*#""#$%&#'(*%(1*#&-*#8/'"&%(+.*12"#($*.(1'1'(&#+*&".%&8.(&

Daniel Flynn, BDentSc, MFDS, RCSI, MClinDent, MRD, qualified from the Dublin Dental Hospital, Trinity College, in 2002. He has joined the EndoCare team, headed by Dr. Michael Sultan. Dr. Flynn teaches endodontics at the Eastman Dental Institute for Oral Healthcare

Sciences in London, England. For more information, contact EndoCare at 011 20 7224 0999, email [email protected], or visit www.endocare.co.uk.

Figure 1: Four-walled chamber, which contains irrigants andprevents contamination

Clinical

power increases as the concentration increases, and a concentration of 1% is required to dissolve necrotic tissue and around 3% to dissolve vital tissue. This dissolving capacity depends on:

!"#$%&'()#%*+$(#,#'-(

when we achieve good technical results; however, cases where the

Figures 2 and 3: Early colonization of dentin by bacteria. Note the way they can grow into the tubules

Figure 4: Smear layer and debris present on dentin Figure 5: The effects of NaOCl and EDTA on dentin

EP

Endodontic practice

!""#$%&'()*'$+%&#,+(#)&"-#.+(#/(+,"&&$+%01#)&"#+%12#34')(0#!/0('0%#5%6+6+%'$*&#7#889:#;"%6'#!'(""'<#=1>+%?)$%#@A#9:B:8


Clinical

Successful endodontics requires mechanical preparation of the root canal system and an efficient method of removing pulpal

tissue and microorganisms. Traditionally, stainless steel hand files have been used; however, they are time-consuming, laborious, and prone to causing procedural errors. The advent of nickel-titanium instruments has helped the practitioner consistently produce nice tapered preparations. But this is only part of the equation. Irrigant flow in root canals is fraught with problems and, as yet, there is no consensus of opinion of the correct canal parameters (apical size and canal taper) that should be prepared to give the best clinical results. Fluid dynamic research has shown that the larger the canal dimensions, the easier it is to get the irrigant to penetrate apically, which is logical. This does not, however, address the complex anatomy that is often seen in cleared teeth – that was originally demonstrated by Dr. Hess, and can also lead to unnecessary loss of tooth dentin, making it more susceptible to fracture. It is now becoming accepted that to simply use syringe delivery of the irrigant is not sufficient, but that the irrigant must also be dispersed or agitated within the canal space to make it more effective. Using rotary nickel-titanium instruments produces a large amount of debris that can be packed laterally into isthmi and lateral anatomy, thereby blocking it. The use of ultrasonic agitation of the irrigant has been shown to aid in removing this debris, thus rendering root canals cleaner.

!"#$#%&"'%&()'The patient was referred following a bout of acute toothache that culminated in receiving antibiotics from his GP. On presentation, he was no longer in pain and complained of a swelling on his gum on his lower right side that occasionally swelled up and discharged. The tooth was occasionally tender to bite on, but he was eating comfortably and had not had any significant pain since completing the antibiotic course. Clinical examination revealed a small swelling adjacent to the lower right second premolar. There was no pocketing of note, and the tooth had recently had a provisional crown placed, and did not respond to sensibility tests compared to adjacent teeth. Radiographically, the root canal showed some widening of the lamina dura both apically and about 5 mm short of the radiographic apex on the mesial aspect. The primary canal was obvious in the coronal and middle third, but became less apparent in the apical 5 mm, suggesting a bifurcation.

*+),&+&-#.$Anesthesia was achieved via buccal and lingual infiltration, the provisional crown removed, and the tooth isolated with rubber dam. On removal of the provisional crown, there was an apparent exposure of the pulp horn. The access cavity was prepared with a 541 diamond bur and refined with a safe-ended access cavity bur (Schottlander). Rotary shaping was performed with RaCe nickel-titanium instruments.

The working length (WL) was determined electronically as 22.5 mm, and the master apical size was ISO 30 (the canal was prepared to an ISO size 35). Copious amounts of 3% NaOCl (Schottlander) were used during the preparation phase.

!")&$#$/Once the shaping of the primary canal was completed, the IrriSafe™ (Satelec®) instrument was used on power setting seven on the P5 Newtron® (Satelec). Three intermittent flushes of 3% NaOCl via a 3ml Monoject™ syringe fitted with a 27g needle were made. After each flush of irrigant, the IrriSafe was inserted to 21 mm and activated for 20 seconds. Recapitulation was performed after each cycle with a pre-curved size 10 K-Flex file. During this process, the tip was rotated incrementally and advanced apically to feel for additional anatomy. Another canal was found, which exited buccally and measured electronically to 17 mm. This was subsequently enlarged to a size 25, and the cleaning procedure repeated with 3% NaOCl and IrriSafe. Seventeen percent ethylenediaminetetraacetic acid (EDTA) was introduced, allowed to soak for 60 seconds, and was also agitated for 20 seconds with IrriSafe, prior to a final flush with NaOCl.

01-2+&-#.$The master cone (size 35/.04) was fitted to length and shortened by 0.5 mm to allow for thermoplastic displacement. The main canal was dried with paper points (Schottlander) and AH Plus® sealer (Dentsply) applied to the apical 3 mm of the GP cone. This was seated to length in the canal in one single movement. An incremental downpack was performed (warm vertical

!"#$%&'"&#($($#)*+" +'&,#*#-",#("./,0*#-",001$,+/213"4,5&."61*+/,1("&70',*#."/*."01&8&11&("+'&,#*#-",#("./,0*#-"5&)/$(.

James Prichard, BDS, LDSRCS, MFGDP, DRDP, MSc, is an

endodontist at James Prichard Endodontics in Coventry,

England. He completed his undergraduate dental

training at the Royal London Hospital in 1994. He

subsequently returned to general practice. Dr. Prichard

is an associate clinical teacher in endodontics and clinical

supervisor in endodontics at the University of Warwick.

Figure 1: Photograph showing 2 ISO size 10 steel hand files with different curvature applied


Clinical

condensation technique as described by Schilder) with System B (Obtura Spartan), and the apical plug of GP was condensed with manual pluggers. The backfill was performed with Obtura II (Obtura Spartan) in three separate increments; condensing of the GP was performed as before. The final coronal seal was achieved with a composite restoration (Venus Diamond®, Heraeus Kulzer) bonded in with Clearfil™ SE Bond (Kuraray Dental). The provisional crown was recemented with flowable composite (Venus® Diamond Flow, Heraeus Kulzer), the dam was removed, and the occlusion was checked.

!"#$%##"&'The final radiograph reveals a well-condensed filling in the primary root canal, which appears flush with the radiographic apex. There are two lateral canals in the middle third of the root: one exiting distally and one exiting buccally. The presence of the mesial radiolucency had suggested a lateral portal of exit, but the distal was less obvious. The tissue-dissolving ability of the NaOCl has clearly helped in this case; however, it needed to be dispersed in to the spaces in order to be effective, which is much more difficult when syringe irrigation only is employed. The use of IrriSafe to agitate the irrigants has, in this situation, significantly improved their effect within the root canal space. There has been good penetration of the irrigants to allow improved cleaning compared with filing alone. This has allowed the obturation material to flow well in to the accessory anatomy. This challenging case would appear relatively straightforward from the preoperative radiograph, but a combination of meticulous cleaning and shaping has hopefully allowed for a successful result.

One tough foam...

Our new e-Foam® Rotary HD inserts are specially designed for cleaning rotary instruments. A rotating file secured in a hand piece can be placed directly into the

high density foam to assist in cleaning debris from rotary flutes. Our Rotary HD foam minimizes tearing

or shearing of the foam while a file is in motion. Precisely engineered to fit Jordco’s Endoring II organizer.

Jordco e-Foam Rotary HD, endodontic foam inserts, REF: ERFBHD-s (48 high density blue inserts)

Introducing e-Foam Rotary HD

The Endoring® II organizer enables the clinician to directlyplace, store, measure and clean endodontic hand and

rotary instruments within the operating field. It reduces therisk of cross-contamination and minimizes the passing ofsharps between dentist and staff. Using the Endoring II

organizer helps make endodontic procedures safer, faster and reduces patient chair time.

Endoring II, hand-held endodontic assistant, REF: ERK2-s (Premium Kit), ER2SK-s (Starter Kit), ER2-s (with metal ruler)

Joins the endodontic assistantyou’ve come to trust.

To order, please contact your dental supply dealer.

Or visit us @ www.jordco.com or call 800-752-2812

Manufactured by Jordco, Inc.www.jordco.com • TEL 800-752-2812 • FAX 503-531-3757

To view a video on Jordco’s new e-Foam Rotary HDpoint your smartphone here:

JOR_EP_AD_0912_Layout 1 8/7/12 9:29 AM Page 1

Figure 2: Preoperative radiograph

Figure 3: Postoperative radiograph showing lateral anatomy and a well-condensed filling

EP

Endodontics in focus

There is no doubt that radiography is one of the cornerstones of endodontics. We use radiographs to aid diagnosis, during

endodontic treatment, to judge the quality of the root treatment we have just completed, and to monitor healing. We live in exciting times in dental radiography. Having moved from the bisecting angle technique to the long cone paralleling technique for periapical radiography, in the last decade, there has been a shift from wet film radiographs to digital, with the quality of the digital image improving all the time. Most recently, cone beam CT scanners have been introduced to dentistry and have proven to be an invaluable aid to diagnosis. Whatever the purpose of the radiograph, the aim is to get consistently high quality images, with the minimum radiation dose, and nowhere is that more important than in endodontics. There are many ways that this can be achieved with an existing X-ray set. Interpreting the information from a radiograph is notoriously subjective; different examiners won’t always agree when examining radiographs at different times, let alone with each other. In endodontics, it is crucial that we get the best possible image (Figure 1), and that is usually achieved with the long cone paralleling technique, using some form of receptor (film or sensor) holder and aiming device. Let’s look at the variables that can help you achieve that goal:

!"#"$%&'()*+"(,-.(&'*"-%,%*&-When using films for intraoral periapical radiography, all the

or landscape orientation for the posterior teeth. There are many situations when deviating from those recommendations can prove very advantageous. Where there is a large lesion associated with an anterior tooth, the complete lesion may not be captured on a small receptor, so if there are no anatomical constraints, a large film can

If it may not be possible to capture a tooth with long

receptor because of their position in the arch, the shape of the

the vertical orientation will often overcome these difficulties

larger receptors very uncomfortable, and with some their use is

because a more parallel image can be achieved, and it may well

!"#"$%&'(,-/0"The position of the receptor can be fine tuned by altering its

!"#$%&'$%(#)*!(#$'+,-&.$/$0$123("4.2#567'$5()$%5(.3$2.%(89&$":$%5&$)&.(&);$<.=$!"'6$<.+%%,2'$3()8+))&)$(,24('4$,&%5"3)

Endodontic specialist Tony Druttman,

MSc, BChD, BSc, has extensive expertise

in treating dental root canals, resolving

difficult endodontic cases, and saving teeth

from being extracted. His two London,

England practices, one in the West End and the other

in the City of London are restricted to endodontic

treatment. www.londonendo.co.uk.

Figure 1: Long cone periapical image using a sensor holder

Figure 2A: Size 1 sensor shows tooth No. 12 with part of an associated lesion

Endodontic practice Volume 5 Number 5

Figure 2B: Size 2 sensor shows the complete lesion


Volume 5 Number 5 Endodontic practice

Figure 4A: Periapical of tooth No. 15 using a size 2 sensor

Figure 4B: Periapical of tooth No. 15 using a size 1 sensor

Figure 5A: Periapical of tooth No. 27 using a size 2 sensor

Figure 5B: Periapical of tooth No. 27 using a size 1 sensor

Figure 3A: Size 2 horizontal orientation Figure 3B: Size 2 vertical orientation

Figure 6: Slight change of horizontal angulation shows both mesial canals of tooth 46


changed when root separation is desired (Figure 6), i.e., looking at both roots of an upper premolar or both canals of a lower molar without superimposition. If the front of the receptor is angled mesially, the palatal or lingual root is thrown mesially, and the buccal root is thrown distally. Vertical angulation is changed to get a parallel view of a divergent root. Upper molars are the classic example: when the paralleling device is lined up with the buccal roots, the palatal root is foreshortened, the root tip may be cut off, and its relationship with the periradicular bone may be

be a few degrees. Excessive alteration will obscure the image, because the X-rays have to penetrate too much bone.

!"#$%&'(The only setting on the X-ray set that is likely to be altered for every patient is the exposure timer, and the guide on the control panel is used to adjust the time. This will only give a dose based on an average for the tooth type, without taking into account bone density. The X-rays are likely to have penetrated through far more bone in the maxilla of a 6-foot rugby forward than a small 70-year-old lady, so the timer should be adjusted accordingly. Often the exposure has to be increased slightly to improve image quality for endodontics.

