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CE article
Use and abuse of antibiotics
technique
Cutting endodontic access cavities—
for long-term outcomes
case report
Er,Cr:YSGG laser and Internal
Root Resorptions
Welcome to visit us at
ROOTS Summit Dubai
December 1- 3 to try
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editorial |
Welcome to the
Roots Summit Dubai 2016!
On behalf of the organising committee, it is my sincere pleasure to welcome you to our
Roots Summit Dubai 2016 meeting: “Endodontics these days is better than ever”.
We have built a worldwide Endodontic community through the use of social media, specifically
in our case, Facebook. Our Facebook Group, ROOTS is a leader in online discussion with well over
22,000 members. This allows us to exchange ideas, clinical cases, treatment options, and discuss our
profession with people from multiple continents and countries on a daily basis, 24/7.
Let me share some of the exciting things that we have prepared for you.
Dubai 2016 is our 12th Roots Summit. By moving to Facebook, ROOTS has grown in its ability
to support the creative and educational basis of our specialty. This is of paramount importance
for our continued success as clinicians.
Dr David E. Jaramillo
Steve Jones and Freddy Belliard have been working tirelessly to organise this year's event.
My role is programme director for this edition. Together, we have organised a unique event, where
we will have 20 of the top opinion leaders in Endodontics. These top-level clinicians will present
and share their daily work with the attendees.
We have the opportunity to make the Roots Summit event not only a clinical and scientific
event. This is an opportunity to gather together people from all over the world. One of the
strengths of ROOTS over the years has been having so many people from diverse locations and
backgrounds get to know each other better, exchange ideas, develop and strengthen friendships,
and help improve our profession for the benefit of all.
We have organised a series of hands-on courses where the participants will be able to observe
and learn from the best in their areas of expertise, and to practice the new techniques with the
help of our great lineup of clinicians. We hope that you will take advantage of this great oppor-
tunity. Our speakers spend most of their time traveling the world helping to improve the efficiency,
and more importantly raise the standard of endodontic practice. Having them all in one place will
be one of the best endodontic learning opportunities of the year.
In addition to a very full programme of speakers, we will also have a period on Saturday afternoon
for oral presentations. We wanted to provide the time and opportunity to our community members
to present others what they are doing in their academic areas or Endodontic offices. We will have
also poster presentations for all of those who would like to share their knowledge with us.
You are invited to explore this meeting and discover for yourself the great opportunity to be
found here. However, the real keys of the Roots Summit event experience lie within each of you
and every single participant. Share your experiences and you will meet active and engaged learn-
ers who are breaking new ground and engaging in the world of Endodontics with the purpose as
they seal to find powerful and effective ways to improve their knowledge.
Dr David E. Jaramillo
Programme Director
Root Summit, Dubai 2016
roots
4 2016 03
| content
| practice management
| industry report
06 Manager versus clinician
Lina Craven 40 The role of the operating microscope
Dr Anthony C. S. Druttman
| CE article
| products
08 Use and abuse of antibiotics
Dr Steven G. Morrow 44 Latest technology and products information
04 roots
4 2016
Planmeca ProMax 3D ®
Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland. Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com
| practice management realistic expectations
© George Rudy/Shutterstock.com
Manager versus clinician
How to manage expectations of the
management role and turn it into success
Author: Lina Craven, UK
Practitioners’ expectations of the kind of manager they otherwise, are not developed in a vacuum. You should
want for their practice vary considerably in terms of consider instances when you were let down by your
experience and skills. How guilty are you of promoting manager and ask yourself how that expectation was
a nurse or receptionist to a management role without derived. Was it based on an agreement with your
determining the skills gap and providing the necessary manager after a discussion or was it based on some-
training? It is a common scenario in our industry. thing you said or thought in passing? In retrospect,
Info you may wonder how realistic that expectation was
Practitioners have a responsibility to their teams and and why you thought your manager was in the stron-
Introducing a new to the financial success of their practices to appoint gest possible position to fulfil it.
qualification in leader-
ship and management someone who either has the necessary skills or has the
specifically for dental capacity to learn them in the appropriate time frame. In my experience, the following scenarios are
managers How realistic are your expectations and how can you typical of how unrealistic expectations are created:
This course is a Level 5 ensure your management role results in success? · The practitioner is busy and needs someone to take
management qualification charge. He or she chooses the “best of the bunch”,
awarded by the Institute of
Leadership and Manage- Creating and managing hoping he or she will learn on the job.
ment and is ideal for realistic expectations · The new manager has his or her expectations of the
orthodontic and general job and these are often unrealistic.
dental practice managers or Expectations are difficult to control and impossible · No detailed job description or objectives are ever
anyone who has direct line to turn off. According to Brazos Consulting, “Expec- provided. No on-the-job or any other type of train-
management responsibility.
The training covers team tations are deeper and broader than ‘requirements’. ing is provided; the practitioner simply assumes the
leadership, management, Expectation is your vision of a future state or action, manager will learn as he or she goes along.
coaching, performance usually unstated but which is critical to your success.” · The manager is excited about the new position. For
management, as well as By learning to identify and influence what you expect, some, the empowerment, the title and the kudos
employment law and and by ensuring it is clearly communicated, under- mean a great deal; for others, the challenge and the
planning. This is a highly
practical course enabling you stood and agreed with your manager, you can dra- task at hand mean more. When reality hits, so does
to test out your skills and matically improve the quality, impact and effective- the realisation that the original motivating factors
management styles within ness of your business. are no longer as important.
the group, with the support · Both practitioner and manager are reticent to dis-
and guidance of our highly Expectations are created by many different circum- cuss what is not working and often brush the issues
trained and qualified
management tutors. For more stances. It may be something you said or the way that under the carpet until it is too late.
information, please visit you said it, something you or someone else did, or · Resentment grows and what is at stake—the pa-
www.dp-practiceconsultants. an expectation of your prospective manager based on tients, the practice and the staff—outweighs the
com. his or her previous experience. The vital point here is actual issue, which is poorly managed expecta-
that expectations, whether right or wrong, rational or tions.
