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Tạp chí nội nha tháng 11 & 12 /2013 Vol6 No 6
clinical articles • management advice • practice profiles • technology reviews PROMOTING EXCELLENCE Top ten tips 10 # When things go wrong IN ENDODONTICS TO SHARPEN YOUR VISIBILITY November/December 2013 – Vol No Fiber posts and tooth reinforcement Drs Leendert Boksman, Gary Glassman, Gildo Santos, and Manfred Friedman Corporate profile Planmeca Practice profile Dr Brian Trava Pride Institute “Best of Class” special awards tribute PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR! VISIT PAGE Dr Tony Druttman The Perfect Chairside Solution “Cover the complete coronal to apical length and provides more mesial-distal information.” CONVENIENT CHAIRSIDE WORKFLOW • Easy for your assistant; efficient for you EXCEPTIONAL DIAGNOSTIC CLARITY Norman Rich, DDS • Up to 38%* more image area―capture every root tip (even on maxillary canines) UNMATCHED PATIENT COMFORT • Flexible, cordless phosphor sensors for easy, comfortable placement, even for third molars EXCELLENT DIGITAL RADIOGRAPHY • Get 100% of the images you want, even for patients with small mouths, large tori, or gag reflexes SMART INVESTMENT Ask for a Product Demo in Booth# 3809 @ GNY • Less expensive than rigid sensors (and no insurance needed) Digital Imaging Without Limits * An Independent, non-profit, dental education and product testing foundation: Issue 9, September 2011 To order please contact your local dealer For more information, visit www.airtechniques.com IMAGING UTILITY ROOM MERCHANDISE No in a Series “And ye shall know the truth and the truth shall make you free…” ~ JOHN VIII-XXXII ASSOCIATE EDITORS Julian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICD Richard Mounce DDS Clifford J Ruddle DDS John West DDS, MSD EDITORIAL ADVISORS Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A Baumann Dennis G Brave DDS David C Brown BDS, MDS, MSD L Stephen Buchanan DDS, FICD, FACD Gary B Carr DDS Arnaldo Castellucci MD, DDS Gordon J Christensen DDS, MSD, PhD B David Cohen PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen MS, DDS, FACD, FICD Simon Cunnington BDS, LDS RCS, MS Samuel O Dorn DDS Josef Dovgan DDS, MS Tony Druttman MSc, BSc, BChD Chris Emery BDS, MSc MRD, MDGDS Luiz R Fava DDS Robert Fleisher DMD Stephen Frais BDS, MSc Marcela Fridland DDS Gerald N Glickman DDS, MS Kishor Gulabivala BDS, MSc, FDS, PhD Anthony E Hoskinson BDS, MSc Jeffrey W Hutter DMD, MEd Syngcuk Kim DDS, PhD Kenneth A Koch DMD Peter F Kurer LDS, MGDS, RCS Gregori M Kurtzman DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd BDS, MSc, FDS RCS, MRD RCS Stephen Manning BDS, MDSc, FRACDS Joshua Moshonov DMD Carlos Murgel CD Yosef Nahmias DDS, MS Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot DCSD, DEA, PhD David L Pitts DDS, MDSD Alison Qualtrough BChD, MSc, PhD, FDS, MRD RCS John Regan BDentSc, MSC, DGDP Jeremy Rees BDS, MScD, FDS RCS, PhD Louis E Rossman DMD Stephen F Schwartz DDS, MS Ken Serota DDS, MMSc E Steve Senia DDS, MS, BS Michael Tagger DMD, MS Martin Trope, BDS, DMD Peter Velvart DMD Rick Walton DMD, MS John Whitworth BchD, PhD, FDS RCS CE QUALITY ASSURANCE ADVISORY BOARD Dr Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com Tel: (480) 403-1505 MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Kay Harwell Fernández Email: kay@medmarkaz.com Tel: (386) 212-0413 EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com Tel: (727) 393-3394 DIRECTOR OF SALES | Michelle Manning Email: michelle@medmarkaz.com Tel: (480) 621-8955 NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595 PRODUCTION MANAGER/CLIENT RELATIONS Adrienne Good Email: agood@medmarkaz.com Tel: (623) 340-4373 PRODUCTION ASST./SUBSCRIPTION COORD Lauren Peyton Email: lauren@medmarkaz.com Tel: (480) 621-8955 MedMark, LLC 15720 N Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.endopracticeus.com SUBSCRIPTION RATES year (6 issues) years (18 issues) $99 $239 © FMC, Ltd 2013 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 Volume Number This quote from the book of John is inscribed on the lobby wall of the Central Intelligence Agency headquarters in Langley, Virginia, and I think of it often while treating patients In clinical endodontics, as with all science, few things are as important as truth Our essential sworn duty is to “do no harm.” We risk no greater harm to our patients than when we proceed on the basis of assumption, presumption, or habit, without first doing everything we can to ascertain the truth of our patient’s condition Fortunately, we have tools today that allow us to see more, appreciate more, and evaluate more of a patient’s condition than ever before My first epiphany in this realm was while still practicing general dentistry My insatiable quest for continuing education took me to Santa Barbara, California, under the guidance of Dr Cliff Ruddle It was there that I first looked through a dental operating microscope I was literally AMAZED! French author Marcel Proust once observed, “The true voyage of discovery consists not in seeking new landscapes, but in having new eyes.” As soon as I integrated a dental