)*+,-$'-.*/*01+The number of practitioners using digital radiography is increasing. I see that in my own practice as the number of films sent by referrers is reducing. Film has always been the benchmark of image quality and is obviously cheaper. There is, however, a continuous supply of chemicals to be bought and disposed of

responsibly. Digital radiography, on the other hand, requires a significant capital investment, but has so many advantages over film. The image quality is continuously improving. Radiographs can be read instantly and are a great communication tool. There is nothing better than showing the pre-op and post-op together or the pre-op and review image that shows healing to convince your patient that endodontic treatment is worth the investment.

a “film.”

be considered to be easier than CCD/CMOS, because the sensors have the same dimensions as film, they do not last and get easily scratched, making them progressively more difficult to read. For endodontics, and to my mind all radiography, the power of digital radiography is in the ability to read the image instantly while the holder is still in the mouth and make changes accordingly. I am an unashamedly enthusiastic user of Schick Sensors. I have used both CDR and more recently Elite sensors, and I use

The technique I use is a follows:

teeth in relation to other anatomical structures, shape of the palatal vault, curvature of the arch, presence of tori, etc.

have to be much more accurate).The patient’s height is sometimes a good indication of the length of the roots.

density.

the timer.5. While the device is still in the same position (tell the patient not

Endodontic practice Volume 5 Number 5

Figure 7A: Long cone periapical view of tooth No. 26 using a size 2 sensor

Figure 7B: A slight change of vertical angulation and using a size 1 sensor. Note the lesion over the MB root is less prominent than in 7A

Figure 8A: Radiograph underexposed

Figure 8B: Radiograph at correct exposure. Note the lesion on the distal root of tooth No. 46 is now clearly visible

Figure 9: Digital image shown on a monitor

Figure 10A: Preoperative radiograph of tooth No. 25 using Schick CDR

Figure 10B: Postoperative radiograph of tooth No. 25 using Schick Elite


Volume 5 Number 5 Endodontic practice

to remove it until you are ready), assess the image.6. If it gives an acceptable, but not an ideal result, make a note of which parameters to change for the next radiograph. If it is not

The radiation dose with the CCD/CMOS sensors is considerably reduced compared to the dose required for a film, and it is perfectly justifiable to repeat an exposure while adhering

Make a note of the exposure used so that when you review the endodontic treatment, the radiographs can be compared “like for

review radiograph so that you can set the aiming device in the same position.

!"!#The most recent addition to the radiographic armamentarium in endodontics is the cone beam CT scanner. For use in endodontics,

that were previously unimaginable. The full extent of resorptive lesions can be assessed, and lesions and structures that are hidden on the conventional periapical are fully visible (Figures 11 and

Next issue: Rubber dams

Figure 11A: Periapical radiograph of tooth No. 27 shows a normal appearance

Figure 11B: Cone beam CT image of tooth No. 27 shows a periapical lesion

Figure 12A: Periapical radiograph of tooth No. 27 shows an impacted tooth No. 28

Figure 12B: CBCT images show the presence of a supernumerary tooth overlying buccally tooth No. 27 as well as the impacted tooth No. 28

EP


Continuing education

It has been approximately 3 years since we introduced bioceramics (for both surgical and non-surgical use) to the

endodontic community. The response has been excellent, and we sincerely believe that we have changed the way obturation is performed and, more importantly, the way we think about obturation. In this article, we want to concentrate specifically on the surgical applications of bioceramics and to share with you some of the impressions of your endodontic colleagues. Through the years, dental specialists have used all kinds of material for retrofills following apical surgery and for root perforation repairs. The introduction of mineral trioxide aggregate (MTA) [Dentsply Tulsa] more than a decade ago, was a significant advancement in surgical endodontics, particularly in perforation repairs. Recently, there have been other new materials introduced into surgical endodontics, although we view some of them as being more in the pulp capping space. So, when we wish to compare bioceramics as a surgical material, we really need to compare it to MTA. Both of these materials are excellent, and they have produced outstanding results, but there are some significant differences. While we are all familiar with the success of MTA, we must also realize that it is basically a modified Portland cement. Consequently, there are some real challenges in its handling characteristics. The first is that MTA does not come premixed either in a syringe or in a jar. This can be a problem because any hand mixing of a powder and liquid may result in inconsistencies. This inconsistency of mix can lead to erratic setting times. This can be especially troublesome when the material is hand mixed by a new assistant. Secondly, MTA, just like Sakrete® is difficult to control and can be a challenge to place into retrofill preparations. Nonetheless, there are numerous endodontists who have overcome these challenges and continue to use MTA in their retrofills. However, it would be preferable if we had a material that could be used successfully by a great majority of dentists, not just a few talented ones. This lack of handling ability can be a significant challenge to general practitioners, particularly when they attempt a perforation repair. The good news is that dentistry is moving in the direction of premixed materials, but this is still going to be an issue with mineral trioxide aggregate. The particle size of MTA is too large to be extruded through a reasonable-sized syringe. It should be noted, however, that it has a number of favorable properties including a pH of 12.5 which is strongly antibacterial. However, with the introduction of a true medical-grade bioceramic material, we now have, for the first time, the opportunity to employ a material that has all the benefits of MTA but none of its handling issues. But, prior to a discussion of bioceramic technology in surgical endodontics, a quick review of bioceramics, in general, would be helpful.

!"#$%&#'()*+$%,-%",.("'When evaluating bioceramic technology over a 3-year period, we really must ask ourselves, “Why has there been such excitement associated with its use?” The answer is clearly related to its physical

!"#$%&'("$)*"+*%+,#,#+-"$*).&/%&01'*$2"+"$'2*&%3"%45&)6*5%++")*!&'3%7*8%++%-9*8#$9*'+,*:22%+*:2"*;'))%9*"22.)-&'-%*-9%*<%+%="-)*#=*<"#$%&'("$)

properties as well as to its superior handling characteristics. Similar to MTA, bioceramics are very biocompatible and are chemically stable within the biological environment. Also, true bioceramics do not shrink upon setting. In fact, they expand slightly upon completion of the setting process (0.002). A further advantage of this material is its ability (during the setting process) to form hydroxyapatite and to ultimately establish a chemical bond with dentin. Being hydrophilic in nature, not hydrophobic, is a significant advantage and makes this material very unique1 (Figure 1). The bioceramic material that we recommend is the EndoSequence® Root Repair Material (RRM) [Brasseler USA], which comes premixed in a syringe and premixed as a putty (Figure 2). Note, that in the very near future, the putty will be available in unit dose packages. This will be even more cost effective and will enhance sterility.

Educational aims and objectivesThe purpose of this article is to:Discuss the surgical applications of bioceramics and show how colleagues have used these materials for specific cases.

Expected outcomesCorrectly answering the questions on page 31, worth 2 hours of CE, will demonstrate that you can:

between MTA and bioceramics.

bioceramics.

bioceramics.

Figure 1: Biocompatibility (fibroblast adhesion) of ProRoot MTA (left image) and ESRRM (right image)

Figure 2: EndoSequence Root Repair Material putty



The ability to come premixed in a syringe or in a unit dose package is a tremendous help, not just in terms of assuring a proper mix, but also in terms of ease of use. Finally, we now have a root repair material that is associated with an easy and efficient delivery system. This is a serious upgrade from MTA because it allows all clinicians to take advantage of its properties. EndoSequence RRM has all the attributes of MTA, but is a true medical-grade bioceramic. It (ESRRM) has a compressive strength of 50-70 MPa, which is similar to that of MTA and BioAggregate, but its small particle size (approximately one micron) allows it to be extruded through a syringe.2 The nanotechnology associated with its development allows this material to be very “user friendly.” In fact, the highly acclaimed CLINICIANS REPORT (CR) recently (November 2011) published its findings on EndoSequence RRM. Some of its noted advantages as an RRM were:

Furthermore, the final conclusion was that 95% of 19 CR evaluators stated that they would incorporate EndoSequence RRM into their practice. Also, 95% rated it excellent or good and worthy of trial by colleagues.3

Drs. Karen Lovato and Christine Sedgley also published a very significant piece of research in the Journal of Endodontics that investigated the antibacterial activity of EndoSequence RRM material against Enterococcus faecalis. The aim of their study was to determine whether EndoSequence RRM possessed antibacterial properties against a collection of E. faecalis strains. As a standard, they compared the EndoSequence RRM to MTA. Their conclusion was that EndoSequence RRM, in both the putty and syringeable forms and ProRoot® White MTA demonstrated similar antibacterial efficacy against clinical strains of E. faecalis. They also noted that clinical strains varied in their susceptibility to the root repair materials.4

This research again validated earlier studies that found that EndoSequence RRM putty and EndoSequence RRM paste displayed similar in vitro biocompatibility to MTA. Additionally,

other studies have found that the EndoSequence RRM had cell

set and fresh conditions.5 Furthermore, recent research concerning cytotoxicity was conducted at the Case School of Dental Medicine. The purpose of this study was to compare the cytotoxicity and cytokine expression profiles of EndoSequence Root Repair Material and ProRoot MTA using osteoblast cells. Their conclusion was that “ESRRM and MTA showed similar cytotoxicity and cytokine expressions.” They also made the astute observation that more clinical studies are needed to assess if the elevation of cytokines is relevant clinically.6

As we have mentioned previously, the bioceramic material to use in surgical cases is the EndoSequence RRM, and it is available in two different modes; there is a syringeable RRM (very similar to the basic BC Sealer in its mode of delivery), and there is a RRM putty that is both stronger and more malleable. The consistency of the putty is similar to Cavit™

RRM in a syringe is obviously delivered by a syringe tip, but the technique associated with the putty is different. When using the putty, simply remove a small amount from the room temperature jar and knead it for a few seconds with a spatula or in your gloved hands. Then start to roll it into a hot dog shape. This is very similar to creating similar shapes with desiccated zinc oxide eugenol or SuperEBA™ (Bosworth). Once you have created an oblong shape, you can pick up a section of it with a sterile instrument, and use this to deliver it where needed (Figure 3). This is an easy technique for apico retrofills, perforation repairs, and even for resorption defects. After placing the putty into the apical preparation (or defect), simply wipe with a moist cotton ball, and finish the procedure. While the above mentioned technique is very much “user friendly,” we must keep in mind the results of the aforementioned study that agreed with a previous study. The study, which compared the biocompatibility of MTA and ERRM putty and paste, reported that all specimens displayed similar biocompatibility to MTA in human gingival fibroblasts. So, if the products are “essentially” the same, which technique should you employ? We believe the technique that works most predictably and easily in your hands is the preferred technique.

Figure 3: ESRRM putty on a plastic instrument Figure 4A: Pre-op X-ray Figure 4B: Cortical bone was intact

Figure 4C: Retro-preparation connecting MB-ML

Figure 4D: Immediate post-op X-ray Figure 4E: 1-year recall X-ray



As evidence of how beautifully this technique works, and the salubrious properties associated with its use, we would like to show the following surgical case by Dr. Allen Ali Nasseh in Boston, Massachusetts. This case is so significant because it again clearly demonstrates the extraordinary healing capability of bioceramics, when used as a surgical repair material. The radiographs display excellent healing and bone fill (in 1 year) in the mandible! Concerning the case itself: this specific case was seen previously by an endodontist who attempted retreatment but who was unfortunately prevented from instrumenting the final apical curvature. As one can see from the pre-op X-ray, it appears that there may have been a slight perforation during the retreatment process. The case was then referred to Dr. Nasseh who proceeded

to cut the root too short (to incorporate the transportation of the canal), but to only address the lesion at the apex and fill the isthmus (he found) between the two mesial canals. The 1-year postoperative radiograph shows excellent healing following this conservative apicoectomy (Figures 4A-4E). We have been excited about the use of bioceramics for a number of years, but the question we must ask ourselves is, “What has been the experience of other specialists?” Let’s begin with a perforation repair case from Dr. Art Lane in Florida. “All too often, endodontic teeth are condemned, the tooth extracted, and a bridge or implant placed without a thorough evaluation of the possibilities to retreat and salvage a tooth that appears to have a poor prognosis. This case is representative of an open-minded dentist and patient who were willing to think

Figure 5A: Pre-op X-ray Figure 5B: Post removed

Figure 5C: Immediate perforation repair Figure 5D: Healing underway Figure 5E: Recall X-ray showing complete healing

Figure 6A: Pre-op X-ray Figure 6B: Pre-op X-ray

Figure 6C: Immediate post-op Figure 6D: 3-1/2 month recall Figure 6E: 9-month recall X-ray



outside the box and to trust the endodontist.” A 50-year-old female presented to Dr. Lane’s office with a chief complaint of a dull ache in tooth that had received root canal treatment 2 years previously. She also complained of swelling and sensitivity of the gum area when she rubbed her finger over the tooth. Her dentist told her that her symptoms were related to a post perforation, and she was consequently sent to his office for further evaluation. Clinical examination revealed tenderness to palpation on the distal aspect of the buccal gingival. However, there was no probing in the gingival sulcus, and the tooth was not sensitive to percussion. Radiographic examination revealed tooth No. 30 to have an extensive post perforation, as well as bone loss along the distal aspect of the root. Dr. Lane advised the patient of the risks, alternatives, and benefits of treatment, and thereafter, the patient expressed a desire to try and save the tooth. He then proceeded with the appropriate treatment to repair the post perforation. “The tooth was isolated with a rubber dam, and the access cavity filling material was removed and dissected from around the post. With the aid of ultrasonics and the Masserann Kit, the post was uneventfully removed. The post perforation area was lavaged with sodium hypochlorite, and the Biolase Waterlase MD™ was used to further disinfect the defect. EndoSequence Root Repair Material putty was used to seal the perforation utilizing a small Messing gun. A moist cotton pellet was placed over the EndoSequence RRM, and then Cavit was used to seal the access cavity. One week later, a permanent composite filling was placed. “We had the patient return on a regular basis and noticed,

Figure 7A: Pre-op Figure 7B: Fistula traced

Figure 7D: Post-op X-ray Figure 7E: Recall showing healing

Figure 7C: High magnification shot

almost immediately, resolution beginning. As one can see from the radiographs, we now have total resolution of the post perforation defect. Periodic radiographs will continue to be taken” (Figures 5A–5E). This is extraordinary healing and demonstrates how dedication to the preservation of the natural dentition can actually pay off in big dividends for the patient. Too often we are seeing dentists rush to an “extract and replace with an implant” decision. We can do better. Dr. Nasseh has contributed another case (tooth No. 19) where the patient presented with a chief complaint of some aching in the jaw bone (Figures 6A-6E). The tooth was slightly percussion sensitive, but there was no significant probing. After analyzing the pre-op X-rays, Dr. Nasseh elected to perform an apicoectomy

X-rays), because we can see some healing being established at the

the 9-month recall. A very important point to remember is that this excellent healing at 9 months is occurring in the mandible! Another terrific example of how this material works for lateral perforations (whether iatrogenic or natural) is the following case done by Dr. Brad Trattner of Maryland. We’ll let Dr. Trattner describe it. “A patient presented with a sinus tract over tooth No. 8, which was traced with gutta percha to a lateral lesion on the mesial aspect of the tooth. A flap was reflected during endodontic microsurgery revealing a bony lesion, with an associated lateral canal on the mesial. A preparation was made with the Varios 350 ultrasonic (Brasseler USA), and we then filled the preparation with EndoSequence RRM. A decision was made to use the EndoSequence RRM due to its ease of use and physical properties. (Ease of placement, manipulating ability, cleanup, and working time are paramount with microsurgery.) A 1-year followup shows complete radiographic healing with an intact periodontal ligament” (Figures 7A–7E). The last surgical case we would like to present was performed by Dr. Samuel Kratchman of the University of Pennsylvania. Dr. Kratchman is an accomplished endodontic surgeon, and we can see how beautifully he was able to work with the bioceramic material and the outstanding result he achieved in this surgical case (Figures 8A–8E). So, where are we after 3 years of bioceramic use in endodontic surgery? There are a few points worth mentioning.

a) There is more than ample research to demonstrate that both EndoSequence Root Repair Material and ProRoot MTA work well from a biological perspective. There will be advocates of both



MTA and ESRRM, but dentists should make their own personal decisions as to which material works best in their hands. b) Yes, as endodontists, we are better trained to repair perforations, but the truth is many general dentists also want to be able to repair minor perforations when they occur. (And we all know how critical time is in the long-term success of perforation repair.) We now finally have a material (and technique) that will work in all capable hands.

c) It’s about saving the natural dentition whenever possible. Having a “user friendly” (and predictable) technique for surgical repair is a big asset for all of us.d) Don’t be misled by false, contrived, or managed information from competing dental companies. We are the providers of our patients’ care. Your patients have every right to expect the best that is available; be critical in your thinking and demanding in your expectations.