06 roots
4 2016
realistic expectations practice management |
Of course, there are many practices managed The following are tips on getting started: Vocalize
by very capable staff members. However, for all the your vision, agree that your vision is realistic and
well-functioning practitioner–manager relationships, share it with your team. Create a job description with
there are more people in these roles who prefer not to and a training plan for your manager, as well as iden-
talk about the problems inherent within and who are tify skills gaps and create smart objectives with and
only too glad for someone else to address the issues. for her or him. Also agree and schedule regular one-
to-one meetings and plan to assess and review with
One of my aims is to facilitate management teams your manager. Most importantly, however, keep com- about
to assess where they are at present, to plan for appro- municating.
priate change and to implement that change. The
outcome is that a weight is lifted from your shoulders Drive your success
and focus moves to a united partnership working to-
wards the success of the practice. In order to move Expectations always exist, even if we do not know
forward, however, you must recognise where you are what they are and despite them often being unrealis-
now. tic. Managers have expectations of their roles and their
employers have expectations of the person given re-
An alternative approach sponsibility for managing the practice. The problem is
that mismatched expectations can lead to misunder-
The first step towards achieving a successful standing, frayed nerves and ruffled feathers. More Lina Craven is founder and
management partnership is to honestly appraise seriously, they often lead to flawed systems, failed Director of Dynamic Perceptions,
your current situation. If anything I have said so far projects and a drain on resources. an orthodontic management
has touched a nerve, if frustration exists between consultancy and training firm in
you and the manager, or if you simply think things There is nothing wrong with having expectations; Stone in Staffordshire, and has
could be better, then acknowledge the fact and take the trick is to communicate them and to agree how many years of practice-based
action. Knowing what action to take for the best is they might be satisfied over time and with the right experience. She can be contacted
probably the most difficult thing to assess. support. Managed expectations drive your success._ at info@linacraven.com
AD
3D agility_
The One to Shape your Success
roots 07
FKG Dentaire SA
www.fkg.ch
4 2016
| CE article antibiotics
08 roots
4 2016
antibiotics CE article |
and contagious staph infections kill thousands of pa- conceptions or “myths” may help to establish general
tients in the most sophisticated hospitals in Europe, guidelines to aid us in making clinical decisions re-
North America and Asia, there is virtually no sign of garding the use of antibiotic therapy, thereby leading
this “killer superbug” in Norway. The reason? Norway to optimum use and therapeutic success.11
stopped using so many antibiotics.
Myth No. 1: Antibiotics cure patients
“We don’t throw antibiotics at every person with a Except in patients with a compromised immune
fever. We tell them to hang on, wait and see, and we give system, antibiotics are not curative, but instead func-
them a Tylenol to feel better,” said Dr John Haug, infec- tion to assist in the re-establishment of the proper
tious disease specialist at Aker University Hospital.8 In balance between the host’s defenses (immune and
Norway’s simple solution, there is a glimmer of hope. inflammatory) and the invasive agent(s). Antibiotics
do not cure patients; patients cure themselves.
The proper clinical use
of antibacterial drugs Myth No. 2:
Antibiotics are substitutes for surgical intervention
In 1997, the ADA Council on Scientific Affairs issued Very seldom are antibiotics an appropriate substitute
a position statement on Antibiotic Use in Dentistry.9 for removal of the source of the infection (extraction,
The Council stated: “Microbial resistance to antibiotics endodontic treatment, incision and drainage, peri-
is increasing at an alarming rate. The major cause of odontal scaling and root planning). Occasionally, when
this public health problem is the use of antibiotics in an the infection is too diffuse or disseminated to identify
inappropriate manner, leading to the selection of dom- a nidus for incision, or the clinical situation does not
inance of resistant microorganisms and/or the in- allow for immediate curative treatment, the prudent
creased transfer of resistance genes from antibiotic- dentist will choose to place the patient on appropriate
resistant to antibiotic-susceptible microorganisms.”9 antibacterial therapy until such time as curative treat-
ment can be implemented. It is imperative to remove
The council’s position statement further identified the cause of the infection prior to, or concomitant with,
that “Antibiotics are properly employed only for the antibiotic therapy, when the cause is readily identifiable.
management of active infectious disease or the pre- Whenever antibiotic therapy is used, the risk of bacterial
vention of metastatic infection, such as infective en- selection for antibiotic resistance is present.
docarditis, in medically high-risk patients.”9
Myth No. 3: The most important decision is
One method of education is to teach from errors which antibiotic to use
rather than principles. Psychologists from the Univer-
sity of Exeter have identified an “early warning signal” To avoid the deleterious effects of needless antibiot-
in the brain that helps us avoid repeating previous ics on patients and the environment, the most import-
mistakes. Published in the Journal of Cognitive Neu- ant initial decision is not which antibiotic to prescribe
roscience,10 their research identifies for the first time, but whether to use one at all. It has been estimated that
a mechanism in the brain that reacts, in just one-tenth up to 60 percent of human infections resolve by host
of a second, to things that have resulted in us making defenses alone following removal of the cause of the
errors in the past. Evaluating the following eight mis- infection without antibiotic intervention.
Fig. 1 Fig. 2
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4 2016 09
| CE article antibiotics
Fig. 3 Fig. 4
Fig. 3: Acute apical abscess with Endodontic disease is infectious. Microorganisms with diffuse facial cellulitis. When the abscess is in-
intraoral localized swelling. cause virtually all pathoses of the pulp and periapical traoral and localized (Fig. 3), debridement of the pulp
Fig. 4: Acute apical abscess with tissues. There is ample evidence to support that op- space and placement of calcium hydroxide and surgi-
extraoral diffuse facial cellulitis. portunistic normal oral microbiata colonize in a sym- cal incision for drainage is usually sufficient to resolve
biotic relationship with the host, resulting in end- the problem. Systemic antibiotic therapy is not rou-
odontic infections.12 The majority of endodontic tinely indicated, depending on the patient’s general
infections do not require systemic antibiotic therapy medical status. However, when the patient presents
when the cause of the infection has been properly with diffuse facial swelling (cellulitis) resulting from
managed (complete debridement of the pulp space an acute apical abscess or an infection with systemic
and proper obturation and sealing of the pulp space involvement (fever or malaise) (Fig. 4), debridement of
from the oral environment). the pulps pace with placement of calcium hydroxide,
surgical incision for drainage, when possible, and an
Apical periodontitis lesions of pulpal origin are appropriate regimen of systemic antibiotics (oral or
generated by the immune system and are the result of IV) are the treatments of choice.