microscope into my general practice and peered through the lenses, I understood the truth of Proust’s wisdom Thanks to the lighting and magnification of the scope, I was seeing the closest thing possible to the truth of my patient’s condition Now I could see, with vivid clarity, every tooth margin I looked, in intimate detail, at things that I saw clinically…but had not really seen Shortly, I came to realize another truth: we cannot treat what we cannot see And the better we can see it, the better we can treat it Proper use of the microscope impacts everyone involved in patient care: the clinician who immediately gains confidence, the assistant (hopefully utilizing the assistant’s binoculars) who can better anticipate and understand the clinical conditions and needs, the office staff who know that their clinicians are providing the most well-informed care possible, and of course, the patients themselves who benefit from potentially reduced chair time, reduced pain and discomfort, decreased recovery times, and less risk of the need for future treatment While attending graduate school at Boston University, my mentor, Dr Herb Schilder, sometimes referred to me as “The Virus,” because I was so excited about new dental technologies — and I was all too eager to share that enthusiasm with my classmates, my teachers, and anyone else who would listen But the truth is that my love affair is not really with technology itself, but with what I can with it And that still holds true today The things that we are able to today with technology in dentistry are truly amazing Without question, I consider the dental operating microscope the single most important piece of technology that I have incorporated into my practice Like the microscope, which I discovered purely by accident, more recently, Cone Beam Computed Tomography (CBCT) has proven to be a practice game changer for me And like the microscope, it has transformed both the way that I practice and the way that I think about truth I never anticipated the impact that visualizing dental anatomy in 3D would have on my staff, my patients, my practice, and me CBCT has literally changed the way that I approach clinical endodontics This technology is the epitome of John’s verse: it represents three-dimensional truth, and the freedom to treat patients confidently, creatively, and effectively because of the truth it provides CBCT allows me to visually strategize the clinical execution of a procedure before I actually it, whether it’s endodontic therapy, a careful manipulation of the Schniderian membrane for a sinus lift, or the placement of a dental implant — either done “free hand” or utilizing CBCT’s DICOM data to create a computer-generated surgical guide Beyond visualizing the anatomy prior to the procedure, having the 3D scan on a large highresolution monitor chairside provides a true representation of the operating space, and an incredible level of pretreatment confidence along with it Procedures that once were difficult and created significant pretreatment anxiety for doctor, staff, and patient are now commonplace and are executed with ease To the benefit of all, with CBCT we can digitally document the entire scope of a procedure, from initial evaluation, through treatment planning, and eventually, years of follow-up This gives us the great luxury of going back to review past cases and learn from our own experiences, as well as to provide extensive treatment feedback to our referring doctors and the colleagues with whom we consult With today’s technologies, endodontic professionals are closer than ever to attaining that ultimate scientific pursuit of truth New tools and ever-evolving technologies add limitless stimulation to the practice careers of those who embrace them, and ultimately set us free in the greatest way imaginable: by giving us the freedom to continue to grow at what we best, for our patients, our colleagues, and ourselves Thomas V McClammy, DMD, MS aka: Clamdawg North Scottsdale Endodontics & Implantology (Arizona) Foundational Dental Seminars Endodontic practice INTRODUCTION Few things are as important as truth November/December 2013 - Volume Number TABLE OF CONTENTS Corporate profile Planmeca® Innovative, upgradeable imaging technology 10 Practice profile Dr Brian Trava Continually learning and training, Dr Trava discusses the joys of being a “tooth saver.” Endodontics in focus Top ten tips: Tip number 10 When things go wrong In the last article in this series, Dr Tony Druttman focuses what to when things not go according to plan 18 Case study 12 Endodontics in 3D Drs Derek Chu, David Jaramillo, Chad Gustafson, and Dwight Rice study the benefits of CBCT, and its role in helping to diagnose and treat endodontic problems Endodontic practice Volume Number simple, adaptable endodontic solutions A decade of success EndoREZ facts SaveS time For more than 10 years, EndoREZ has given you the ability to buy time When used conventionally, EndoREZ will be completely set in 30 minutes And when used with EndoREZ Accelerator, this time can be reduced to only minutes Compare this to the approximate 10-hour set time other sealers