Figure 8A: Pre-op Figure 8B: High magnification after resection

Figure 8C: High magnification showing ESRRM retrograde fill

Figure 8D: Immediate post-op X-ray Figure 8E: 1-year recall X-ray

References

1. Koch KA, Brave D (2009). Bioceramic technology – the game changer in endodontics. Endodontic Practice US. 12:7-11.

Dent Today. Vol.31; No. 2: 118-125.3. (2011). Premixed root repair material is easy to use, biocompatible, hydrophilic, and radiopaque. Clinicians Report. Nov: 6.4. Lovato KF, Sedgley CM (2011). Antibacterial activity of EndoSequence root repair material and ProRoot MTA against clinical isolates of Enterococcus faecalis. J Endod. 37:1542-1546.

5. AlAnezi AZ, Jiang J, Safavi KE, et al (2010). Cytotoxicity evaluation of EndoSequence root repair material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 109: e122-e125.

cytotoxicity and proinflammatory cytokine production of EndoSequence root repair material and ProRoot mineral trioxide aggregate in human osteoblast cell culture using reverse-transcriptase polymerase chain reaction. J Endod. 38:486-489.

Dennis Brave, DDS, is a Diplomate of the American Board of Endodontics and a member of the College of Diplomates. Dr. Brave received his DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his certificate in Endodontics from the University of Pennsylvania School of Dental Medicine. He

is an Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas Odontologic Honor Society Member. In endodontic practice for over 25 years, he has lectured extensively throughout the world and holds multiple patents, including the VisiFrame. Dr. Brave was voted one of “Baltimore’s Best” endodontists by Baltimore Magazine. Formerly an associate clinical professor at the University of Pennsylvania, Dr. Brave currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on endodontics, Dr. Brave is a co-founder of Real World Endo.

Kenneth Koch, DMD, received both his DMD and Certificate in Endodontics from the University of Pennsylvania School of Dental Medicine. He is the founder and past Director of the New Program in Postdoctoral Endodontics at the Harvard School of Dental Medicine. Prior to his endodontic career, Dr. Koch spent

10 years in the Air Force and held, among various positions, that of Chief of Prosthodontics at Osan AFB and Chief of Prosthodontics at McGuire AFB. In addition to having maintained a private practice, limited to endodontics, Dr. Koch has lectured extensively in both the United States and abroad. He is also the author of numerous articles on endodontics. Dr. Koch is a co-founder of Real World Endo.

Allen Ali Nasseh, DDS, MMSc, received his Masters in Medical Sciences degree and Certificate in Endodontics from the Harvard School of Dental Medicine in 1997. He received his DDS degree in 1994 from Northwestern University Dental School. He maintains a private endodontic practice in Boston, Massachusetts (MSEndo.

com) and holds a staff position at the Harvard’s postdoctoral endodontic program. Dr. Nasseh has done research in the areas of bone biochemistry and has lectured extensively nationally and internationally on such diverse topics as endodontic diagnosis, anesthesia and sedation, treatment planning, efficiency of care, and microsurgery. Dr. Nasseh is the endodontic editor for several dental journals and periodicals and serves as the Alumni Editor of the Harvard Dental Bulletin. He serves as the Clinical Director of Real World Endo and maintains an educational website www.Nasseh.net.

EP

Endodontic Practice CE

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

Certificate details !"#$%&'()*

+,-%$)./01$'1/"2%2"*

+33$)00*

4('/5*

6)5)78"2)9:';*

REF: EP V5.5 BRAVE

Bioceramics in endodontic surgery: a clinical review1. Bioceramics are:

a. hydrophobic b. hydrophilic c. able to form hydroxyapatite upon setting d. both b and c

2. !e introduction of MTA more than a decade ago, was a signi"cant advancement in surgical endodontics, particularly in_______.

a. perforation repairs b. pulp capping c. bone grafting d. replacing gutta percha for !lling canals

3. While we are all familiar with the success of MTA, we must also realize that it is basically a _______.

a. new type of amalgam b. intracanal lubricant c. modi!ed Portland cement d. derivative of gutta percha

4. Consequently, there are some real challenges in its handling characteristics. !e "rst is that MTA _______either in a syringe or in a jar.

a. is usually premixed b. is already packaged

c. does not come premixed d. none of the above

5. !e particle size of MTA is _____to be extruded through a reasonable-sized syringe.

a. too small b. just the right size c. easily altered d. too large

6. It should be noted, however, that it (MTA) has a number of favorable properties including a pH of _____, which is strongly antibacterial.

a. 7 b. 8 c. 9 d. 12.5

7. Similar to MTA, bioceramics are ______within the biological environment.

a. very biocompatible b. chemically stable c. overly reactive d. both a and b

8. ESRRM has a compressive strength of ______, which is similar to that of MTA

and BioAggregate, but its small particle size (approximately one micron) allows it to be extruded through a syringe.

a. 5-10 MPa b. 10-20 MPa b. 50-70 MPa c. 500-750 MPa

9. Once you have created an oblong shape, you can pick up a section of it with a sterile instrument, and use this to deliver it where needed (Figure 3). !is is an easy technique for ______.

a. apico retro!lls b. perforation repairs c. resorption defects d. any of the above

10. !e purpose of this study was to compare the cytotoxicity and cytokine expression pro"les of EndoSequence Root Repair Material and ProRoot MTA using osteoblast cells. !eir conclusion was that “ESRRM and MTA showed ______cytotoxicity and cytokine expressions.”

a. similar b. vastly di"erent c. ESRRM to have higher d. MTA to have higher

To provide feedback on this article and CE, please contact Endodontic Practice US15720 N Greenway Hayden Lp. #9, Scottsdale, AZ 85260 | fax: (480) 629-4002 | email: [email protected]

</=)20)%2"*

>/1?@%A1'1)%'23%B/7%>"3)*


Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2010 to 11/30/2012 Provider ID# 325231

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either:

Post the completed questionnaire to: Endodontic Practice US CE15720 N. Greenway-Hayden Loop. #9Scottsdale, AZ 85260

Fax to (480) 629-4002.Legal disclaimer: !e CE provider uses reasonable care in selecting and providing accurate content. !e 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. !e instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.



The cleaning and shaping of the root canal system are considered key requirements for success in root canal treatment. However,

numerous researchers have reported limitations in the overall quality of preparations obtained by manual and automated root canal instrumentation (Weine, 1976; Bolaños, et al, 1988). Cleaning and shaping can be easily accomplished in straight canals. However, many canals have moderate, severe, or abrupt curvatures that make them susceptible to procedural accidents such as ledges, zips, perforations and blocked canals (Hülsmann, Stryga, 1993; Hülsmann, et al, 1997; Bertrand, et al, 1999). The removal of pulp tissue, debris, smear layer, and bacteria from the root canal space prior to obturation is one of the primary aims of root canal treatment. The degree of difficulty experienced during the cleaning and shaping procedure is affected by the curvature of canal, access to the canal space, canal length, and canal diameter (Hülsmann, et al, 2001; Hülsmann, et al, 2003a). Novel instrumentation systems have been introduced with the aim of improving biomechanical preparations, using nickel-titanium alloys for the instruments, and applying a crown down technique. Rotary preparation of the root canal takes less effort and time than manual methods and is less tiring for the clinician and patient. Only a few studies have been published on the cleaning ability of rotary nickel-titanium files (Hülsmann, et al, 2003b; Schäfer, Lohmann, 2002; Schäfer, Schlingemann, 2003; Prati, et al, 2004). Most of these studies conclude that hand instrumentation does not clean the root canal, especially the apical region of curved canals. While irrigants such as sodium hypochlorite are helpful in dissolving organic debris (Zehnder, et al, 2002), thorough instrumentation is a necessity. The effectiveness of endodontic space cleaning depends on both instrumentation and irrigation. Irrigation plays an important role in successful debridement and disinfection. The most widely used irrigant for root canal treatment is sodium hypochlorite (NaOCl) at concentrations of 0.5 to 5.25%. The tissue-dissolving capacity and microbicidal activity of NaOCl make it an excellent irrigating solution (Zehnder, et al, 2002). Of all the currently used substances, sodium hypochlorite appears to be the most ideal, as it covers more of the requirements for endodontic irrigant than any other known compound. Hypochlorite has the capacity to dissolve necrotic tissue (Naenni, et al, 2004) and the organic components of the smear layer. Inactivation of endotoxin by hypochlorite has been reported (Sarbinoff, et al, 1983; Silva, et al, 2004); the effect, however, is minor compared to that of a calcium-hydroxide dressing (Tanomaru, et al, 2003). Acid solutions have been recommended for removing the smear layer, including:

!"#$#%%#&'()#*#++$,%$%,-.$(..(/0'(*/$+,1-'(,*+$ (*$ .,,'$ &0*01$ &1#0*(*/$0%'#.$.,'0.2$(*+'.-3#*'0'(,*4.+5$6,./#$70.#8#+$9(#2.0:$6(3;*#<$=*.>?-#<[email protected]*&(+&,$60)(#.:$A0+B0.$CDE#<$F.'(<:$0*8$G1#H0*8.,$G1&0*'0.$=*.>?-#<$#)01-0'#$'"#$8#I.(+$.#3,)01$0I(1('2$,%$%,-.$(..(/0'(*/$+,1-'(,*+$8-.(*/$.,,'$&0*01$(*+'.-3#*'0'(,*

active at a concentration of 15 to 17%, and pH of 7 to 8 (Naenni, et al, 2004)

(Senia, et al, 1971; Garberoglio, Becce, 1994). Although sodium hypochlorite appears to be the most desirable single endodontic irrigant, it cannot dissolve inorganic dentin particles, and thus prevents the formation of a smear layer during instrumentation (Ferrer, et al, 1996). In addition, calcifications hindering mechanical preparation are frequently encountered in the canal system.

in removing the smear layer (Lester, Boyde, 1977). In addition to their cleaning ability, chelators may detach biofilms adhering to root canal walls.

superior to saline in reducing intracanal microbiota (Zehnder, et al, 2005), despite the fact that its antiseptic capacity is relatively limited (Yoshida, et al, 1995). Antiseptics such as quaternary

citric acid irrigants, respectively, to increase their antimicrobial capacity. The clinical value of this, however, is questionable.

Educational aims and objectivesThis clinical article aims to evaluate the debris removal ability of EDTA, MTAD, 1.0% NaOCl and chlorhexidine (4.0%) when used as irrigants during root canal instrumentation.

Expected outcomesCorrectly answering the questions on page 36, worth 2 hours of CE, will demonstrate you understand:

than the middle third.

root canal walls totally free of debris.



resistance to tetracycline is not uncommon in bacteria isolated from root canals (Torabinejad, et al, 2003). Generally speaking, the use of antibiotics instead of biocides such as hypochlorite or chlorhexidine appears unwarranted, as the former were developed for systemic use rather than local wound debridement, and have a

Chlorhexidine is a strong base and is most stable in the form of its salts. The original salts were chlorhexidine acetate and hydrochloride, both of which are relatively poorly soluble in water

chlorhexidine digluconate. Chlorhexidine is a potent antiseptic, which is widely used for chemical plaque control in the oral cavity (Foulkes, 1973; Addy, Moran, 2000). Aqueous solutions of 0.1 to 0.2% are recommended for that purpose, while 2% is the concentration of root canal irrigating solutions usually found in the endodontic literature (Zamany, et al, 2003). Several new nickel-titanium instruments have been developed to facilitate the difficult and time-consuming process of cleaning and shaping the root canal system, and to improve the quality of root canal preparation.

The new designs of hand and rotary instruments include non-cutting tips, radial lands, and varying tapers. These features are meant to improve the safety of canal preparation, shorten working time, and create a greater flare preparation. Most are used in a crown down sequence. The purpose of the present study was to evaluate the debris

(4.0%) when used during root canal instrumentation.