intra radicular infections (Fig.1). In most situations,
this inflammatory process successfully eliminates the Understanding the enemy is an important factor
bacteria emerging from the apical foramen and pre- in winning any battle. The rational choice and use of
vents their spread to the periapical tissues. This pro- antimicrobial agents begins with the knowledge of
cess is primarily facilitated by the polymorphonuclear the microorganisms most likely responsible for com-
leukocytes that eventually phagocytize and kill the mon dental infections of pulpal origin. The bacterial
bacteria.13 Asymptomatic apical periodontitis of pul- flora found in endodontic infections is indigenous,
pal origin does not routinely require systemic antibi- mixed (Gram-positive and Gram-negative) and pre-
otic therapy for satisfactory resolution and healing. dominately anaerobic. Several species have been im-
Endodontic therapy alone is usually sufficient. plicated with acute apical abscesses. These species
include dark-pigmented bacteria (Prevotella and Por-
When the intraradicular infection is able to over- phyromonas), eubacteria, fusobacteria and Actino-
whelm the host’s immune response, viable bacteria myces.12
are able to gain access to the periapical tissues and
colonize, forming an active infection. This results in the Baumgartner and Xia published a report of the sus-
formation of an apical abscess. A chronic apical ab- ceptibility of bacteria recovered from acute apical ab-
scess usually presents with gradual onset, no to mild scesses to five commonly used antibiotics in dentistry.
symptoms and the presence of a sinus tract or parulis Antibiotic susceptibility data from 98 species of bac-
(Fig. 2). The majority of chronic apical abscesses of teria recovered from 12 acute apical abscesses led to
endodontic origin do not require systemic antibiotic the following conclusions:
therapy for satisfactory resolution and healing. 1. Pen-V-K is the antibiotic of choice for endodontic
infections due to its effectiveness inpolymicrobial
An acute apical abscess usually presents with rapid infections, its relative narrow spectrum of activity
onset, spontaneous pain and swelling, both localized against bacteria most commonly found in end-
and intraoral, sometimes with exudate present, or odontic infections, its low toxicity and low cost.
10 roots
4 2016
antibiotics CE article |
2. Clindamycin is the antibiotic of choice for patients Myth No. 6: Bactericidal agents are always
allergic to penicillins. superior to bacteriostatic agents
3. While amoxicillin and augmentin (amoxicillin plus Bactericidal agents are required for patients with
clavulanate) demonstrated a higher antibacterial impaired host defenses.3 However, bacteriostatic
effectiveness than Pen-V-K, due to the broader agents are usually satisfactory when the host’s de-
antibacterial spectrum of amoxicillin and the in- fenses against infections are unimpaired. Post anti
creased cost of augmentin, the authors recom- biotic effects (PAEs —persistent suppression of bacte-
mended that amoxicillin/augmentin be reserved rial growth after previous exposure to antibiotics) are
for unresolved infections and patients who are im- more persistent and reliable with bacteriostatic agents
munocompromised. (erythromycin, clindamycin) than with bactericidal
4. Metronidazol demonstrated the greatest amount agents (beta-lacatamase) because the clinical effects
of bacterial resistance and is only effective against of bacteriostatic agents are less dose-dependent.
anaerobes. Therefore, it should not be used alone
for the treatment of endodontic infections.14 Myth No. 7: Antibiotic dosages, dosing intervals
and duration of therapy are established for most
Myth No. 4: infections
Antibiotics increase the host’s defense to infection After more than 80 years of antibiotic usage, the
proper dosages, dosing intervals and duration of
The increased prevalence in organ and tissue trans- therapy are essentially unknown for most specific in-
plants, resulting in patients with compromised im- fections.3 Infectious diseases are associated with a
mune systems, has heightened the interest in the po- high number of variables that affect treatment out-
tential effects of antimicrobial drugs on the host’s come (microbial characteristics and drug sensitivity,
resistance to infection.15 In vivo and in vitro studies are diverse resistance mechanisms, tissue barriers to an-
highly variable and sometimes contradictory. How- tibiotic diffusion, and the integrity and activity of the
ever, the following considerations appear valid: 1) An- host’s defense mechanisms). However, basic princi-
tibiotics that can penetrate into the mammalian cell ples are available to guide the dental health care pro-
(erythromycin, tetracycline, clindamycin and metro- vider in establishing proper dosages, dosing intervals
nidazole) are more likely to affect the host defenses and duration of therapy once the microbial patho-
than those that cannot (beta-lactams); 2) Tetracy- gen(s) is suspected or identified and a rational choice
clines may suppresswhitecellchemotaxis; 3) Most of antimicrobial agent is made.
antibiotics (except tetracycline) do not depress phago-
cytosis; and 4) T- and B-lymphocyte transformation The following principles of antibiotic dosing are
may be depressed by tetracyclines. The greatest poten- adapted from Dr Thomas J. Pallasch3:
tial harm to the host defenses may result from antibi- 1. The current recommendation is to employ an
otics that easily penetrate into the mammalian cell antimicrobial on an intensive basis with vigorous
and the least harm is observed with bactericidal, non- dosage for as short a period of time as the clinical
penetrating agents (penicillins and cephalosporins). situation permits. The major factor in the clinical
success of most antimicrobial agents is the height
Myth No. 5: Multiple antibiotics are superior to a of the serum concentration of the drug and the re-
single antibiotic sulting amount in the infected tissue(s). Also im-
It is often assumed that a combination of antibiot-
ics is superior to a single carefully chosen antibacte-
rial agent. When the purported benefits of antibiotic Primary Reasons for Revision of Infective Endocarditis
combinations are weighed against the possible con- Guidelines
sequences to the host as well as to the bacterial envi-
ronment, this assumption is not always reality. The 1. IE is much more likely to result from frequent exposure to random bacteremias
usual sequela to combined antibiotic therapy results associated with daily activities than from bacteremias caused by a dental,
in a greater selective pressure on the microbial popu- GI tract or GU tract procedure.
lation to develop drug resistance. The greater the an-
tibacterial spectrum of the antimicrobials used, the 2. P rophylaxis may prevent an exceedingly small number of cases of IE, if any,
greater the number of drug-resistant microorgan- in individuals who undergo a dental, GI tract or GU tract procedure.
isms that develop, and the more difficult it is to treat
a resulting superinfection. The primary clinical indi- 3. The risk of antibiotic-associated adverse events exceeds the benefit, if any,
from prophylactic antibiotic therapy.