may require, and it’s clear: EndoREZ makes every RCT faster Unmatched hydrophilicity and adaptability EndoREZ contains a special hydrophilic organophosphate methacrylate monomer that increases its hydrophilicity and produces a resin with a strong affinity for moisture with resin penetration of 1200μ into the tubules EndoREZ penetrates into tubules and adapts to the walls like no other sealer on the market Don’t change your technique Make it easier with EndoREZ Scan to watch a short video about EndoREZ 800.552.5512 ultradent.com Use NaviTip to easily deliver EndoREZ to the entire anatomy of the canal in one step ©2013 Ultradent Products, Inc All Rights Reserved EndoREZ ® TABLE OF CONTENTS Abstracts The latest in endodontic research Dr Kishor Gulabivala presents the latest literature, keeping you up-todate with the most relevant research .48 Product insight The rationale and use of electronic Fiber posts and tooth reinforcement 22 apex locators Dr L Stephen Buchanan offers advice on getting to the root of the matter 50 Endospective The martensitic transformation: Continuing education Fiber posts and tooth reinforcement: evidence in the literature Drs Leendert Boksman, Gary Glassman, Gildo Santos, and Manfred Friedman look at the literature for fiber posts and the best techniques for placement 22 Management of an upper first molar with three mesiobuccal root canals Dr Peet van der Vyver presents a case report to illustrate the clinical management of an upper first maxillary molar tooth with three mesiobuccal root canals, using the ProTaper Next system 28 Endodontic practice Special section Tribute to Pride Institute’s “Best of Class” Technology Awards .34 Legal matters Upholding the Endodontist’s Standard of Care Drs Stephen Cohen and Edwin Zinman discuss how to avoid patient distrust 44 Technology Endodontics made more efficient with the ScanX Swift™ Dr Howard Golan discusses a different type of imaging technology .46 still transforming endodontics Dr Rich Mounce discusses the second generation of heat-treated nickel-titanium alloys .53 Practice management Technology leads the charge for improved patient experience, increased cash flow Jena McCoy-Lovern tackles some challenges to establishing and maintaining a positive relationship with patients 54 Industry news 56 Materials & equipment 56 Volume Number ORTHOPHOS XG 3D The right solution for your diagnostic needs Implantologists Endodontists Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement General Practitioners will achieve greater diagnostic accuracy for routine cases ORTHOPHOS XG 3D “With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, fractures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients Combine that with the metal artifact reduction software that reduces distortions from metal objects, my treatment process is a lot less stressful My patients benefit from the technology and my referrals appreciate the value.” ~ Dr Kathryn Stuart, Endodontist - Fishers, Indiana The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977 www.facebook.com/Sirona3D PRACTICE PROFILE Dr Brian Trava Multidimensional endodontics What can you tell us about your background? I grew up in Northern New Jersey, and would like to say I spent endless summers hanging at the shore, but I actually spent summers working with my father doing construction since the fourth grade I benefited from a liberal arts education and graduated from Lycoming College with honors I attended the University of Medicine and Dentistry, receiving both graduate and postgraduate degrees I also enjoyed being an Associate Clinical Professor for 10 years I started my first practice right out of school and have opened five offices in New Jersey since then Is your practice endodontics? limited to I am often asked if our practice is just limited to endodontics My answer is we are limited to comprehensive endodontics We limit ourselves to root canals, surgical endodontics, facial pain diagnosis, occlusion, TMD, and patients with special needs A complete postgraduate program touches upon many areas of endodontics, and it is up to individuals what they limit themselves to What training undertaken? have you You are never done training and learning Take continuing education courses that are not endodontic in nature Anatomy, microbiology, restorative, and pathology helps you communicate with your peers on a more thorough comprehensive basis Why did you decide to focus on endodontics? So, why endodontics? At first, I thought it was fun, I had an aptitude for it, and loved doing it I had a deep respect for the instructors in my department To this day, I still love going to work How long have you been practicing, and what systems you use? I have been fortunate to be practicing for close to 25 years There was once a time when I use to say: “We have to be able to Endodontic practice this on computers!” Careful for what you wish for Plumber, move over on my speed dial, computer technician, step right in We review radiographs from many different software systems We have been exceptionally pleased with companies such as Adec, Schick, and Planmeca The detail and support