!"#$%&"'(")*(+$#,-*.

straight root canal extracted from 40- to 60-year-old patients with periodontal disease were randomly selected, radiographed buccolingually and mesiodistally, then placed in individual containers with 2% formalin and stored in a refrigerator at 10˚C. The average root length was 12 mm. At the time of use, the teeth were removed from formalin, washed in running water for 30 minutes, and randomly separated into four groups of 20 teeth

(Table 1).

Figure 1: Typical SEM photomicrographs showing the cervical, middle, and apical thirds of root canal dentin surface in 17% EDTA, MTAD, 2.5% NaOCl, and 2% chlorhexidine (1,000x-5,000x)

Cervical third Middle third Apical third

17% EDTA

MTAD

2.5% NaOCI

2% CLX



!""#$%&'&($)*+)&*&#,"'After preparing a conventional access preparation for each tooth,

Switzerland) was used to determine the working length (WL) by penetrating the apical foramen and pulling back into the clinically visible apical foramen. WL was established 0.5 mm coronal to the apical foramen and confirmed radiographically. All the root canals were then explored and prepared by rotary instrumentation with a #25 LightSpeed® LSX instrument

measured up to 0.5 mm below the root apex. All WLs were confirmed radiographically. Rotary instrumentation was performed with #25 to #80 LightSpeed LSX instruments in the apical third. They were used with a constant speed of 2000 rpm (LightSpeed electric handpiece,

instruments were changed every six canals, and instrumentation was performed according to the manufacturer’s instructions. Gates Glidden drills (Mani, Japan) #2 to #4 were used on the body of the root canal walls (cervical and middle thirds). Apical stops prepared with LightSpeed instruments were shaped to size 80 respectively.

-**,.&#,"'

irrigating solution. The same method was used with all of the 20 teeth of each group, only changing the irrigating solutions tested. In all groups, irrigation was performed using a plastic syringe with 30 gauge closed end needle (Hawe Max-i-Probe®, Hawe Neos, Bioggio, Switzerland). In all cases, the needle was inserted as deeply as possible into the canal. After cleaning and shaping, all root canals were finally flushed with 5cc with their corresponding irrigant and

/01$+2&3,'&#,"'All were separated longitudinally and evaluated from cervical, middle, and apical third. Roots were split longitudinally in the buccolingual plane. To facilitate fracture into two halves, all roots were grooved longitudinally on the external surfaces with a diamond disk, avoiding penetration of root canals. The half of each root in which the entire canal was visualized was selected. Root surfaces were grooved to three levels at 3, 6, and 9 mm from the root apices using a diamond bur. Canal halves were secured on metal stubs, desiccated, sputter-coated with gold, and viewed with

The cleanliness of each canal wall was evaluated in three thirds and photographed at 1500-2000 of magnification at the same height as the groove that defined each third.

The scoring procedure was carried out by the operator who could not identify the specimen, using the following five score system (Hülsmann, et al, 1997):

wall covered

by debris.

/#&#,4#,%&($&'&(54,4The experimental data used in this study consisted of four groups with a Q-Cochran test (Siegel, Castellan, 1998). The Q-Cochran test showed statistical significance between the four groups. The Kolmogorov-Smirnov test was used for checking the normality of the data distribution. As the results for each group did not follow a normal distribution, the variables were analyzed using a non-parametric test. The level of statistical significance was set at p less than 0.05.

!+46(#4The results showed that the increase in the percent of debris always occurs in the same direction, i.e., from the middle region to the apical, no matter which solution is utilized. Table 2 shows the debris findings and the comparisons among irrigating solutions. To define which of the irrigation solutions was significantly different from the others, the complementary Tukey test was used for this factor of variation. The Tukey test showed a statistical

™

removal than the rest of the irrigant solutions (Table 2).

7,4%644,"'Chemical-mechanical preparation forms the key requisite for the success of root canal instrumentation. The objective of these two interdependent factors consists of the cleaning of the canal and its eventual ramifications, removing the largest possible amount of debris in order to establish ideal conditions that allow a functional recuperation of the dental organ and a regeneration of tissues eventually injured by infection.

the performance of irrigating solutions in root canal treatment,

(O’Connell, et al, 2000; Olmos, et al, 2000).

are effective chelating agents to smear layer removal. Numerous authors (Yoshida, et al, 1995; Patterson, 1963; Ostby, 1957)

both organic and inorganic components. No significant differences were found by Hulsmann, et al, (2001; 2003a; 2003b) in either debris or smear layer removal, when using 3% NaOCl as initial and final irrigation, and 17%

techniques.

in the interior of the canals, followed by NaOCl and finally, chlorhexidine, which left the greatest amount of debris. With the rotary instrumentation technique, the results for

previous reports (Cerviño Vázquez, et al, 2002; Wayman, et al,



References

Addy M, Moran JM (1997). Clinical indications for the use of chemical adjuncts to plaque control: chlorhexidine formulations. Periodontol 2000 15: 52-4.

Ahlquist M, Henningsson O, Hultenby K, Ohlin J (2001). The effectiveness of manual and rotary techniques in the cleaning of root canals: a scanning electron microscopy study. Int Endod J 34: 533-7.

smear layer using the Quantec system. A study using the scanning electron microscope. Int Endod J 32: 217-24.

Bolanos OR, Sinai IH, Gonsky MR, Srinivasan RA (1988). A comparison of engine and air driven instrumentation methods with hand instrumentation. J Endod 14: 392-6.

Rev Eur Odont Estomatol 14: 275-80.

susceptibility of enterococci isolated from the root canal. Oral Microbiol Immunol 15: 309-12.

Int Endod J 33:46-52.

Ferrer Luque CM, González López S, Navajas Rodríguez de Mondelo JM (1996).

image analysis. Bull Group Int Rech Sci Stomatol Odontol 39: 111-7.

J Periodontal Res Suppl 12: 55-60.

Garberoglio R, Becce C (1994). Smear layer removal by root canal irrigants. A comparative scanning electron microscopic study. Oral Surg Oral Med Oral Pathol 78: 359-67.

Hülsmann M, Stryga F (1993). Comparison of root canal preparation using different automated devices and hand instrumentation. J Endod 19:141-5.

Hülsmann M, Rümmelin C, Schäfers F (1997) Root canal cleanliness after preparation

investigation. J Endod 23: 301-6.

Hülsmann M, Schade M, Schafers F (2001). A comparative study of root canal Int Endod J 34:

538-46.

Hülsmann M, Gressman G, Schäfers F (2003a). A comparative study of root canal Int Endod J 36:

358-66.

preparation using Lightspeed and Quantec SC rotary NiTi instruments. Int Endod J 36: 748-56.

Lester KS, Boyde A (1977). Scanning electron microscopy of instrumented, irrigated and filled root canals. Br Dent J 143: 359-67.

resistance. Clin Microbiol Rev 12: 147-79.

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

Nygaard Östby B (1957). Chelation in root canal therapy. Odontol Tidskr 65: 3-11.

O’Connell MS, Morgan LA, Beeler WJ, Baumgartner JA (2000). A comparative study of J Endod 26: 739-43.

barrido. Endodoncia 18: 207-14.

Patterson SS (1963). In vivo and in vitro studies of the effect of the disodium salt of ethylenediaminetetraacetate on human dentine and its endodontic implications. Oral Surg Oral Med Oral Pathol 16: 83-103.

Prati C, Foschi F, Nucci C, Monteburgnoli L, Marchionni S (2004). Appearance of the

investigation. Clin Oral Investig 8: 102-10.

Sarbinoff JA, O’Leary TJ, Miller CH (1983). The comparative effectiveness of various agents in detoxifying diseased root surfaces. J Periodontol 54: 77-80.

instruments compared with stainless steel hand K-Flexofile. Part 2. Cleaning effectiveness and shaping ability in severely curved root canals of extracted teeth. Int Endod J 35: 514-21.

compared with stainless steel hand K-Flexofile. Part 2. Cleaning effectiveness and shaping ability in severely curved root canals of extracted teeth. Int Endod J 36: 208-17.

J Endod 27: 741-3.

pulp tissue of extracted teeth. Oral Surg Oral Med Oral Pathol 31: 96-103.

Siegel S, Castellan NJ, Jr. (1998). Non Parametric Statistics for Behavioral Sciences. McGraw-Hill Book Co. NY.

Silva LA, Leonardo MR, Assed S, Tanomaru Filho M (2004). Histological study of the effect of some irrigating solutions on bacterial endotoxin in dogs. Braz Dent J 15:109-14.

Tanomaru JM, Leonardo MR, Tanomaru Filho M, Bonetti Filho I, Silva LA (2003). Int Endod

J 36: 733-9.

Torabinejad M, Khademi AA, Babagoli J, et al (2003). A new solution for the removal of the smear layer. J Endod 29: 170-5

nickel-titanium instruments compared with stainless steel hand instrumentation. J Endod 23: 170-3.

Versumer J, Hülsmann M, Schafers F (2002). A comparative study of root canal preparation using Profile.04 and Lightspeed rotary Ni-Ti instruments. Int Endod J 35: 37-46.

canal irrigant in vitro. J Endod 5: 258-65.

on original canal shape. J Endod 2: 298-303.

Yoshida T, Shibata T, Shinohara T, Gomyo S, Sekine I (1995). Clinical evaluation of the J Endod 21: 592-3.

Zamany A, Safavi K, Spångberg LS (2003). The effect of chlorhexidine as an endodontic disinfectant. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 96: 578-81.

and antimicrobial effect of buffered and unbuffered hypochlorite solutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94: 756-62.

Zehnder M, Schmidlin P, Sener B, Waltimo T (2005). Chelation in root canal therapy reconsidered. J Endod 31: 817-20.

are recommended.

canal confirms the findings of Tanomaru, et al, (2003). This may be due to the potentiation of the solvent action when energized by temperature (Senia, et al, 1971). Irrigating solutions used in endodontic treatment not only present antimicrobial action, but they also clean the pulp chamber (Sarbinoff, et al, 1983). None of the irrigating solutions studied in the present study were capable of eliminating all of the debris in the root canal walls, since none of them left the root canals completely free of debris. In the present study, no significant differences in presence of debris were observed among root canal thirds in the manually and rotary instrumented groups irrigated with NaOCl. Similar results were found by Tucker, et al, (1997) who compare the rotary instrumentation with the hand technique, using 1% NaOCl as irrigating solution; and Ahlquist, et al, (2001) who compare the rotary instrumentation technique, ProFile®

instrumentation with S-files using 0.5% NaOCl. The removal of debris and smear layer depends not only on the irrigation method, but also on the endodontic instrument, the way the instrument is used, and the preparation technique. The root

canal cleaning capacity of manual versus rotary instrumentation techniques with NaOCl is somewhat controversial (Hülsmann, et al, 1997).

!"#$%&'("#1. The apical third showed a greater amount of debris than the middle third, regardless of the solution used. 2. None of the solutions used for irrigation of the root canals allowed full removal of the debris from the interior of the canal.

canals with less debris than 1% NaOCl and chlorhexidine. EP

Jorge Paredes Vieyra is a full-time lecturer of endodontics at the Autonomous University of Baja California, Tijuana Campus, Mexico.

Jiménez Enríquez Francisco Javier is a lecturer of oral surgery and endodontic surgery at the Autonomous University of Baja California, Tijuana Campus, Mexico.

Gaspar Núñez Ortiz is an endodontist as well as chairman of the endodontic program at the School of Dentistry, Mexicali, Mexico.

Alejandro Alcantar Enríquez is chairman of the School of Dentistry, Mexicali, México.

Endodontic Practice CE

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

Certificate details !"#$%&'()*

+,-%$)./01$'1/"2%2"*

+33$)00*

4('/5*

6)5)78"2)9:';*

REF: EP V5.5 VIEYRA

!e e"ectiveness of four irrigating solutions in root canal cleaning after rotary instrumentation1. Many canals have ________ that make them susceptible to procedural accidents such as ledges, zips, perforations and blocked canals.

a. moderate curvatures b. severe curvatures c. abrupt curvatures d. any of the above

2. !e e"ectiveness of endodontic space cleaning depends on ________________.

a. instrumentation b. irrigation c. curvature of the canal d. both a and b

3. !e most widely used irrigant for root canal treatment is ______at concentrations of 0.5 to 5.25%.

a. EDTA b. citric acid solutions c. sodium hypochlorite (NaOCl) d. quaternary ammonium compounds

4. Demineralizing agents such as EDTA show ______ in removing the smear layer.

a. low e!ciency b. high e!ciency

c. no e"ect d. di!culty

5. Generally speaking, the use of _______ instead of biocides such as hypochlorite or chlorhexidine appears unwarranted, as the former were developed for systemic use rather than local wound debridement, and have a far narrower spectrum than the latter.

a. antibiotics b. sodium hypochlorite c. BioPure d. Milton’s solution

6. Chlorhexidine is a potent antiseptic, which is _______for chemical plaque control in the oral cavity.

a. not currently used b. widely used c. used in very high concentrations d. a time-consuming method

7. !e new designs of hand and rotary instruments include ______.

a. non-cutting tips b. radial lands c. varying tapers d. any of the above

8. Chemical-mechanical preparation forms the ________ of root canal instrumentation.

a. debris particles b. least ideal element c. key requisite for the success d. average length

9. _____used in endodontic treatment not only present antimicrobial action, but they also clean the pulp chamber.

a. Irrigating solutions b. Manual instruments c. Rotary instruments d. Gates Glidden drills

10. _____ depends not only on the irrigation method, but also on the endodontic instrument, the way the instrument is used, and the preparation technique.

a. Conventional access preparation b. #e removal of debris c. #e removal of the smear layer d. Both b and c

To provide feedback on this article and CE, please contact Endodontic Practice US15720 N Greenway Hayden Lp. #9, Scottsdale, AZ 85260 | fax: (480) 629-4002 | email: [email protected]

</=)20)%2"*

>/1?@%A1'1)%'23%B/7%>"3)*

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2010 to 11/30/2012 Provider ID# 325231

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either:

Post the completed questionnaire to: Endodontic Practice US CE15720 N. Greenway-Hayden Loop. #9Scottsdale, AZ 85260

Fax to (480) 629-4002.Legal disclaimer: !e CE provider uses reasonable care in selecting and providing accurate content. !e 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. !e instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.