cation for combined antimicrobial therapy is a severe
infection in which the offending organism(s) is un-
4. M
aintenance of optimal oral health and hygiene may reduce the incidence of
known and major consequences may ensue if anti bacteremia from daily activities and is more important than prophylactic antibiotics
biotic therapy is not instituted immediately before for a dental procedure to reduce the risk of IE. Table 1
culture and sensitivity tests are available.3
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4 2016 11
| CE article antibiotics
12 roots
4 2016
antibiotics CE article |
fections from occurring. Orofacial infections do not to the antibiotic drug used is considered an anti
“rebound” if the source of the infection is properly biotic-associated adverse event.
eradicated. Most orofacial infections persist for two
to seven days, and often less. Patients placed on anti- The majority of published studies regarding IE be-
biotic therapy for an orofacial infection should be ing caused by oral bacteria have focused on dental
clinically evaluated on a daily basis. When there is suf- procedures. Although the infective dose required to
ficient clinical evidence that the patient’s host de- cause IE in humans is unknown, the number of micro-
fenses have regained control of the infection and that organisms present in the blood following a dental
the infection is resolving or resolved, the antibiotic procedure is low. It has long been assumed that dental
therapy should be terminated. procedures may cause IE in patients with underlying
cardiac risk factors and that antibiotic prophylaxis
Antibiotic prophylaxis for is effective. However, scientific proof is lacking to sup-
medically at-risk patients port this assumption. Cases of IE caused by oral bac-
teria probably result more from exposures to low in-
Antibiotic prophylaxis is the administration of ocula of bacteria in the bloodstream that result from
antibiotics to patients without evidence of infection routine daily activities (brushing and flossing) and not
to prevent bacterial colonization and reduce subse- from a dental procedure.17
quent postoperative or post-treatment complica-
tions. The only established use of antibiotic prophy- The 2007 AHA report regarding prevention of IE
laxis in dentistry is in the attempt to reduce the concludes: “If prophylaxis is effective, such therapy
potential consequences of bacteremias induced by should be restricted to those patients with the highest
dental treatment in certain medically at-risk patients. risk of adverse outcomes from IE and who would de-
The principle indication for antibiotic prophylaxis for rive the greatest benefit from prevention. In patients
dental patients is the prevention of infective endocar- with underlying cardiac conditions associated with
ditis during specified dental treatment of patients the highest risk of adverse outcomes from IE, prophy-
who also have specific medical conditions. Contro- laxis for some dental procedures is reasonable, even
versial indications include dental patients with ortho- though we acknowledge that its effectiveness is un-
pedic prosthetic devices, indwelling catheters and known.”17
impaired (immunosuppressed) host defenses.
Therefore, the 2007 AHA guidelines suggest that
Dental patients presenting for treatment with im- antibiotic prophylaxis should be considered for pa-
paired host defenses (chemotherapy, organ trans- tients presenting for treatment with the cardiac con-
plant or tissue graft recipient, insulin-dependent ditions identified in Table 2, and who are undergoing
diabetes, alcoholics) or patients with indwelling cath- any dental procedure that involves the gingival tis-
eters (hemodialysis) may benefit from antibiotic sues or periapical region of a tooth and for those pro-
prophylaxis if their white cell count is below 2,500 cedures that perforate the oral mucosa. This would
(normal = 4,000–11,000). It is not currently recom- include procedures such as biopsies, suture removal,
mended that patients with AIDS receive routine anti- placement of orthodontic bands, and intraligamen-
biotic prophylaxis prior to dental treatment. The op- tary and intraosseous local anesthetic injections, but
portunistic pathogens common to this disorder are it does not include routine local anesthetic injections
not susceptible to routine prophylactic antibiotics through non infected tissue (Table 3).
and such a practice may result in the development of
antibiotic-resistant microorganisms, thereby result-
ing in a serious superinfection.3 Dental Procedures for Which Antibiotic Prophylaxis is
Reasonable
Antibiotic prophylaxis for
prevention of infective endocarditis – Dental extractions
– Periodontal procedures, including surgery, subgingival placement of antibiotic fibers/
The American Heart Association has published strips, scaling and root planing, proving, recall maintenance
guidelines for the prevention of IE in medically at-risk – Dental implant placement
patients for more than 50 years. The most recent – Replantation of avulsed teeth
guidelines, published in April 2007, represent a signif- – Endodontic (root canal) instrumentation only if beyond the root apex and endodontic
icant change from the previous guidelines.17 One of surgery
the stated reasons for the development of the current – Initial placement of orthodontic bands (not brackets)
– Intraligamentary and intraosseous local anesthetic injections
revised guidelines was that the risk of antibiotic-as-
– Postoperative suture removal (in selected circumstances that may create significant
sociated adverse events exceeds the benefit, if any, bleeding)
from prophylactic therapy (Table 1). It is well accepted – Prophylactic cleaning of teeth or implants where bleeding is anticipated Table 3
that the risk for developing bacterial resistant strains
roots
4 2016 13
| CE article antibiotics
Antibiotic prophylaxis for prevention of sistent with the current guidelines. In this case, the
delayed prosthetic joint infection dentist is encouraged to consult with the patient’s
physician to discuss the nature of the needed den-
In 1997, the ADA and the American Academy of tal treatment, to review the current guidelines re-
Orthopedic Surgeons convened an expert panel of garding antibiotic prophylaxis and to determine if
dentists, orthopedic surgeons and infectious disease there are any special considerations that might af-
specialists and published an Advisory Statementon fect the physician’s decision regarding antibiotic
Antibiotic Prophylaxis for dental patients with pros- prophylaxis for the patient. After this consultation,
thetic joints.18 A 2003 advisory statement included the dentist may decide to follow the physician’s rec-
some modifications of the classification of patients ommendation or, if in his or her professional judg-
at potential risk and the stratification of bacteremic ment antibiotic prophylaxis is not indicated, decide
dental procedures (Table 4), but no changes in terms to proceed with the needed dental treatment with-
of suggested antibiotics or antibiotic regimens.19 out antibiotic prophylaxis. The dentist is ultimately
Antibiotic prophylaxis is not indicated for most responsible for making treatment decisions for his
dental patients with total joint replacements or for or her patient based on the dentist’s professional
patients with pins, plates or screws. However, it is judgment.
advised to consider antibiotic premedication in a
small number of patients who may be at potential In February 2009, the AAOS published an infor-
increased risk of experiencing hematogenous total mation statement in which the organization, “rec-
joint infection (Table 5). ommends that clinicians consider antibiotic pro-
phylaxis for all total joint replacement patients prior
While bacteremias can cause hematogenous to any invasive procedure that may cause bactere-
seeding of total joint implants, it is likely that more mia.”20 In response to this statement, the American
oral bacteremias are spontaneously induced by rou- Academy of Oral Medicine published a position pa-
tine daily events than are dental treatment-induced. per in the June 2010 edition of the Journal of the
Patients who have undergone total joint arthro- American Dental Association.21
plasty should be encouraged to perform effective
daily oral hygiene procedures in order to maintain The authors of the AAOM position paper stated
good oral health. The risk of bacteremia is much hat they reviewed the available literature on the
higher in a mouth with chronic inflammation than subject as it relates to the AAOS 2009 information
one that is healthy and well maintained. statement and concluded: “The risk of patients’ ex-
periencing drug reactions or drug-resistant bacte-
Occasionally, a patient with a total joint prosthe- rial infection sand the cost of antibiotic medications
sis may present for dental treatment with a recom- alone do not justify the practice of using antibiotic
mendation from his or her physician that is incon- prophylaxis in (all) patients with prosthetic joints.”