we feel has been consistent and dependable Who has inspired you? Professionally, what are you most proud of? On a professional level, I am most proud of my fellow colleagues in the office, both doctors and staff “I’d rather be having a root canal.” Guess what? — you are! We work hard to make our patients want to come back What has been your biggest challenge? I was first and still inspired by my family dentist, Dr Anthony Cipriano I could tell as a teenager he really enjoyed what he did Patients can sense that, young to old That may be the tip of the day The biggest challenge we face is to have others understand that many teeth indicated for extraction can be saved Quality CBCT imaging makes diagnosing and treatment more predictable What is the most satisfying aspect of your practice? What would you have become if you had not become a dentist? We are tooth savers! When told the tooth can’t be saved, nothing is more satisfying then keeping that tooth right where it erupted Origin of facial pain, yes, we have it figured out; let’s put you in the right direction The practice’s scope of treatment expands as well as the opportunity to collaborate with many of our colleagues from medicine to dentistry I was fortunate to choose my profession As a child growing up, I wanted to be an astronaut My career would have ended early; I have to take Dramamine before I go on carnival rides with my daughter What is the future of endodontics and dentistry? The future of endodontics is found in Volume Number Achieve the Optimal Treatment Room with ASI The Cart, With Only One Foot Control The versatility of ASI’s custom integrated cart system allows for infinite positioning of the cart to easily maneuver within close reach during procedures and then out of patient view after procedures Adding a monitor mount creates an intimate environment for both patient education and clinical use Side Delivery An ASI cart positioned at the doctor’s dominant side requires the least amount of tasking movements during a procedure and works efficiently with microscope dentistry Foot Control Placement The foot control tubing of an ASI system can be run underneath the floor through a conduit from the junction box to the patient dental chair The end result creates easy access to the foot control without tubing running across the floor The Junction Box In addition to attractively concealing the standard connections of compressed air, suction and electricity, ASI’s unique in-wall junction box allows computer connections such as video, USB, network and other IT connections throughout the office to be easily organized and safely hidden from view “The ASI Endodontic carts are a great convenience This space saving design allows me to be organized and efficient with only one foot control and without all of the cords draped over my counters.” – Dr Kelly Jones 1-800-566-9953 • asimedical.net PRACTICE PROFILE research and technology Endodontic research has given us a much more comprehensive understanding of microbial infections, biofilm, and anatomy Our practice has been the first to incorporate both CBCT and lasers in many ways to treat our patients Patients are more educated, they want to save their natural teeth, and we have the tools available to us endodontist is twofold Look beyond the tooth Take what you learned in school, and use it to treat the whole patient To make it easier, invest in quality equipment backed by quality companies Do your research Look for a quality CBCT machine, a machine that allows you to study and diagnose the oral maxillary complex, TMJ, and sinus with great detail What are your top tips for maintaining a successful practice? What are your hobbies, and what you in your spare time? Listen to the patient Be fair to the patient Make sure the patient understands what you’re doing and why you’re doing it Communicate with the patient and the dentists Endodontics can be demanding It is best to have distractions to take your mind away from the office So, I became a soccer mom with my wife There is nothing like kids to help you forget about the office for a weekend Typically, when I am asked to lecture across the country, the first place I look for is a National Park to incorporate into our trip It’s a great way to really appreciate what we work for EP What advice would you give to budding endodontists? The best advice that I can give to a budding Endodontic practice TOP 10 FAVORITES LIST My number one most indispensible piece of equipment in my office, our Promax 3D Explaining to patients how their CBCT image has given me the detail I need to help them Being the first to use the Waterlase MD to treat lesions without making a surgical flap Working with the NBA in Africa to help children Treating kids and special needs individuals when they were turned away from other practices Telling patients at a.m that it is normal; everybody calls me at this time to tell me they had a toothache for weeks Having the opportunity to learn from other colleagues while lecturing in different areas of the country Enjoying problem solving and interacting with my colleagues Watching my daughter’s athletic ability and