Technology

Radiography has an important role in the assessment of morphology and the diagnosis of pathology of the pulp

and root canal system, but conventional planar radiography only provides a two-dimensional representation of this complex anatomy. The limited 2D representation might not yield sufficient information for the clinician to fully diagnose pathological states and therefore effectively treatment plan. Limited volume cone beam computed tomography (CBCT) provides high-resolution three-dimensional undistorted images of the maxillofacial skeleton, including the teeth and their surrounding tissues. Although the effective radiation dose used in CBCT is higher than that of conventional radiographic techniques, it is substantially lower than conventional CT1. The advantages of this relatively new technology in all fields of dentistry have not been overlooked, and guidelines for its safe use have been prescribed by SEDENTEXCT (http://www.sedentexct.eu/content/guidelines-cbct-dental-and-maxillofacial-radiology). CBCT has a demonstrated efficacy in a large number of endodontic applications, including, but not limited to, the investigation of complex dental anatomy and hidden pathology2. I have been using CBCT for diagnosis, treatment decision-making and planning, along with surgical guidance for the past 5 years in my specialty practice. I believe that the advantages of the extra dimension and superior resolution substantially enhances the level of advice and treatment offered to patients, reducing failure with effective diagnosis, and increasing success and efficiency through the accurate identification of canal anatomy and the surrounding tissues. This series of case discussions highlight the use of CBCT in clinical endodontics and how it is used to enhance diagnosis, decision making, treatment planning, and the treatment itself.

!"#$%&'#()##'*+%,%-%"%.'&&$+%/$#'*+%Clinical details A 56-year-old female patient with no relevant medical history was referred to the practice by a restorative consultant for root canal treatment of her lower right second molar (LR7). The patient had presented a week earlier to the referring dentist complaining of an intermittent pain in her lower right jaw. The dentist had identified the LR7 as the source of the pain and carried out a pulpectomy. He was only able to identify and negotiate a distal canal and a single mesial canal. A week following the emergency treatment, the pain was still present, and the referral requested further treatment through the location of a missed mesial canal. At the time of consultation, the patient described the pain as intermittent, and moderate to severe. The timing was mostly random, lasting for hours, occasionally disturbing sleep, and it would invariably follow eating. It was poorly localized toward the posterior part of the right mandible with the pain radiating up toward the right ear. It was controlled with regular analgesics. Following the pulpectomy, the pain had worsened briefly but was now similar to that prior to the emergency procedure. Clinical examination revealed a temporary filling in the LR7, which was slightly tender to percussion (TTP). The tooth did not respond to vitality tests (Endo-Ice® [Hygenic®] and electric pulp testing [EPT]). The lower right first molar (LR6) had a well fitting bonded precious metal full veneer crown, and the lower right second premolar (LR5) was a bonded precious metal full

veneer crown on an implant. Neither LR5 or LR6 was TTP, and without visible dentin around the LR6, it was not possible to carry out an electric pulp test. Periodontal probing depths around all lower right posterior teeth were within normal limits, and there were no discernible occlusal issues. A periapical radiograph (Figure 1) showed a deep restoration in the LR7 with widening of the periodontal ligament (PDL) space associated with the mesial root apex. Apart from some sclerosis in the distal canal of the LR6, the PDL is clearly intact around this root, and no other pathology was noted. A limited volume (4 cm x 4 cm) cone beam computed tomograph was taken of the lower right mandible using a Morita Epochs 3D (80kV, 5mA, 9.4 sec). The scan confirmed widening of the PDL at the mesial root of LR7 (Figure 2), but also revealed a 2.5 mm diameter lesion associated with the distal root of the LR6 (Figures 3 and 4). The scan also showed the presence of a single canal in the mesial root of the LR7 (Figure 5). A diagnosis of chronic periapical periodontitis (CPP) associated with pulpal inflammation and necrosis was made for the LR7 and also CPP for the LR6 associated with likely necrosis or partial necrosis. As the LR7 had already been opened and dressed without pain resolution, a pulpectomy of the LR6 was carried out through the crown. The pulpal tissues in both mesial and distal canals were found to be necrotic, and the canals were dressed with

!"#$%&$'(%!)%'#*%$#*"*"#+,-.

Richard Kahan is an endodontist working in Harley Street and the former director of endodontic courses at UCL Eastman CPD. He has lectured on endodontics and technology and has set up the Academy of Advanced

Endodontics to teach the fundamentals of endodontics to GPs through extended mentoring within his practice. With years of experience in endodontic CBCT, his clinic has become a referral center for complex cases used by both endodontists and GPs. For more information visit www.endodontics.co.uk.

Figure 1: Preoperative periapical radiograph. Widening of the PDL observed around the mesial root of the LR7. PDL intact around the mesial and distal roots of the LR6

/01%2,-3'0*%4'3'#%*,.-5..$.%'%-'.$%.+5*6%5.,#7%-"#$%&$'(%-"(85+$*%+"("70'836

Technology

calcium hydroxide. Within 2 to 3 days, the patient reported a resolution of her pain symptoms. Endodontic treatment of both the LR6 and LR7 was subsequently completed without complication (Figure 6).

!"#$%##"&'(The limitations in standard radiographic detection of apical lesions have been known for many years3 noting that a lesion will only be visible with involvement of the overlying cortical plate of bone. There is no literature evidence for the proportion of apical lesions that do not involve the cortical plate, and it is unlikely that we will ever know this figure. The ability of a standard periapical radiograph to accurately detect apical pathology (diagnostic sensitivity) is therefore dependent on the size of the lesion and the proximity of the root apex to its closest cortical plate (Figure 7). This can explain the historically low scores seen in the literature for the diagnostic sensitivity and specificity of standard periapical radiography. In this case, a periapical lesion had formed beneath the distal root of the LR6, and as clearly seen in the CBCT coronal slice (Figure 4), it is positioned in the cancellous bone space between the cortical plates of the mandible. No matter how hard we peer at the 2D periapical radiograph, digitally enhance it, or take views from different angles, this lesion will not be visible. Unfortunately for the dentist, the pain suffered by the patient in this case was poorly located, there were no clinical signs or symptoms associated with the LR6, and it was impossible to carry out a vitality test. No retrospective judgement could be made on the veracity of carrying out the pulpectomy at the LR7, as there certainly was widening seen in the periapical radiograph and TTP, but this could have been as a result of the procedure carried out the week before. Certainly the fact that the pain had not resolved was a powerful indicator that the source of the problem had not been addressed. The appearance of a lesion associated with the LR6, along with confirmation of a single mesial root canal in the LR7, despite any further evidence of pathology associated with the LR6, provided

the confidence to make a diagnosis and therefore to logically proceed with treatment. We can speculate as to what would have occurred without the benefit of a CBCT scan and the third dimension. In the absence of any other pathology, an attempt would have been made to locate a second canal in the mesial root of the LR7. Although symmetry of the canal system would have dictated a cautious approach to the location of a second mesial canal, the continuing pain would have been a motivator to go drilling into the root hunting the elusive (and nonexistent) pulp tissue, removing structural dentin, and damaging the root. Having not found any further canal anatomy, the tooth would have been dressed (or filled), with the patient returning, no doubt on numerous occasions, still complaining of pain. This unfortunate situation would have continued until either the pain located itself more specifically to the LR6, or with the lesion increasing in size leading to cortical plate involvement, it would finally become visible on a standard radiograph. Without these two confirmatory signs, the patient would have been moved from specialist to specialist, possibly losing the LR7 after a few unsuccessful treatments and being referred for atypical facial pain. This is not an uncommon scenario. As it was, the problem was quickly identified and dealt with successfully in a single appointment, as the patient and the referrer would have expected. EP

References

1. Patel S, Dawood A, Pitt Ford T, Whaites E (2007). The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J, 40, 818–830.

2. Nair MK, Nair UP (2007). Digital and advanced imaging in endodontics: a review. J Endod 33, 1-6.

3. Bender IB, Seltzer S (1961). Roentgenographic and direct observation of experimental lesions on bone: J Am Dent Assoc. 62:152 Feb.

Figure 2: CBCT Saggital slice – widening of the PDL space around the mesial root of the LR7 (arrowed) can be observed. Also arrowed at the LR7 is a distal vertical periodontal defect. The width of this defect (seen axially) suggests it is likely to be of periodontal etiology and not a vertical root fracture

Figure 3: CBCT Saggital slice – a 2.5 mm diameter periapical lesion is associated with the distal root of the LR6. There is also widening of the PDL space around the distal root of the LR7

Figure 4: CBCT Coronal slice – the lesion associated with the distal root of the LR6 is positioned between the buccal and lingual cortical plates and therefore invisible on a traditional 2D periapical radiograph

Figure 5: CBCT Axial slice – this slice confirms the position of the lesion at the LL6 distal root between the cortical plates and also shows the presence of a single canal in the mesial root of the LR7

Figure 6: Postoperative periapical radiograph

Figure 7: The ability to detect a periapical lesion on a standard periapical radiograph will be dependent on its proximity to the cortical plate, most usually determined by the position of the root apex in the maxilla or mandible



Technology

Today’s high-tech world demands advanced state-of-the-art equipment – both inside and outside the general

dental and specialty practice. Numerous studies have shown that dental professionals who reinvest in their practices with modern technology tend to be leaders in their respective fields with increased production and higher profits. The challenges of our current economy, however, can often limit a practitioner’s practical and financial ability to adopt these innovative products and services. The use of creative purchasing techniques and tools such as Section 179 tax deductions and financing, trading in your current X-ray, or purchasing used or refurbished systems can help minimize the impact of upgrading and keeping up with current imaging technology.

!"#$#%&'()*$+,-$.%./&'()*Historically, one of the easiest ways to realize immediate savings on capital dental equipment purchases is through the IRS Section 179 deduction. This incentive allows business owners to deduct the full price of purchased, financed or leased qualifying depreciable equipment and software for the current tax year. The equipment purchased or leased must be within the specified Section 179 dollar limits and must be placed into service in the same tax year that the deduction is taken. In recent years, the size of the deduction provided an exceptional opportunity for dental practitioners to upgrade, modernize, and invest in their practices. Prior to the economic downturn following the 9/11 tragedy, Section 179 allowed for a deduction of up to $25,000 of qualifying depreciable property used in trade or business activities. To help boost the economy through increased spending in manufacturing and technology, the Jobs and Growth Tax Relief Act of 2003 increased the Section 179 deduction limit from its annual ceiling of $25,000 to $100,000. The annual deduction limit was further increased in 2007 to $125,000 and then again in 2008 to allow for an annual deduction of up to $250,000. It was revised significantly in 2010 to allow a maximum annual deduction of up to $500,000 for tax year 2011 and then dramatically reduced the deduction back to an inflation-indexed $125,000 ($139,000) in 2012. Starting in 2013, the annual deduction limit under Section 179 is scheduled to return to its pre-2003 $25,000 level (see Figure 1). As a result of these significant upcoming changes to Section 179 deductions at the end of this year, dental practitioners should contact their tax advisors to discuss the benefits of acquiring depreciable business assets, such as dental X-ray and cone beam systems in the remaining months of 2012.

012.%3(*The introduction of dental cone beam and the release of newer generations of these systems have created a previously unprecedented trade-in value for 2D panoramic digital X-ray and first generation cone beam units. Due to this demand, several reputable companies have surfaced that purchase, refurbish, and sell used dental X-ray equipment, allowing practi-tioners to recoup a portion of their initial investment by selling or trading their panoramic or cone beam systems. Often, these funds can be provided to the practitioner directly upon removal or sent to the equipment dealer or vendor to apply to the down payment of the new unit. Used equipment dealers can also work directly with the new equipment vendor to coordinate removal of their existing system with the implementation of the new unit, minimizing office “down time” or loss of production. The fair market value of used dental X-ray and cone beam equipment, like that of used vehicles, depends on several factors such as the unit’s make and model, age, condition, and exposure count. Included hardware and networking components such as cephalometric capabilities, ethernet connectivity, and multiple sensors can affect the system’s value. Additional features such as extraoral bitewings, touch panel controls, and other upgrades can also impact the purchase price. Some practitioners opt to sell their existing equipment on their own in an attempt to achieve the greatest profit. However, these transactions often result in improperly licensed software, missing parts, and non-transferable warranties. Plus, delicate X-ray components can be easily mishandled in removal, shipment

!"#$$%&'(#)%*(+&%),%-./#(0$%+,-#%#(01,/#(."+%12%),0(+3&%$4,2,'+

Bryan Delano is a co-founder of Renew

Digital, the leading provider of refurbished

dental X-ray systems. With more than a dozen

years in dental technology experience, he has

held key management positions at Carestream Dental

(KODAK Dental Systems), 360imaging, and topsOrtho.

His extensive background includes practice management

software, dental X-ray technology, implant planning and

patient education. Mr. Delano lives in Atlanta, Georgia

with his wife and two children.