The authors called for a future multidisciplinary,
systematic review of the literature relating to anti-
Patients at Potential Risk of Experiencing biotic prophylaxis use in patients with prosthetic
Hematogenous Total Joint Infection19 joints. In the meantime, they concluded that the
new AAOS 2009 information statement20 should
Patient Type Condition Placing Patient at Risk not replace the 2003 joint consensus statement.19
All patients during first two years N/A In December 2012, a panel of experts representing
following joint replacement the American Academy of Orthopedic Surgeons
and the American Dental Association published a
Immunocompromised/ Inflammatory arthropathies such as systematic review and clinical practice guideline,
immunosuppressed patients rheumatoid arthritis, systemic lupus titled “Prevention of Orthopaedic Implant Infection
erythematosus
in Patients Undergoing Dental Procedures: Evidence
Drug or radiation-induced immunosup- based Guideline and Evidence Report.”23 This report
pression contained the following three recommendations:
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4 2016
antibiotics CE article |
The report also stated that the above recommen- Patients not allergic to Cefazolin or ampicillin Cefazolin 1g or ampicillin
penicillin and unable to 2 g IM or IV 1 hour prior to
dations “are not intended to stand alone. Treat-
take oral medication dental procedure
ment decisions should be made in light of all cir-
cumstances presented by the patient. Treatments Patients allergic to Clindamycin 600 mg orally 1 hour prior to
and procedures applicable to the individual patient penicillin dental procedure
rely on mutual communication between patient,
physician, dentist and other healthcare practi- Patients allergic to Clindamycin 600 mg IV 1 hour prior to
tioners.” penicillin and unable to dental procedure
take oral medication Table 5
In 2014, a panel of experts convened by the
American Dental Association Council on Scientific *Note: No second doses are recommended for any of these dosing regimens.
Affairs developed an evidence-based clinical prac-
tice guideline on the use of prophylactic antibiot- A fundamentally changed view of antibiotics is (Tables: Provided by American
ics in patients with prosthetic joints who are un- needed. They must be looked on as a common good, Association of Endodontists)
dergoing dental procedures. This clinical practice where individuals must be aware that their choice to
guideline was published in The Journal of the use an antibiotic will affect the possibility of effec-
American Dental Association in January 2015 and tively treating bacterial infections in other people. All
contained the following recommendation: antibiotic use, appropriate or not, “uses up” some of
the effectiveness of that antibiotic, diminishing our
“In general, for patients with prosthetic joint ability to use it in the future. For current and future
implants, prophylactic antibiotics are not recom- generations to have access to effective prevention
mended prior to dental procedures to prevent and treatment of bacterial infections as part of their
prosthetic joint infection. The practitioner and right to health, all of us need to act now. The window
patient should consider possible clinical circum- of opportunity is rapidly closing.22_
stances that may suggest the presence of a signif-
icant medical risk to providing dental care without Editorial Note: This article originally appeared in END-
antibiotic prophylaxis, as well as the known risks of ODONTICS: Colleagues for Excellence, Winter 2012. Re-
frequent or widespread antibiotic use. As part of printed and updated with permission from the American
the evidence-based approach to care, this clinical Association of Endodontists, ©2012. The AAE clinical
recommendation should be integrated with the newsletter is available at www.aae.org/colleagues.
practitioner’s professional judgment and the pa- A complete list of references is available from the publisher.
tient’s needs and preferences.”24
author
Summary
Dr Steven G. Morrow
Since their discovery eight decades ago, safe Having taught future oral health-care professionals at Loma Linda
systemic antibiotics have revolutionized the treat- University School of Dentistry since 1965, Steven Morrow, DDS,
ment of infections, transforming once deadly dis- MS, is currently a professor in the department of endodontics that
eases into manageable health problems. However, he chaired from 1987 to 1990. He maintains responsibilities he
the growing phenomenon of bacterial resistance, accepted in 2000 as director of patient care services and clinical
caused by the use and abuse of antibiotics and the quality assurance. He was director, District VI, of the American
simultaneous decline in research and develop- Association of Endodontists from 1990 to 1993. He has also served
ment of new antimicrobial drugs, is now threaten- as president of the Southern California Academy of Endodontics
ing to take us back to the pre-antibiotic era. With- and as president of the California State Association of Endodontists. In 1997, he earned
out effective treatment and prevention of bacterial diplomate status from the American Board of Endodontics. Since 1998, he has been a fellow
infections, we also risk rolling back important of the American College of Dentists; and since 2003, he has served on the editorial review
achievements of modern medicine such as major board of the Journal of Endodontics. A life member of the American Dental Association, the
surgery, organ transplantation and cancer chemo- American Association of Endodontists and the California State Association of Endodontists,
therapy.22 he is currently serving his second term as a member of the Dental Board of California.
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4 2016 15
| CE article traumatic dental injuries
The treatment of
traumatic dental injuries
Author: Dr Asgeir Sigurdsson, USA
16 roots
4 2016
traumatic dental injuries CE article |
its socket, one should immediately place the tooth in a Fig. 2c: Clinical pictures of the
physiological solution of specialized media (such as minimal pulpotomy.