realizing it does skip a generation 10 Finally, being able to hang at the shore Volume Number LEGAL MATTERS Upholding the Endodontist’s Standard of Care Drs Stephen Cohen and Edwin Zinman discuss how to avoid patient distrust W e endodontists were initially trained as restorative (general) dentists Then we extended our studies by completing additional years of post-graduate training to enable us to list ourselves as specialists We are licensed by the state, and recognized by our national and state dental organizations to employ our additional skills to render the highest level of endodontic therapy But from what I have seen in over 40 years of practice, and serving as an expert witness for defense counsel (and yes, plaintiff’s counsel too), is that some of our endodontic colleagues get caught up in legal entanglements — even when they meet the Standard of Endodontic treatment care How does this happen? And how can we avoid it? This can occur if the endodontists fail in their communication skills, also known as informed consent, or postoperatively, which can be akin to abandonment My colleague, Dr Ed Stephen Cohen, MA, DDS, FACD, FICD, is a Diplomate of the American Board of Endodontics and is in Private Endodontic Practice in San Francisco, California He lectures worldwide on endodontics and is the senior editor for all nine editions of the definitive endodontics textbook, Pathways of the Pulp, and a coeditor of the renamed 10th edition Cohen’s Pathways of the Pulp Dr Cohen served as the Chairman of the Endodontic Department, University of the Pacific Arthur A Dugoni School of Dentistry and has continued as an Adjunct Clinical Professor of Endodontics In addition to his academic appointments, Dr Cohen has held leadership positions in many of the major professional and academic organizations in endodontics and dentistry, including as a Director of the American Association of Endodontists and as a fellow of both the American College of Dentists and the International College of Dentists Edwin J Zinman, DDS, JD, graduated from the University of Pittsburgh School of Dentistry and received a Certificate in Periodontics and Oral Medicine from New York University College of Dentistry He also received a JD from University of California, Hastings College of Law He has served on the Journal of Periodontology Editorial Board from 2000 to the present He is a member of the American Academy of Periodontology, American Dental Association, California Dental Association, San Francisco Dental Society, Consumer Attorneys of California, and the American Association for Justice He is currently practicing law in San Francisco, California He has authored many articles and also has served as a teacher and consultant 44 Endodontic practice Zinman and I would submit that we need to consider a new non-legal term for judging ourselves — The Standard of Endodontic Excellence Let’s first remember some of the traditional axioms, e.g., “Patients don’t care how much you know until they know how much you care.” Another axiom: “If you take good care of your patients, they’ll take good care of you.” So how these axioms apply to our endodontists’ practices? We have seen a number of legal complaints filed against some of our wellintentioned colleagues, not always because they provided negligent therapy, but rather patients feel the endodontist betrayed their trust How? Below are just a few examples of what engenders distrust of some patients causing them to write negative reviews on Yelp, sometimes filing complaints with the Department of Consumer Affairs, or even engaging a lawyer to file a malpractice complaint We are all trained to perform microsurgery Our specialty training includes knowledge of the anatomical variations of the inferior alveolar neurovascular bundle So we are surprised and disappointed when there is a legal complaint filed against an endodontist from a patient suffering from permanent dysthesia, anesthesia, or persistent paresthesia With the newer techniques and technologies available today, we wonder why an endodontist would perform periapical surgery on a mandibular posterior tooth without the benefit of a CBCT for treatment planning Sure, years ago we could only count on a panoramic X-ray and periapical films to help us guide patients through the risks, benefits, and alternatives (implant, bridge, maybe just extraction) to periapical surgery on a mandibular posterior tooth — that was then w-a-y back in the 20th Century But for years now, we’ve been able to refine our treatment planning with the benefit of CBCT An endodontist is potentially placing the otherwise trusting patient in harm’s way if he/she recommends and/or performs lower premolar or molar surgery without first reviewing CBCT images Of course, even without CBCT, most surgeries will turn out well — except when they don’t! As today’s health care is undergoing a transformation, providing endodontic therapy is undergoing a transformation as well; this is best illustrated by more specialists functioning in the capacity of independent contractors, providing specialty care in the office of a general dentist When an endodontist