Figure 1

5#+(2%6$7(2,8%4,9:,-20$#%,:%;$2$*%61/1)(78%01&4-&&$&%4#$()1<$%)$4"21=-$&%:,#%12<$&)12/%12%122,<()1<$%)$4"2,7,/1$&


Technology

or installation, resulting in expensive repairs. All of these issues, combined with lost production while managing the process, can be more costly and time consuming than initially anticipated. !"#$%&'()"*+",$'-."/0Many practitioners have chosen to purchase used or refurbished equipment that is current generation or only one generation behind. This strategy can offer a significant cost savings on more advanced 2D digital panoramic systems, 2D/cone beam 3D-hybrid units, or cone beam 3D scanners. Companies that offer used and refurbished dental X-ray systems can often provide the “new” product experience with up to 50% savings off the cost of new equipment. This equipment is typically inspected at time of pick up, refurbished as needed at the company’s warehouse, thoroughly tested again, and resold in an “almost new” condition. They then coordinate product delivery and installation – including the latest imaging software, conduct on-site training, and provide after-purchase service and support. Some companies even include comprehensive product and manufacturer’s warranties. Because refurbished X-ray companies are “vendor neutral” and have access to a wide variety of models, they can help practitioners select systems that best fit their practices, regardless of manufacturer. They can also help find previous generation models to “match” X-ray systems in primary offices for secondary locations, minimizing staff learning curve and software integration issues. Because they are equipment resellers, these companies are also often willing to take existing 2D digital equipment as trade-ins for more advanced 2D or cone beam systems, further reducing the purchase price. For increased affordability, used or refurbished X-ray equipment is eligible for certain low-interest financing programs and Section 179 tax deductions. There are many ways in which modern dental and dental specialty practices can benefit from innovative imaging technologies – and numerous ways to incorporate them, even in today’s tough economic landscape. Implement your smart X-ray upgrade plan today!

Others claim a closedtip, but a microscopemay reveal a muchdifferent story.

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

Care for your patients with the irrigating probe named

the bestin the Journal of Endodontics.

“... the Max-i-Probe removed significantly morebacteria ... the unique side vent of these safety-ended needles produces upward turbulence thatenhances complete cleaning of root canals.”

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

Max-i-Probe®

Endodontic/Periodontal Irrigation Probes

Request a FREE sample at www.RinnCorp.com

‘Closed-end’ generic probe Max-i-Probe

About Renew DigitalRenew Digital is the leading provider of quality refurbished panoramic X-ray and cone beam 3D systems to dentists and dental specialists throughout the U.S. and Canada. Since all systems include delivery*, installation, training, and a comprehensive warranty, Renew Digital offers dental professionals the features and reliability they need to deliver superior patient care more affordably. Visit www.renewdigital.com or call 888-246-5611 for more information.

*Continental U.S. only.

EP

Service profile

DentalBanc has designed a solution to help dentists offer monthly payment options to their patients without creating

extra work for their staff. As an alternative to third-party financing, DentalBanc has saved practices thousands of dollars each year that would otherwise be lost to these third-party companies. !"#$%&'#$()"#*+,$(--"&)#'$,+-+./(01+$2,"3,(4Through the use of DentalBanc’s credit recommendations, practices can easily identify patients who represent a low financial risk and offer them the right payment plan. This helps practices build an accounts receivable portfolio without giving up 10% of their treatment fee. In addition, DentalBanc fully manages the payment plan while leaving the staff free to provide excellent dental care.

5"6(78'$2(#.+)#'$(,+$2,.-+$'*"22.)3Patient trends are changing. Whitening used to be just for the super-wealthy, and braces were just for teenagers. Today, many American adults are willing to spend thousands of dollars to improve their smiles. These changes in patient trends have allowed dental professionals to increase revenues by offering a wide variety of treatments to a new generation of appearance-conscious consumers. Just as patient care preferences are changing, so are patient payment preferences. Cost-conscious patients are exploring their options, literally “price shopping” costly dental procedures, by obtaining several quotes and researching payment options offered by various providers. As a result, consumers with good credit ratings expect no interest financing — even on their dental treatments.

9.)(117:$()$(1#+,)(#./+$#"$#*.,6;2(,#7$<.)()-.)3While some finance companies boast a “12 months, no interest” payment plan, they are charging practices an administrative fee as high as 10% for these plans. Meanwhile patients, believing they are receiving an interest-free option, find that only one missed payment results in retroactive interest as high as 23.99 percent. Third-party finance companies have done their homework and depend upon a calculated percentage of patients failing to meet their obligation of paying on time, thereby incurring usurious levels of interest. Many practices feel that these plans are detrimental to the relationship of trust being built with the patient. By offering a DentalBanc payment plan to patients with a low credit risk, practices can increase profits by 10% or more, maintain patient relationships, and still have the security that they will receive payment for services rendered.

=+,+8'$*">$.#$>",?'@Step 1: DentalBanc provides a credit recommendation to help an office determine the risk associated with each patient. There is no lengthy credit report to analyze. Instead, the doctor receives a credit level along with a payment plan recommendation. DentalBanc’s credit inquiry does not affect the patient’s credit score. With DentalBanc, a practice can determine the risk associated with each patient and offer the appropriate payment plan.

Step 2: Once a practice decides to offer payment terms to a patient,

!"#$%&'#()$*+#,+#-(%./0'%#1+2(&'&3(&4+5$&#'"6'&3+.(*37**$*+(#*+0'18$&#+8,.$"+#-'#+3'&+(80%,)$+3'*$+'33$0#'&3$+'&.+(&3%$'*$+0%,2(#*+91+:;<+,%+8,%$+91+0%,)(.(&4+2"$=(9"$>+&,/(&#$%$*#+0'18$&#+,0#(,&*

DentalBanc will completely manage those accounts. Payments are drafted directly from the patient’s checking account or credit card. The funds are deposited directly into the practice’s bank account each month. If the payment fails for any reason, DentalBanc contacts the patient and schedules the secondary draft. Patients can even check their balance and print receipts directly from DentalBanc’s secure website.

Step 3: DentalBanc will deposit collected payments, four times per month, into the practice’s bank account and provide a Deposit Statement Report with complete details for payment posting.

5(?+$A-#.")@Consider your current payment options. Are you being flexible with your low-credit risk patients by offering them a true no-interest payment plan? Do you have an accounts receivable program? Are you collecting 100% of the treatment fees? Are you working with a professional payment management company that offers reliable, on-time payments or is your office staff overwhelmed with managing customer accounts and collecting late payments? If you answered “no” to any of these questions, call 1-888-758-0584 to learn more about how DentalBanc can work for your practice.

OrthoBanc LLC (DBA OrthoBanc, DentalBanc, and PaymentBanc) is a payment management company that has been serving medical practices since 2001. OrthoBanc currently serves more than 4,000 providers nationwide and manages over half a billion dollars in patient payments annually. They have been on the Inc. 5000 List of Fastest Growing American Companies for the last 4 years. This growth can be attributed to excellent customer service and solutions that are cost effective yet extremely valuable to practices needing an office payment plan.

This information was provided by DentalBanc.


EP

Do you offer expensive procedures that necessitate

an office payment plan?DentalBanc can help!

Call (888) 758-0584 today to learn more.

www.dentalbanc.com

Offer payment plans without sacrificing 10% or more of your treatment fees to

3rd party financing companies.

Determine a patient’s credit worthiness in seconds and offer payment options

based on their ability to pay.

DentalBanc fully manages your accounts and frees your staff to spend more time

building great patient relationships.

!

!

8"


Product profile

With more than 67 years of optical experience, Seiler Instrument is a worldwide leader in the field of microscopy.

Seiler offers a full line of dental and medical microscope products including its newly designed dental operating microscopes: Evolution ZOOM, Evolution XR6, and Seiler IQ, featuring technical advances in their illumination systems, an innovative fluid design, and all Apochromatic lenses for superior optics. The new line of Seiler Dental Microscopes has truly revolutionized the way the dental microscope performs and operates with a greater depth of field, higher levels of magnification, a wide variety of illumination systems, and an enhanced movement specifically engineered for the dental professional. They all provide superior visualization and have been specially designed for ergonomic positioning. In addition, Seiler Instrument Company has recently launched its much anticipated revolutionary illumination systems: the LED and Plasma. Seiler is the first dental surgical microscope company to incorporate Plasma Illumination into its dental product line. The Plasma technology is the next generation in illumination, with over 100,000 LUX and 10,000 hours of bulb life. It has been introduced as an alternative to the expensive Xenon light source, which has typically been regarded as the gold standard compared to other high-level light sources on the market. Unfortunately, this incredibly bright “daylight” technology has its disadvantages: cost and bulb life. The average Xenon bulb costs roughly $800, and the life of the bulb is only about 500 hours. With the introduction of the new Plasma technology, Seiler was able to achieve the same level of brightness and color temperature as the Xenon, at ~5800 Kelvin, but also extend the life of the bulb to around that of an LED or 10,000 hours. In addition to the Plasma light, Seiler has also launched the new LED system. With over 3 years of research into LED illumination, Seiler has achieved the perfect solution for dental microscopy applications. Many LED lights tend to have a blue spectrum and are not as bright when increasing the magnification levels on the microscope. With this, Seiler has created an LED system that eliminates those disadvantages and offers the following characteristics; 50,000 hour bulb life, 5800 Kelvin temperature, and over 80,000 LUX. It is a magnificent light and even better, the end user will never have to replace a bulb again. Along with the introduction of the new illumination systems, Seiler has continued to provide the highest quality in optics with the utilization of all Apochromatic lenses in each and every optical pod. An Apochromatic lens uses three pieces of glass to focus the three primary colors of light (red, green and blue) into focus at the same spot, which in turn, reduces or eliminates chromatic aberration and sharpens the image. Another feature of the Seiler Microscope is the option of video and digital documentation, which has become extremely vital in the dentistry field. With the use of documentation, one is able to educate the patient and help to facilitate the process. Seiler offers a full line of documentation tools such as the new HD CCD live video camera, DSLR cameras, and the HD Video Handy Cams. Each of these can be easily attached to any of the firm’s dental operating microscopes. In addition to the many benefits of owning a Seiler Microscope, Seiler Instrument Company offers a wide range of

options to meet any budget; from the high-end Evolution ZOOM to the very affordable Seiler IQ, which starts off at just under $10,000. The Evolution ZOOM is equipped with motorized ZOOM and motorized focus, which can be can be done either from the optical pod or a foot pedal and offers a continuous zoom magnification from 3x to 24x. The Evolution XR6, the company’s highest rated microscope and top seller, comes standard with six steps of magnification ranging from 2.1X to 20X, while the Seiler IQ is a equipped with three steps (3X, 7X, and 12X). Seiler retains more than 210 employees and has a dedicated sales representative in every state. As part of its commitment to excellence, the firm stands behind all of its products by offering a free, no obligation opportunity to demo a Seiler Microscope. Seiler also offers a lifetime warranty on the mechanics and optics of each microscope. For additional information, please contact Seiler Instrument and Manufacturing Company, Inc. at 800-489-2282, or visit www.seilermicro.com.

This information was provided by Seiler Instrument and Manufacturing Company, Inc.

!"#$%&'("$%%)"*+",'-$'(".-#(%&#%/'&"*01"234"-$$5.-0*+-%0

EP


Product profile

!"#"$%&%&'("&#)#)&*%+,-%)+"./0%+(*"+1&)2)'3

4&#)5"67"&+"8(-9(5"/2".:(/&#(!))*(!";/%.(</*".%/2(=!!<:>

EndoSequence BC Sealer and Root Repair Material are redefining the way many specialists approach endodontic obturation and

root repair procedures. For years, scientists and practitioners alike have been in search of a root canal sealing and repair material which contains the following characteristics:· Biocompatible· Antibacterial· Optimal handling (user friendly consistency and premixed)· Osteogenic (healing)· Non-shrinking (dimensionally stable)· Chemical bond to dentin and filling material· Excellent flow (small particle size)· Radiopaque· Sets in the presence of moisture Recent advancements in Bioceramic Nano-Technology have allowed for the creation of two novel materials (EndoSequence BC Sealer and Root Repair Material) which contain all of the above characteristics.

!"#$%&'(&")&*+,-+%&./&01Unlike conventional base/catalyst sealers, BC Sealer utilizes the moisture naturally present in the dentinal tubules to initiate its setting reaction. The canal should be dried, but unlike other sealers, the set will not be inhibited by moisture. This highly radiopaque and hydrophilic sealer forms hydroxyapatite upon setting and chemically bonds to both dentin and to our bioceramic points (EndoSequence BC Points™). BC Sealer is antibacterial during setting due to its highly alkaline pH (+12), and unlike traditional sealers, BC Sealer exhibits absolutely zero shrinkage

and is extremely biocompatible! BC Sealer can either be syringed directly into the coronal third of the canal or delivered via a hand file or point. BC Sealer can be used with cold or heated methods. However, many specialists have come to the conclusion that heat is not necessary with BC Sealer because of its slight expansion (.02%) and its ability to bond to dentin. This truly revolutionary sealer has remarkable healing properties and is designed specifically to be non-resorbable. In the event of a slight overfill (puff), an anti-inflammatory reaction will not occur because the sealer is essentially a root repair material with a flowable viscosity.

!"#$%&'(&")&*+2$$3+2&4.50+6.3&05./+722618EndoSequence® Root Repair Material (RRM™) is available in two specifically formulated consistencies (syringable paste or condensable putty) and contains many of the same characteristics as BC Sealer. Like BC Sealer, the setting reaction of RRM is driven by the moisture naturally present within the dentinal tubules so there is no mixing required. The favorable handling properties, increased strength and shortened set time (~1.5-2 hours), make RRM highly resistant to washout and ideal for all root repair and pulp capping procedures. The putty consistency is ideal for retrofills, one step apexifications (apical barrier technique), external resorptions, and pulp capping. The syringable version is recommended for retrofills, perfs, internal resorptions, and pulp capping. Many specialists employ a retrofill technique that involves syringing some of the flowable RRM into the prep and following it up with pre-formed cones of the RRM putty. The consistency of RRM putty is similar to that of Cavit™, and it is extremely resistant to washout making it ideal in difficult fields. The unique properties of RRM putty allow the practitioner to adjust the consistency to his/her liking. The more the material is manipulated (via kneading it with a sterile instrument within the jar provided), the more flowable it will become. RRM is antibacterial (12+ pH) and is extremely biocompatible and osteogenic. Join the thousands of specialists that have set their spatulas aside and joined the RRM revolution!