Hank’s Balanced Salt Solution) or milk, or saline if those
are not available. Only after the tooth is secured in solu-
tion should one obtain the patient’s information. Once
the patient is seated in the dental chair, it is necessary
to do a quick central nervous system (CNS) evaluation
before proceeding with further assessments. Fig. 2c
Often, the dentist is the first health-care provider to lateral angulations for all dental injuries, including
see the patient after a head injury (any dental trauma crown fractures. If cone-beam computed tomogra-
is, by definition, a head injury) and must assess the risk phy is available, it should be considered for more se-
of concussion or hemorrhage. It has been estimated by rious injuries, such as crown/root, root and alveolar
a meta-analysis that the prevalence of intracranial fractures, as well as all luxation injuries.
hemorrhage after a mild head injury is 8 percent, and
the onset of symptoms can be delayed for minutes to Additionally, sensibility tests should be conducted
hours.4 The most common signs of serious cerebral on all teeth involved as well as opposing teeth. Cold
concussion or hemorrhage are loss of consciousness testing is recommended over electric pulp testing in
or post-traumatic amnesia. Nausea/vomiting, fluids young individuals.6 Both testing methods should be
from the ear/nose, situational confusion, blurred vi- considered, however, especially when there is no re-
sion or uneven pupils, and difficulty of speech and/or sponse to one of the two. The pulp might be non-re- Fig. 3a: Schematic drawing of a
slurred speech may also indicate serious injury.5 sponsive for several weeks after a traumatic injury, so common situation after root fracture:
a pulp test should be done at every follow-up ap- The crown portion is displaced inward
Once the patient has been cleared of any CNS issues, pointment until a normal response is obtained.7 toward the palate and the fractured
the dental trauma should be assessed. The key is to ob- piece is stuck to the facial cortical
tain comprehensive information about the injury and, Once the diagnosis is confirmed and more serious plate.
to do so, one must conduct thorough extra-oral and complications such as CNS and jaw or other facial Figs. 3b & c: It is impossible to move
intraoral clinical exams as well as appropriate radio- bone fractures have been ruled out, the emergency the coronal portion back to its original
graphic evaluations. phase of the treatment needs to be initiated. The aim location without releasing it from the
of treating dental trauma should be to either maintain cortical plate. This is accomplished by
The new AAE guidelines recommend taking one oc- or regain pulpal vitality in traumatized teeth. This is pulling the coronal portion down and
clusal and two periapical radiographs with different because dental trauma most frequently occurs in pre- then repositioning it.
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4 2016 17
| CE article traumatic dental injuries
Table 1
Follow-Up Procedures for Fractured Permanent Teeth and Alveolar Fractures
Crown Fracture Crown-Root Fracture Root Fracture Alveolar Fracture
TIME
Uncomplicated Complicated Uncomplicated Complicated
Clinical and Clinical and Clinical and Clinical and Clinical and Clinical and
6–8 Weeks radiographic radiographic radiographic radiographic radiographic control radiographic control
control control control control
Clinical and Clinical and Clinical and Clinical and Clinical and Clinical and
1 Year radiographic radiographic radiographic radiographic radiographic control radiographic control
control control control control
*Splint removal in apical third and mid-root fractures; **Splint removal with a root fracture near the cervical area.
Fig. 3d: A periapical radiograph of teens or young teens in whom the teeth have not Crown fractures
a root fracture a few hours after yet fully developed, and root development will cease The first thing to do in any crown or crown-root
the injury. It was established that without a vital pulp. fracture is to look for the broken-off tooth fragment.
both fragments were in good With modern bonding technology it is possible to re-
approximation of each other. Clinical examples bond the fragment to the tooth, which is esthetically
Splinting was done for two weeks. the best solution. Prior to reattaching the tooth frag-
Fig. 3e: At the nine-month recall, Dental trauma can be roughly divided into two ment, the remaining dental thickness immediately
internal root resorption was noted, groups: fractures and luxation injuries. The frac- covering the pulp needs to be assessed radiographically
but no defect in the PDL or adjacent tures are then further divided by type: crown, and clinically. If there is at least 0.5 mm of the dentin
bone, indicating a ‘normal’ healing crown-root and root fractures. If the pulp is exposed remaining, there is no need to cover it with a protective
process. to the oral environment, it is called a complicated liner. If it is estimated that the remaining dentin is less
Fig. 3f: Five-year recall, no fracture; if not exposed, it is called an uncompli- than 0.5 mm, it is advisable to cover the deepest part,
endodontic treatment was needed. cated fracture. closest to the pulp, with a cavity liner, and then dimple
the fragment accordingly.8, 9 If the tooth fragment was
kept dry, it should be rehydrated in distilled water or sa-
line for 30 minutes prior to reattachment. This process
will increase its bonding strength10 (Figs. 1a–c).
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4 2016
traumatic dental injuries CE article |
Table 2
Follow-Up Procedures for Luxated Permanent Teeth
TIME Concussion/Subluxation Extrusion Lateral Luxation Intrusion
Clinical and radiographic Clinical and radiographic Clinical and radiographic Clinical and radiographic
6–8 Weeks
examination examination examination examination
Clinical and radiographic Clinical and radiographic Clinical and radiographic Clinical and radiographic
6 Months
examination examination examination examination
Clinical and radiographic Clinical and radiographic Clinical and radiographic Clinical and radiographic
1 Year
examination examination examination examination
2–5 Years Yearly up to 5 years Yearly up to 5 years Yearly up to 5 years Yearly up to 5 years
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4 2016 19
| CE article traumatic dental injuries
Subluxation 2 weeks
Extrusive luxation 2 weeks
Avulsion 2 weeks
Lateral luxation 2 weeks
Intrusion 4 weeks
Root fracture (middle 1/3) 4 weeks
Alveolar fracture 4 weeks
Fig. 5
Root fracture (cervical 1/3) 4 months Table 3
Fig. 5: Once the tooth has been cal portion of the tooth is stable once the two pieces might not be possible or advisable to manipulate the
repositioned, the patient bites into a have been approximated, no splint or a flexible splint tooth immediately. When an immature tooth is in-
softened pink wax plate that had been for two weeks produces the best treatment out- truded up to 7 mm, it is recommended to wait three
previously rolled one or two times. This come.2, 18 Longer splinting time is recommended only weeks and watch for signs of re-eruption. If no signs
will ensure that the luxated (or avulsed) when the fracture is close to the cervical area. exist, one can initiate orthodontic repositioning. For
tooth stays in place while being intrusion of more than 7 mm, surgical or orthodontic
splinted. In this case, a 16-pound Luxation injuries repositioning should be performed with in three weeks.