provides endodontic therapy in the office of a general dentist, does the endodontist have a microscope readily available? And what about the complete armamentarium of instruments and materials; are they also readily available in the general dentist’s office? Certainly this is possible, but improbable Thus, two levels of specialty care are emerging in endodontics: the higher level in the endodontist’s office and a lower level in the clinical setting of the general dentist There may be a short-term gain of more profit for the endodontist in exchange for compromising the quality of endodontic care that generations of endodontic professors, researchers, and Volume Number LEGAL MATTERS MAX-I-PROBE ® ENDODONTIC/PERIODONTAL IRRIGATION PROBES The irrigating probe confirmed THE BEST in the Journal of Endodontics “ the Max-i-Probe removed significantly more bacteria the unique side vent of these safety-ended needles produces upward turbulence that enhances complete cleaning of root canals.“ — Journal of Endodontics, Vol.33, No 6, June 2007 FREE SAMPLE AT WWW.RINNCORP.COM ‘Closed-end’ generic probe Others claim a closed tip, but a microscope may reveal a much different story clinicians worked so hard to establish But our endodontic patients will pay the longterm price of increased retreatment of cases failing If this trend continues, we are undermining the necessity for endodontics to be regarded as a specialty, and we will have sold our souls and ethics by potentially sliding down this slippery slope descending from excellence to mediocrity Just as there is no double standard for endodontics in an HMO setting, there should not be a different standard depending upon the office location where endodontics is provided Endodontists set and uphold the endodontic standard of care, and it should never be compromised for profit.1 After apical surgery, patients receive instructions regarding post-surgical care Some endodontists not reinforce the verbal instructions with written instructions Some endodontists neglect to call surgical patients in the evening to follow-up on how the patients are faring after the local anesthesia has dissipated Patients are Volume Number Max-i-Probe The RINN Max-i-Probe tip is welded closed to protect your patient from fluids expressing past the apex grateful (and pleasantly surprised) when the doctor calls them at home following surgery In case patients have a worry (bleeding, pain, sutures irritating the lip or cheek, paresthesia, etc.) and cannot reach the endodontist by phone, they may become so agitated that they call their general dentist or go to the ER for help Consequently, this now becomes a double loss for the endodontist insofar as being unreachable by the patient (patients feel very put off) and also sowing seeds of doubt in the mind of the referring dentist about the endodontist’s conscientious care for his/her referred patient A worst case scenario is a patient with postoperative paresthesia and/or dysesthesia from an overfill into the inferior alveolar nerve canal (IAN) This otherwise avoidable injury can be reversed with microsurgery in the first 48 hours.2 If the endodontist did not prevent this adverse event with careful CBCT planning, the endodontist misses a second chance by not phoning the patient postoperatively to be alerted, if not alarmed, that an immediate referral to a microsurgeon is mandated Serving our patients to the best of our ability is the most satisfying reward Any extra treatment time in the pursuit of excellence in the long run will more than compensate for the additional time we spend doing our best We will gain the personal and professional satisfaction from our increasingly successful treatment results, fewer retreatments, and less time treating avoidable complications The Standard of Excellent Endodontic Care for our patients will likely be manifested in a greater number of referrals as we distinguish ourselves by always striving to our best and the professional satisfaction of achieving our goal EP References Edelman v Zeigler, 233 Cal App 2d 871(1965) Pogrel MA Damage to the inferior alveolar nerve as the result of root canal therapy J Am Dent Assoc 2007;138(1):65-69 Endodontic practice 45 TECHNOLOGY Endodontics made more efficient with the ScanX Swift™ Dr Howard Golan discusses a different type of imaging technology T echnology has made endodontic treatment faster and more efficient However, there are still parts of the endodontic protocol that cannot be avoided that add time to the procedure Taking radiographs is a fundamental part of endodontics When traditional film radiographs are exposed and processed, there is a unit of time that goes by that the practitioner has to get up from the chair, leave the room, and wait for the X-rays to be exposed and processed Digital sensor technology has significantly decreased this unit of time The instantaneous processing of the digital image allows the practitioner to step out of the room and within minutes return to the procedure No longer does the auxiliary have to process the film in another room, sometimes at the other end of the office, wait for the processing time, either