For more information or to order, contact Brasseler USA: 800-841-4522 or visit www.brasselerusa.com

Cavit™ is not a trademark of Brasseler USA or Endodontic Practice US.

This information was provided by Brasseler USA.

EP


Product profile

!"#$%&'%()$*&+,'(-(./01)&%*)&12$3&'*1-$+&-&4)1*&%$56$/&1)%$(7$!"#$89.9*1-$)189(.)1:,/$

Thirty years after the advent of RadioVisioGraphy (RVG) in 1982, Carestream Dental is celebrating 3 decades of providing

dental practitioners worldwide with unparalleled image quality. Invented and patented by visionary French dentist Dr. Francis Mouyen, RVG imaging delivers digital images instantly, creating a more efficient workflow for practices and improving patient communication. Since its introduction, RVG has established a continuing tradition of innovation in digital radiography, including milestones such as offering the first sensor to provide >20 lp/mm resolution and a wireless sensor that can easily be shared between operatories. Today, Carestream Dental’s RVG family features three sensor options for practitioners.

Serving as entry point into digital dental radiography, the RVG 5100 provides practices with an ideal solution for basic intraoral imaging needs. With two sensor sizes available, this system is easy to use and delivers exceptional images (true resolution of 14 lp/mm) in seconds. Introduced in 2006, the RVG 6100 offers the highest image resolution in the industry (>20 lp/mm) and delivers images in seconds. Perfect for multi-chair practices, this system is designed to streamline workflow with easy image capture, analysis and sharing. RVG 6100 sensors are available in three sizes, including a size 0 sensor for pediatric applications. Delivering the same, best-in-class image quality as wired RVG 6100 sensors, the RVG 6500 system (introduced in 2010) uses proven wi-fi technology to eliminate the need for the sensors to have a wired connection to a computer. This flexible system can be used in a variety of practice configurations, including multi-sensor and multi-computer environments. Available in three sizes, RVG 6500 sensors transfer images to operatory computers within seconds. “The introduction of RVG imaging caused a significant shift in the oral health industry – a shift towards digital technology,” said Edward Shellard, DMD, chief marketing officer and director of business development for Carestream Dental. “Over the years, we’ve continued to develop and strengthen our offerings in the digital radiography category so our products meet clinicians’ diagnostic needs, integrate into practice workflows, and are easy to use. From the invention of the digital sensor to the introduction of a wireless sensor that offers the highest image resolution, our line of RVG products has evolved to serve the ever-changing needs of our customers and their patients.”

EP

Carestream Dental’s current RVG solutions integrate seamlessly with the company’s various imaging software programs. Additionally, Logicon Caries Detector™ Software serves as a computer-aided diagnostic tool that helps practitioners locate and diagnose interproximal caries using a database of known caries problems. Carestream Dental’s RVG sensors are built with rounded corners and rear-entry cables to ensure patients are comfortable. All sensors are also built with shock-resistant casing, providing maximum durability for a long lifespan. For more information on Carestream Dental’s RVG product family, call (800) 944-6365 or visit www.carestreamdental.com.

This information was provided by Carestream Dental.

Practice management

Ultimately, the success of your practice is not limited by the economy, competition, or any other external factor. It thrives

(or simply just survives) on your ability to hire, train, and retain an excellent staff. With an exceptional staff, you are able to consistently deliver outstanding service, which gives your practice a powerful competitive advantage. But, how do we find good people? What’s the best way to select the right person? And, how do we decide if we should keep a new employee? This article will take a detailed look at the hiring process, reviewing the key steps, suggesting ways to improve and, thereby, increasing your chances of choosing the right person.

!"#$!"%##$&''#()*+,$-*%*(.$/0*,,'All of us have experience hiring staff, and no one can presume to know the unique situation or specific challenges you might face in finding good employees. Nonetheless, under all circumstances, hiring the right person for your practice comes down to three basic skills:

find the right person choose the right person

employ and retain only those who are right for your practice So, what are the best strategies to add someone who will become an asset to your practice?

Finding the right personActually, we don’t really “find” the right person; instead, the best practices attract the right person. Good employees will not even consider your office unless it’s a great place to work. So, the best way to find the right person is to make your practice highly attractive to the kind of employee you want. You must get your house in order first if you expect the best applicants to apply. So, even before you’re actively hiring someone, the best way to attract the right person is to make your practice the “employer of choice” for potential staff in your community. The best people will not even consider your practice unless your present staff raves about your office and encourages others to apply.

Finding Strategy #1: Become the “employer of choice”To attract great employees, focus on making your practice the “employer of choice” in four key areas:

— A good salary and benefits package is merely the “price of admission” to be considered by the best person. Since the best people in other offices are usually being paid well already, it will take more than a good financial package to attract them to your practice.

1 — Is your practice staying current and constantly adapting to new technologies and ways of serving your patients? Is your leadership inspiring and your purpose clear? The best people don’t want to remain stagnant; they want opportunities to learn and grow. At the end of the day, they want job satisfaction and the feeling that they have made a meaningful contribution.

— What are the key frustrations that staff feel when working in any dental practice? Have you solved these problems in your office? The best employees

J. Richard (Rick) Steedle, DMD, MSEd, MS, received his dental degree with honors from the University of Pennsylvania, concurrently completing a Masters Degree in Education. He received his Masters Degree in Orthodontics at The University of North Carolina at

Chapel Hill where he was awarded the Morehead Fellowship in Post Graduate Dentistry and a NIH research training fellowship. After orthodontic residency, he served on the faculty of the Wake Forest University School of Medicine for 4 years before entering private practice. During the next 20 years, he and Dr. Bruce McLain built a three-office orthodontic practice with a staff of more than 25 employees in Winston-Salem, North Carolina. In 2005, Dr. Steedle joined the part-time faculty at the Department of Orthodontics in Chapel Hill. Since then, he has developed a 3-year curriculum in Practice Management for the residents, complementing the work of Dr. Robert Scholz there. UNC now has one of the most comprehensive Practice Management residency courses in the country. Contact Dr. Steedle at [email protected].

12%$3%+4)*4#'$)"+)$5+()$)2$"*%#$.%#+)$#63,27##'8$9%:$;*40$/)##<,#$'=..#')'$5"7$72=$6+7$(2)$"+>#$?##($'=44#''@=,$*($)"#$3+')$+(<$2@@#%'$'2=(<$+<>*4#$2($"25$)2$"*%#$?#))#%$')+@@$*($)"#$@=)=%#

HIRING)"#$;*.")$A#23,#


Practice management

are looking for a great working environment that includes a manageable work schedule, a compassionate, yet fair, leave policy, great office systems, sufficient training, and the necessary support to do their jobs well.

How are the interpersonal relationships in your office? Do all staff members work as one team, or do they often annoy each other with petty squabbles? The best people want co-workers who care for each other, a doctor who appreciates them, and a voice in improving the operations of the practice. When you do begin to look for a new employee, how then do you find and attract the best person? Where are the best potential applicants working now, and what type of advertisement would attract them?

Finding Strategy #2: Write an appealing adA standard ad will not get the attention of the best people. Invest your time and money in an ad that appeals to an excellent applicant by wording it to attract the type of person you want. Be sure to include which personal traits are desirable, what makes your practice unique, and how they may have opportunities to grow. It may take a little more time and possibly cost a little more money, but what is the value of finding a great employee?

staff, design a classified ad to attract applicants outside the dental profession. Applicants with the right attitude and outlook are often employed in other customer service jobs. Although Craigslist is a popular and inexpensive way to advertise for a position, consider that the best applicants may be more inclined to read the classifieds in the local paper and scan online services like Monster.com or CareerBuilder.com when choosing new employment. Ask your staff to refer others like themselves. If you’ve made your office the “employer of choice,” they will not hesitate to encourage other great potential employees to join your team.

even when you’re not hiring. This way you can create a pool of potential applicants for when you need it. When you encounter people who give you great service, hand them a business card, and ask them to call if they are considering a job change. “We’re always looking for excellent people like you.” They’ll be flattered by the compliment, and you may have found an excellent future employee.

Choosing the right personThe best way to choose the right person is to have a highly selective hiring process that involves the entire team. In order to choose the best employees, first you need to be clear on what type of individuals are best suited to work in your practice and, second, have an effective way to identify them.

It’s natural to think that you need applicants with experience who can step right in and won’t need much training. However, practices that over-value and hire only the skilled employee may discover that these are the same people who later create interpersonal problems with the staff and patients. We can usually train someone to perform the skills needed to do well, but we can’t train people to have strong interpersonal skills. A better way is to choose self-motivated people who share your core values, can learn their jobs quickly, and who, by their very nature, are caring and compassionate. Therefore, hire and retain “good heads” and “good hearts,” not necessarily just “good hands.” When hiring, it’s great if you can get all three, but it’s

essential that you get the first two.2

If you are the only one who interviews applicants and independently makes the hiring decision, you have created an environment in which your present staff is not fully invested in helping the new employee succeed. In the best practices, the staff is deeply involved in the interview process, and guides the final decision about who to bring on the team. Once applicants have met with your approval, let the final selection be made by a consensus of your staff. If everyone has a voice, then everyone can commit to welcoming the new employee and training him/her to be a productive member of your team.

To be highly selective, you need a systematic approach for choosing the best applicant rather than counting on just a favorable impression from an application and interview. This should include:

— prepare an attractive advertisement, and conduct a wide-ranging search.

— identify applicants whose resumes display the qualities desired, and have a trained staff member prescreen them on the phone, inviting for an office visit only those applicants whose telephone interview meets your standards.

— have the applicant meet with the staff who will work closely with the new employee and schedule a short interview with you to get a preliminary impression. If the initial impression is favorable, invite the applicant for a one-half to full day in the practice to better assess the fit. Even though first impressions are important, several hours with the applicant is a better way to gauge his/her true nature.

— hire someone only when there is consensus among the staff that this is a person who is self-motivated, shares your core values, and has a good head and heart. If there are reservations among the staff, don’t hire, keep looking. Taking some additional time to find the right person is preferable to endlessly spending time managing the wrong person.

Retaining the right personThe best way to employ the right person is to have a highly discriminating probationary period, so that an applicant is retained only when you are 100% certain that he/she is right for your practice. Even if you attract and select the right person, you still must be absolutely certain that this new employee can become a productive and harmonious member of your team. Both the team and the new hire need a probationary period of at least 90 days to evaluate the fit. During this time, the new employee is considered a temporary hire, and either party can walk away without giving advance notice.

Even the best new employees need a thorough training program. The program should include several key elements. It should:

best trainer (someone who can give clear guidance and emotional support to the new employee).

protocols documenting your processes and procedures.

(using direct observation of the trainer, followed by the trainee performing the task with the trainer observing, progressing to executing the position with a ready backup, and finally leading to independent performance).


Practice management

During the probationary period, frequent and specific feedback from the trainer is essential. Is the new person learning quickly, displaying professional behavior, demonstrating a caring and compassionate attitude, and taking the initiative to become a team member? At least monthly, the trainer should take some time with the new employee to honestly assess progress and offer suggestions for improvement. Any reservations about the new hire should be communicated immediately to the doctor and team. Everyone should be given a fair chance, but the best future employees will clearly demonstrate their value as high performers and excellent teammates in the first 3 months.

Retaining Strategy #3: Be 100% certainIf you have done your job well in the selection phase, the probationary period usually goes well. In some cases, however, the new employee may learn that the position is not what he/she expected. In other cases, you may discover that he/she is not all that you thought. If you or your team has any doubts, it’s best that you dismiss the new person during the probationary period. As difficult as this might be, you should retain a new hire only when everyone is 100% certain that the employee is right for your team. It’s not a question of whether everyone likes the new person. Usually everyone will. The decision is based purely on the “fit” for your office. Not being decisive at this point only sets the stage for problems later on.

!"#$%#&$'()(*+$,)(*-(./#0Developing an outstanding staff starts with hiring good people

and then forming them into an All-star Team. Unfortunately, as Jim Collins points out in his classic book, Good to Great, “If you have the wrong people on the bus, it doesn’t matter whether you discover the right direction; you still won’t have a great company,”3 or a great practice.

bus,” the “key hiring principles” then are:Attract

By becoming the “employer of choice” for the best people and conducting a wide-ranging search to locate them.

SelectThrough a rigorous selection process in which team members participate in the decision to choose the right type of person, not just the one with the right skills.

RetainBy using a well-designed training program with frequent feedback and retaining the new employee only when you and your staff are 100% certain that he/she is right for the team.

References1. Steedle JR (2011) Becoming the successful, not stressful practice:

Orthodontic Practice US 2 (2): 45-47.