fishing line was used as the splint on All luxation injuries will cause some damage to the In the case of an intruded tooth with a closed apex,
the luxated tooth. periodontal ligament and, in some cases, the pulp as there is a possibility of re-eruption if the tooth is slightly
well. The immediate treatment is to limit further dam- intruded (less than 3 mm) and the patient is younger
age to the PDL and allow for the best possible healing. than 17 years old. If the tooth is not moving after two
As with all dental injuries, follow-up is essential. Late to three weeks, however, orthodontic extrusion or ex-
complications, such as internal or external root resorp- traction and reimplantation is recommended. If a tooth
tions, are relatively frequent and require endodontic with a closed apex is intruded more than 3 mm, ortho-
treatment, especially in more severe injuries. In many dontic or surgical repositioning should be performed
of these cases, referral to an endodontist is advisable. within three weeks. The risk with all intrusions is that
Fig. 6a: An immature tooth that was the intruded tooth may ankylose in the infraposition.
laterally luxated, as can be seen by the Luxation injuries are divided into subcategories, Once that begins, the tooth may not be movable except
empty socket space around the apex mainly by degree of severity. The two mildest are possibly surgically. It is well to advise the patient and
on the radiograph. termed “concussion” and “subluxation.” In those cases, the parents/guardians that the long-term prognosis
Fig. 6b: The tooth was repositioned the tooth is still in its original location, but is tender to of an intruded tooth is unpredictable, as it is likely to
and splinted for two weeks. percussion and/or, in the case of sub-luxation, has in- eventually be lost due to ankylosis.19-21
Fig. 6c: At the six-month recall there is creased mobility. While no immediate treatment is
good evidence that the apex is needed for these injuries, follow-up is critical because Splinting of a luxated tooth is recommended only
maturing and the pulp responds the pulp may become necrotic, making endodontic in- for teeth that are still mobile after repositioning. In all
normally to cold. At the three-year tervention paramount. types of trauma cases, a splint must allow for physio-
recall the pulp chamber is completely logical movement.22, 23 (See Figs. 4a–c & 5, and Table 3,
calcified; however, the tooth responds When trauma has moved the tooth out of its normal regarding splinting time.)
normally to EPT and there is no apical position, it needs to be replaced gently as soon as pos-
pathology. sible. The only exceptions are cases of intrusion when it When assessing luxation trauma, it is important to
consider the maturity of the apex. If it is still open,
there is a chance that the pulp will survive the trauma
or revascularize, allowing the growth of the tooth to
continue (Figs. 6a–c).
20 roots
4 2016
traumatic dental injuries CE article |
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4 2016 21
| technique access cavities
Cutting endodontic
access cavities—
for long-term outcomes
Author: Dr L. Stephen Buchanan, USA
Fig. 1: Maxillary central incisor with Errors accumulate during procedures. That’s the rea- Zen and the art of endo access
slot-like access cavity that is cut short son botching the access at the start of an RCT is so
of the incisal edge, adequately under much more devastating than say, problems that come Robert Persig, in his book “Zen and the Art of
the cingulum, and has been kept from misfitting a gutta-percha cone just before finish- Motorcycle Maintenance,”1 described being deeply
narrow in its mesial-to-distal ing the case. Miss a canal and the case is going down, frustrated when a bolt stripped as he was attempting
dimension. (Photos: Provided by regardless of how brilliant the remaining procedure is to remove the side covers to the engine of his motor-
Dr L. Stephen Buchanan, carried out. Perforate the tooth, and suddenly tita- cycle, before rebuilding it. The rebuild could not con-
unless otherwise noted) nium starts looking better. Cut huge access cavities, tinue until he was able to circumvent this problem.
Fig. 2: Mandibular premolar with and expect to see relatively huge numbers of root-frac- He had expected to spend several days completing
slot-like access cavity for a single tured teeth within five years of treatment. Simply the mission, yet he was amazed at the fury he expe-
canal root. Note how the access cavity cheat the access procedure by beginning the instru- rienced when faced with this conundrum.
is skewed toward the working buccal mentation of canals before a straight, perfectly smooth
cusp tip and shy of the idling lingual path has been cut to each canal orifice, and be pun- The more he thought about it, the more mystified
cusp, yet is centered above the root ished every time a file, an irrigating needle, an explorer, he became about his instinctual response, until he
structure, as evidenced by the rubber a gutta-percha point, a paper point or a plugger is realized that he was tweaked because he had grossly
dam clamp jaws engaged at the CEJ. taken into each of the canals scores of times. undervalued this part of the long rebuild procedure,
Fig. 3: Sagitally dissected maxillary thinking mostly about the more dramatic routines to
molar with mesially inclined access This is not a critique so much as an admission of follow, such as cracking the cylinder case, honing the
cavity, parallel to the mesial surface of the ways that teeth and their root canal systems cylinder, replacing the piston and putting it all back
the tooth and shy of the distal half of have taught me, usually the hard way, to spend together afterward. When he realized that nothing
the tooth. whatever time is needed to create perfect entry was going to progress until he had successfully re-
paths into canals, before I attempt to work in them. moved the side cover, he made removing that side
So why do I have to have a talk with myself before cover a separate and important mission, an accom-
beginning every access cavity—even after doing this plishment that would deliver satisfaction in and of
for 35 years—to be certain to hit the mark I know itself, if it could be completed during the next several
must be met before it is safe to venture further? hours spent.
22 roots
4 2016
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24 roots
4 2016
access cavities technique |
roots
4 2016 25
| technique access cavities
we could “just suck the pulp out, without cutting any 10 years, when a new generation of dentists and en-
tooth structure.” As we talked, I came to better under- dodontists, steeped in the new reality of implant den-
stand the structural imperative of saving teeth in the tistry as an alternative to RCT, have taken up the cry
long term, setting me on a quest for tools and meth- for longer-term outcomes through improved struc-
ods that would allow us to achieve the same consis- tural preservation, ultimately becoming what I jok-
tently ideal endodontic outcomes, through smaller ingly call The Itty Bitty Access Committee (IABC).
access openings and coronal canal shapes.
As so often happens, somebody outside of our spe-
Ultimately, it was the inspiration for my invention cialty, a general dentist named Dr David Clark, started
of the Maximum Flute Diameter (MFD) limitations on lecturing on the access elephant in the endodontic
GT and GTX rotary files (DENTSPLY Tulsa Dental Spe- living room. He got my buddy Dr John Khademi turned
cialties), the LAX (line angle extension) GuidedAccess on to the possibilities that more conservative access
Diamond Burs by SybronEndo, as well as obturation cavities could offer the specialty,4 and one by one a
methods using flexible condensation devices, such as group of young endodontists joined the game of who
System-B Continuous Wave electric heat pluggers can do a perfect RCT through the smallest access cav-
(SybronEndo) and GT/GTX Obturators (DENTSPLY Tulsa ity. This ad hoc group of talent began the IBAC club.