dip or automatic, then return to the practitioner for evaluation However, digital sensor technology does have its negatives First, the sensor girth makes it sometimes very difficult for placement in the patient’s mouth Now compound that by trying to fit this sensor around a rubber dam and clamp As a practitioner who has done his fair share of endodontics, placement of the film is of utmost importance in order to see the apex of the tooth being worked on When Dr Howard Golan is a graduate of the University of Michigan School of Dentistry He completed a general practice residency at North Shore University Hospital on Long Island, New York After his GPR, Dr Golan completed a 2-year Implant Surgery and Advanced Prosthetic Fellowship at NSUH He has maintained a busy private practice on Long Island that he shares with his father, Dr Marshall Golan Dr Golan implemented lasers into his practice in 2004 and has attained his Mastership certification in the World Clinical Laser Institute Dr Golan has been fortunate to be asked to lecture and teach laser-assisted dentistry throughout the United States and internationally He is the co-founder of the Center for Laser Education and is a faculty member with the World Clinical Laser Institute teaching Certification Training Courses for that organization Dr Golan has instituted CAD/CAM technology into his practice for years and has lectured on the subject He is a graduate of the Alleman Center for Biomimetic Dentistry He graduated from Concord Law School and has passed the California Bar Examination, obtaining his license to practice law in that state Dr Golan’s excels in teaching quick and productive integration of laser-assisted dentistry, minimally invasive concepts, and CAD/CAM technology into dental practices He practices and teaches a biomimetic philosophy and is passionate about conserving tooth, soft tissue, and bone 46 Endodontic practice a rubber dam clamp is placed, a rigid sensor can be difficult to place in the right position If it moves or the patient moves it because he/she is uncomfortable, then repeat exposures may be needed A second disadvantage of sensor technology is cost These sensors are expensive, and when they break down, which is inevitable, or they are out of warranty, their replacement cost is high An endodontic clinician has another option that takes advantage of digital technology, reduces the cost in the future, and will not have any placement or exposure issues like one can have with sensors Phosphor storage plates (PSPs) are thin, flexible digital sensors that are exposed similarly to traditional dental film With similar dimensions to film, PSPs allow for ease of placement, due to comparative dimensions with traditional film, and can be used with rubber dams and ring systems Like other digital radiological technology, the dosage required to expose PSPs is less than traditional film Furthermore, the plates are disposable The replacement cost of the plates per the number or exposures per plate end up being similar to traditional film costs The processor for these plates, although an initial investment similar to sensors, has no moving parts and has a lifespan years and years longer than sensors As with sensors, PSP technology can have disadvantages One is the separate processing and exposure mediums Once a PSP is exposed in the patient’s mouth, the PSP is delivered to the processor that is usually in a non-treatment room or hallway with a computer attached Thus, the auxiliary or clinician exposes the PSP, removes his/her gloves, and walks the plate to the digital processor This prevents the instantaneous advantage that sensors have over PSPs However, a new PSP processor has been developed to close the gap between the exposure and the processing The ScanX Swift (Air Techniques) is a one-slot PSP processor that is small enough to fit on a countertop in a dental treatment room Thus, the auxiliary does not need to leave the treatment room after exposing the film Once the plate is exposed, the auxiliary places the plate into the ScanX Swift, and in seconds, the image is in front of the operator ready for evaluation In addition, there is a protective barrier that is placed Volume Number EP CERTIFIED PRE-OWNED KODAK 9000 3D SALE! STARTING AT 49,900 $ Financing Available Delivery Training Installation Manufacturer's Warranty Call 888.246.5611 or visit renewdigital.com © Renew Digital, LLC 2013 Volume Number Endodontic practice 47 TECHNOLOGY over the ScanX Swift’s slot so that the auxiliary exposing the film does not have to deglove in order to process the image The ScanX Swift provides the endodontic practice with almost instantaneous digital X-ray processing by moving the digital processor into the treatment room This saves time The oneslot processor provides a more economical option for those practices like endodontics that not take a large amount of X-ray series The ScanX Swift enhances infection control and lowers the cost of gloves and disposables by allowing the exposer of the X-ray to remain in the treatment room and contain possible cross-contamination Finally, the PSPs are disposable, reducing high