2. Steedle JR (2010) Leading an all-star staff, J Clin Orthod, 44(8): 487-494.

3. Collins, J (2001) Good to Great: Why Some Companies Make the Leap... and Others Don’t

EP


Materials & equipment

Brasseler USA- EndoSequence® BC Sealer™

Introducing a revolutionary premixed root canal sealer utilizing new bioceramic nanotechnology. Unlike conventional base/catalyst sealers, BC Sealer utilizes the moisture naturally present in the dentinal tubules to initiate its setting reaction. This highly radiopaque and hydrophilic sealer forms hydroxyapatite upon setting and chemically bonds to both dentin and to our bioceramic points (EndoSequence BC Points™). BC Sealer is antibacterial during setting due to its highly alkaline pH, and unlike traditional sealers, BC Sealer exhibits absolutely zero shrinkage and is extremely biocompatible. For more information, call BrasselerUSA at 800-841-4522 or visit www.BrasselerUSA.com

Introducing the Evolution xR6 LED dental operating microscope from Seiler

The all-new illumination system comes with a 50,000 hour bulb guarantee, which equates to nearly 20 years without changing a bulb. Seiler’s LED is one of the brightest on the market with nearly 80,000 LUX providing a clear, sharp image every time. Seiler has developed the LED light to attain a 5800 Kelvin temperature, which will remove the blue spectrum found in many other LED lights. The Seiler Evolution xR6 has truly revolutionized the way the dental microscope performs and operates. Seiler continues to stay at the forefront of fine optics and stands behind their products with a lifetime warranty on the optics and mechanics. To experience the Seiler advantage, call 1-800-489-2282 to schedule a demo or visit www.seilermicro.com

New version of Logicon Caries Detector™ software further automates the caries detection process

Carestream Dental’s Logicon Caries Detector™ software version 5.0.22.4 is a computer-aided detection tool that helps dentists identify and treat more interproximal caries at an early stage for improved patient care. Exclusively designed to work with images captured by Carestream Dental’s RVG sensors, Logicon Software is clinically proven to help dentists find more interproximal carious lesions than with traditional methods and automatically highlights possible abnormalities in dental radiographs, calculates the probability that decay is present, and recommends whether a restoration should be considered. To request a product demonstration, call 800-944-6365.

The latest from OSADAEnac Model OE-F15

Osada’s latest model Piezoelectric ultrasonic system, Enac OE-F15, focuses on powerful but safe bone-cutting (power #10 through #15): the surgical tips (a.k.a. ultrasonic scalpels) enable the surgeons to present the magical effect - Osada’s signature - fine, precise cutting results. Combined with newly introduced stronger tips, the OE-F15 makes minimally invasive surgical procedures easier to attain by cutting the bone faster but leaving the adjacent soft tissue, blood vessels, nerves, etc. with minimal injury. The ergonomically designed SE15 handpiece stays cool, and its LED illuminates the surgical area. The built-in peristaltic pump with simultaneous irrigation minimizes temperature increases on the handpiece, tips, and the surgical area. For more details, call 800-426-7232 or visit www.osadausa.com.

NEX tungsten carbide cutters from KOMET USA

NEX tungsten carbide cutters from KOMET USA provide maximal substance removal and virtually vibration-free, smooth operation due to innovative, geometric toothing. Engineered for use on non-precious metals and model cast alloys, the cutters are particularly suited for techniques requiring efficient substance removal, such as shape corrections and occlusal-surface trimming. In addition, the cutters facilitate operation in interdental and hard-to-access areas where working space is limited. Easily identified by their golden shanks, laser marks, and distinctive green rings, user-friendly NEX cutters are gentle to the user’s wrist, facilitating tactile, intuitive operation. For more details visit www.komet-usa.com.

Versa Brush™ rotational utility brush for a variety of endo procedures

In response to growing demand in the endodontic c o m m u n i t y , Vista Dental Products has just reintroduced its popular Versa Brush™, an incredibly strong and bendable spiral utility brush that can be adapted to any low speed rotary device. Exclusively available from Vista, the Versa Brush™ is ideal for use in a wide variety of endo procedures including removal of cement, post hole cleaning, and cleaning coronal access openings. The Versa Brush™ is designed to fit a low speed rotary handpiece for use at 250 rpm or less. For more information, call 1-877-418-4782 or 262-636-9760 or visit www.vista-dental.com.


Diary

!"#$%&'%('%)*+,-%(,(.)/01,&%Dr. Jaimeé MorganSeptember 2-9, 2012Cabo San Lucas, Mexico800-520-6640

2&&%(-,#$)2(34Dr. Jorge VeraSeptember 7, 2012Miami, FLSeptember 14, 2012Salt Lake City, UTNovember 2, 2012Grapevine, TXDr. Joseph D. MaggioSeptember 7, 2012Wichita, KSSeptember 28, 2012Minneapolis, MNOctober 5, 2012Phoenix, AZOctober 12, 2012Covington, KYOctober 19, 2012Des Moines, IADr. John S. OlmstedSeptember 7, 2012Amarillo, TXSeptember 28, 2012Birmingham, ALOctober 5, 2012Westminster, CODr. Garry L. BeySeptember 7, 2012Moorhead, MNSeptember 14, 2012Little Rock, AROctober 19, 2012Albany, NYOctober 26, 2012Bismarck, NDDr. Fred BarnettSeptember 14, 2012Providence, RIDr. Thomas JovicichSeptember 14, 2012Albuquerque, NMSeptember 21, 2012Houston, TXOctober 5, 2012Austin, TXOctober 12, 2012Seattle, WANovember 2, 2012Fresno, CADr. Brett GilbertSeptember 21, 2012Ft. Wayne, INSeptember 28, 2012St. Louis, MOOctober 26, 2012East Elmhurst, NY

Dr. Garry GlassmanSeptember 21, 2012New Orleans, LAOctober 5, 2012Boston, MAOctober 19, 2012Novi, [email protected]

/100%(-)5',%(-,6,')27,3%('%),()2(3434(-,')8+%0#"9Dr. Sergio KuttlerSeptember 8, 2012Honolulu, HIOctober 5, 2012Redding, CADr. Ryan FacerSeptember 14, 2012Boise, IDDr. George BruderSeptember 14, 2012Long Island, NYDr. Karam Ashoo & John PetersSeptember 14, 2012Moncton, NB (Canada)Dr. Diwakar KinraSeptember 14, 2012Seal Beach, CAOctober 26, 2012Cleveland, OHDr. Kevin CalzonettiSeptember 21, 2012Kitchener, ON (Canada)Dr. Jeffrey CoilSeptember 22, 2012Regina, SK (Canada)September 29, 2012Parkville, BC (Canada)Dr. Frank CervoneSeptember 28, 2012Rochester, MNOctober 12, 2012Portland, OROctober 19, 2012Milwaukee, WIDr. Donnie LuperOctober 6, 2012Cincinnati, OHOctober 12, 2012Atlanta, GANovember 2, 2012Minneapolis, MNDr. Larry FarsakianOctober 12, 2012Concord, NHDr. Manor HaasOctober 19, 2012Montreal, QC (Canada)October 26, 2012Toronto, ON (Canada)Dr. Troy McGrewOctober 19, 2012Seattle, WA

Dr. Michael RiberaNovember 2, 2012Pittsburgh, PA800-662-1202 (press option 1)Register.tulsadentalspecialties.com

:%&&4(&)46)-+%);4<(-10(=)>4&,-,4(,(.)640)-+%)?1-10%Dr. Dan Fischer & Carol JentSeptember 14, 2012Austin, TXSeptember 28, 2012Dearborn, MIOctober 13, 2012Philadelphia, PANovember 2, 2012Los Angeles, CAwww.ultradent.com

@%#$,A,(.)51''%&&),()2(3434(-,'&B)C)5',%(-,6,')C""04#'+Dr. William NuderaSeptember 13, 2012Bloomington, MN800-662-1202 (press option 1)Register.tulsadentalspecialties.com

>#-+<#9&)-4)51''%&&B)2(3434(-,')!1-'4D%&)E#&%3)4()5',%(-,6,')27,3%('%Dr. Sergio KuttlerSeptember 14-15, 2012Detroit, MISeptember 28-29, 2012Allen, TXDr. Donnie LuperSeptember 14-15, 2012Naperville, ILDr. Frank CervoneSeptember 21-22, 2012Modesto, CAOctober 5-6, 2012Rochester, NYDr. Troy McGrewSeptember 28-29, 2012Lubbock, TXDr. George BruderOctober 5-6, 2012Denver, COOctober 19-20, 2012Wilmington, DEDr. Michael NimmichOctober 5-6, 2012Richmond, VAOctober 26-27, 2012New Orleans, LADr. William NuderaOctober 12-13, 2012Kansas City, MO800-662-1202 (press option 1)Register.tulsadentalspecialties.com



There are many factors that influence the long-term retention of critically essential teeth. Certainly, endodontic procedures

pose treatment considerations when performing restorative dentistry. Each procedural step that comprises start-to-finish endodontic treatment should be aligned with the restorative goals. Properly performed, interdisciplinary treatment serves to fulfill the general public’s expectation that dentists do no harm while doing good. Those who have practiced dentistry over the years have noticed the remarkable advancements in technologies, instruments, and materials that have occurred within each dental discipline. These advancements are intended to improve the level of care our profession provides patients. Some of these innovations have changed the way we approach various aspects of our clinical work. This means that certain time-honored interdisciplinary treatment techniques have clinically evolved and been redefined. The first endodontic procedural step that directly influences restorative treatment is preparing the access cavity. In general, the mechanical objectives are to create straight-line access to any given orifice and underlying canal system. Further, the axial walls of the access preparation should be flared, flattened, and finished. Finally, the internal triangles of dentin are eliminated to improve radicular access. Creating coronal and radicular access facilitates directing small-sized hand files through multiplanar curvatures and to length. The access preparation serves to influence all subsequent steps of endodontic treatment. The second endodontic procedural step that directly influences restorative treatment is shaping the canal. The mechanical objectives for shaping a canal must balance the desire to disinfect and fill root canal systems with the structural preservation of coronal, cervical, and radicular dentin. Dr. Herb Schilder did just that nearly 40 years ago in his famous article entitled, “Cleaning and Shaping the Root Canal.” In this article, he brilliantly described the five mechanical objectives for shaping canals that would be appropriate for any given root. Recently, attention has refocused on how preparing access cavities and shaping canals directly impacts restoring endodontically treated teeth. Although this attention is clinically relevant, there is no need for opinions to be steeped in an avalanche of marketing hype. To support this assertion, dentists have recently been confronted by a misinformation campaign that reverently positions certain just-to-market access burs. What is claimed is these burs “act as a self-centering guide for straight-line access to canals.” This statement is simply foolish because, by definition, a self-centering bur must fit in an already predetermined and existing pilot hole. With zero evidence, it is further claimed these burs preserve peri-cervical dentin and prevent what is termed “run-off.” Run-off is described as round burs that overzealously remove dentin, gouge, or potentially perforate. Virtually all dentists would agree it is the operator, not the bur, who makes the difference when cutting the access preparation. The overall dimension of the finished canal preparation influences restorative results. Looking back over the decades, there were eras where the shifting shapes could be characterized

as too small or too big. When the shapes were underprepared, we compromised disinfection and the potential to fill root canal systems. On the contrary, when the shapes were overprepared, we invited root thinning, fractures, or strip perforations. The Holy Grail of endodontic canal preparation is not too small, not too big, just right. Recently, the late Dr. Schilder, one of the greatest minds, clinicians, and endodontic educators our profession has ever witnessed, was attacked in absentia. In an astonishing published statement that completely misrepresented Schilder’s classic article, the dental author wrote, “The big aggressive canal-flaring party is officially over.” He is apparently unaware of the strong relationship that exists between general dentists and endodontists by further stating, “Restorative dentists can reclaim endodontics.”* In a recent dental publication, a CEO proclaimed that his company’s recently launched file “really is unique because it has a patented variable taper that at the top of the file is much more conservative and allows for the preservation of cervical dentin to a higher degree than any file system on the market.”* There is no scientific evidence to support this statement. For the record, the ProTaper® NiTi rotary file system came to market more than a decade ago, offering a unique, patented, and decreasing percentage tapered design over the active portion of a single Finishing file. In other words, what the CEO claimed as innovative is exactly what the ProTaper system brought to endodontics in 2001. What the ProTaper development team recognized so many years ago is that a file with a decreasing percentage tapered design would conserve coronal and peri-cervical dentin and improve flexibility compared to a file of the same D0 diameter and apical one-third taper. For example, a 25/08 ProTaper Finishing file has a tip diameter of 0.25 mm and an 8% fixed taper from D1-D3. However, because the 25/08 ProTaper file has decreasing percentage tapers from D4-D16, the D16 diameter is 1.05 mm vs. a dangerous 1.53 mm if, in fact, this same file had a fixed taper of 8% over its entire active portion. I have noticed that an increasing number of recently launched products are marketed through unsubstantiated claims or positioned as “new” discoveries. Clinicians need to make the critical distinction between this marketing hype and the clinical reality that predictably successful endo restorative treatment is achieved through knowledge, skill, and experience, combined with the integration of the most proven technologies and techniques into everyday practice. Keep this on your radar!

*References available upon request.

Clifford J. Ruddle, DDS, FACD, FICD, is founder and director of Advanced Endodontics (www.endoruddle.com), an international educational source, in Santa Barbara, California. Additionally, he maintains teaching positions at various dental schools. Dr. Ruddle can be reached at [email protected].

Ruddle on the radar

!"#$%&'()$&*)+,'%-$"(+#'&*)+$"(

!"#$%&'()*+,-%*./0*12'('1"2*#%"2'&,

EP

TDO IS COMMITTED TO EDUCATIONWe believe educators will determine the future of our specialty. TDO University gives your

endodontic residents the edge they need to be their best.

A state-of-the-art endodontic educational system, TDO University provides sophisticated

educational tools that are easy to use.

At TDO, we believe mentoring is

the best way we can give back to

the endodontic community. For a

one-time fee of $50, postgraduate

residents can join TDO Clinical, an

online forum where they can see

and participate in inspiring cases

and join in discussions between

top clinicians, educators, and

residents from around the world.

With TDO University you can perform complex

clinical, management, and accreditation queries with

a click of your mouse.

TDO University’s EHR certified module is the perfect

complement to axiUm Academic software™.

TDO University is only a one-time fee of $1,000

plus annual technical support.

Set your program apart. Raise the bar with TDO

University. Call 858-248-7757, email sales@tdo4endo.

com, or visit www.tdo4endo.com/TDOPostgrads.

aspx for more information.

This EHR Module is 2011 compliant and has been certified by an ONC!ATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and

Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.

Documents

Endodontic Practice US September 2012 Vol. 5 No. 5