replacement costs in the future Endodontic practices should seriously consider incorporating the ScanX Swift into their X-ray protocols They will enjoy its convenience, long-term cost savings, and quality of image processing ABSTRACTS The latest in endodontic research Dr Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research Incomplete caries removal: a systematic review and metaanalysis [review] Schwendicke F, Dorfer CE, Paris S Journal of Dental Research (2013) 92(4): 306-14 Abstract Aim: Increasing numbers of clinical trials have demonstrated the benefits of incomplete caries removal, in particular in the treatment of deep caries The aim was to systematically review randomized controlled trials investigating one- or twostep incomplete compared with complete caries removal Methodology: Studies treating primary and permanent teeth with primary caries lesions requiring a restoration were analyzed The following primary and secondary outcomes were investigated: risk of pulpal exposure, postoperative pulpal symptoms, overall failure, and caries progression Electronic databases were screened for studies from 1967 to 2012 Cross-referencing was used to identify further articles Odds ratios (OR) as effect estimates were calculated in a random-effects model Results: From 364 screened articles, 10 studies representing 1,257 patients were included Meta-analysis showed risk reduction for both pulpal exposure (OR [95% CI] 0.31 [0.19-0.49]) and pulpal symptoms (OR 0.58 [0.31-1.10]) for teeth treated with one- or two-step incomplete excavation Risk of failure seemed to be similar for both complete and incomplete excavation, but data for this outcome were of limited quality and inconclusive (OR 0.97 [0.64-1.46]) Conclusions: Based on reviewed studies, incomplete caries removal seems Kishor Gulabivala, BDS, MSc, FDSRCS, PhD, FHEA, is professor and chairman of endodontology, and head of the department of restorative dentistry at Eastman Dental Institute, University College London He is also training program director for endodontics in London 48 Endodontic practice advantageous compared with complete excavation, especially in proximity to the pulp However, evidence levels are currently insufficient for definitive conclusions because of high risk of bias within studies Influence of endodontic treatment in the post-surgical healing of human Class II furcation defects de Miranda JL, Santana CM, Santana RB Journal of Periodontology (2013) 84(1): 51-7 Abstract Aim: Treatment of molar furcation defects remains a considerable challenge in clinical practice The degree of success in the management of furcation involvement is highly variable and related to the baseline clinical status of these defects The identification of clinical parameters influential to the treatment outcomes is critical to optimize the results of surgical periodontal therapy The impact of the endodontic treatment (ET) of the tooth on the healing potential of the periodontium is controversial Therefore, the aim of this study was to evaluate the clinical response of buccal Class II furcation defects to openflap debridement (OFD) and to determine the influence of ET in the clinical outcomes of therapy Methodology: Sixty patients were divided into two treatment groups (n = 30): OFD; OFD in endodontically treated teeth (OFD + ET) The clinical variables evaluated were plaque (full-mouth plaque score), bleeding on probing, gingival recession, probing depth (PD), and vertical (VAL), and horizontal (HAL) attachment levels Reevaluation was performed 12 months after the surgical procedures Results: Both treatments resulted in improvements in all the clinical variables evaluated Postoperative measurements from OFD-treated and OFD + ET-treated sites showed, respectively, 1.2 +/- 1.2 and 1.3 +/- 1.3mm reduction in PD, 0.6 +/- 0.8 and 0.7 +/- 0.6mm VAL gains, and 0.7 +/- 1.1 and 0.8 +/- 1.6mm HAL gains No significant differences were found between the groups Conclusions: The present findings demonstrate that adequate endodontic therapy performed more than months before surgical treatment does not significantly influence the clinical parameters of healing of human mandibular buccal Class II furcation defects Correlation between endodontic broken instrument and nickel level in urine Saghiri MA, Sheibani N, Garcia-Godoy F, Asatourian A, Mehriar P, Scarbecz M Biol Trace Elem Res (2013) [Epub ahead of print] Abstract Aim: To evaluate the correlation between the presence of separated endodontic instrument inside the dental canal and the nickel (Ni) level in the urine samples of subjected patients Methodology: Same-gendered and near-aged participants were selected and were instructed to collect their urine in sterile nickel-free plastic containers The procedures were carried out in the office, and samples were stored in a low-temperature cooler for day and then transferred to the laboratory for electrothermal atomic absorption spectrometry The level of Ni was measured, and the correlation coefficient was calculated Data were analyzed using t tests, Pearson’s correlation coefficients, and linear regression analysis at a level of significance P