Dental Specialties).
The cases shown in Figures 4 through 10—mostly
The Itty Bitty Access Committee done by IBAC members—make me very happy and
afraid at the same time. What the heck are they doing?
Since that initial awakening in the ’80s, it has felt Little, tiny entries, leaving pulp chamber roofs intact,
like being a lone voice in the wilderness until the past lateral pulp horns unroofed as well, or just total RCT
through previously cut restorative cavities!
author
After getting over my initial shock at what they
Dr L. Stephen Buchanan, DDS, FACD, FICD, is a diplomate of the were accomplishing, I came to understand that the fu-
American Board of Endodontics, a fellow of the American and ture of endo is very good in these extremely talented
International Colleges of Dentists and serves as part-time faculty hands, and I saw that the procedure I was developing
to the UCLA and USC graduate endodontic programs. He holds patents for endodontic surgery—CT-guided endodontic sur-
on the Endobender Plier (SybronEndo), System-B and Continuous Wave gery (CT-GES)—could be applied to conventional
obturation tools and methods (SybronEndo), treatment as well (Figs. 11a–12d).
GT and GTX file systems (DENTSPLY Tulsa Dental Specialties),
LA Axxess Burs (SybronEndo), and Buc ultrasonic tips (Spartan/Obtura). And morning breaks over the field of endodontics._
Buchanan lives in Santa Barbara, CA, where he enjoys a practice limited
to conventional and microsurgical endodontics and dental implant surgery. He is the founder of Editorial note: This article was first published in the Clinical
Dental Education Laboratories, a hands-on training facility in Santa Barbara that he has directed Masters magazine, Vol. 1, 1/2015. A complete list of refer-
for 28 years. ences is available from the publisher.
26 roots
4 2016
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| case report canal shaping
Stairs to
the Apex Fig. 2
Fig. 2: HyFlex CM Sequence. Sometimes endodontic specialists have to go the Iatrogenic damage
extra mile to save teeth. Only with the proper
endodontic instruments success can be ensured An 18-year old male patient presented with a
in the most challenging situations. This case painful lower right first molar. After thorough exam-
shows how the aid of HyFlex CM-files can help to ination, both clinical and radiographic, tooth #46
deal with multiple iatrogenic deformations after was diagnosed to be the cause of his pain. On the
several previous temporary root canal therapies. pre-operative radiograph a (symptomatic) apical
The use of these pre-bendable NiTi-files help us periodontitis could be recognized together with a
to get the root canal preparation “back on track”. leaky temporary restoration with decay underneath.
Two mesial and a distal canal were filled with calcium
Endodontic intervention after a previous tem- hydroxide. Looking even more into detail a step could
porary treatment can sometimes pose a real chal- be observed in the distal root canal. Clinical the tooth
lenge even for the most skilled endodontist. Some was painful on percussion and biting forces, there
patients have a long history of unsuccessful root was no reaction to cold or warmth and no pockets
canal treatments. In a situation like this it be- could be probed although the gum was inflamed due
comes quite difficult to shape the canal when the to the temporary restoration and decay that was left
natural path of the root canal is almost com- behind.
Fig. 1: Pre-operative radiograph pletely lost. The loss of dentin is often consider-
showing multiple steps in the able after several dentists have literally tried to After further examination the patient explained
mesio-buccal and distal canals. “push their luck”. the tooth had been treated in the recent past by no
less than three different dentists. Recurring pain
had forced him to seek treatment time and again
after each provisional non-surgical root canal
treatment (nsRCT). Apparently, each colleague had
tried to work his or her way around the imperfect
preparation of their predecessors leading to a root
canal with the shape of a staircase. The absence of
a good coronal seal lead to improper healing and
thus caused a chain reaction of re-interventions
which resulted in iatrogenic damage of the root ca-
nal walls.
28 roots
4 2016
canal shaping case report |
present in the distal and in the mesio-buccal canals. move the file in a soft pecking motion through the
In a case like this it is important to redefine the shape canal. In addition to that it is highly advisable to
of the previous preparation and first and foremost an irrigate the canal thoroughly every time a file in the
endodontic file system is needed that is flexible and sequence is changed.
prevents further unproportional loss of tooth sub-
stance. Once the manual glide path was created, it was
very easy to bypass the various steps and ledges with
For the canal preparation a renowned nickel tita- the pre-bendable HyFlex files (Fig. 4). The mechanical
nium file system by Swiss dental specialist COLTENE rotation was started on the endodontic motor only
(Fig. 2) was used. Thanks to a clever combination of after the insertion of the pre-bent instrument in the
unique material properties, pre-bendable HyFlex CM canal beyond the step. By this approach the risk of
files are virtually unbreakable. The reason for this perforation is generally eliminated and no further
phenomenon is simple: the well-known “Controlled damage of the root canal wall takes place at the level
Memory”-effect is flexible enough to find its way of the step. Beyond the step we used the rotating files
around the distorted canals. It improves certain as usual at the normal operating mode of 500 rpm.
physical qualities of the alloy itself. Similar to classi- With only a few files per canal it was possible to in-
cal stainless steel files the instruments can be pre- strument the root canal up to a working length of
Fig. 3
bent, but they do not bounce back like conventional 21 mm. The mesio-lingual canal was finally instru- Fig. 3: Refined shape memory of “CM”
NiTi files. This typical characteristic makes “CM”- mented with a pre-bent .35/0.06 file (Fig. 5). The file – treated NiTi files.
treated NiTi files extremely flexible. Highly versatile was inserted into the canal with two to three subtle
files are particularly helpful if you have to move movements, then withdrawn before it re-entered
around abrupt curves or—in this case—a mutilated the canal. Similarly, the mesio-buccal canal was
anatomy. After usage their form adaptation can be shaped with a size .35 file with a taper of 0.04 (Fig. 6).
quickly reversed in the sterilization process. During To enlarge the apical aspect of both the disto-lingual
autoclaving the instruments turn back to their origi- and the disto-buccal canal a 45/0.04 file was used
nal shape (Fig. 3). The refined NiTi files are very resis- (Fig. 7).
tant to cyclic fatigue and can be reused safely, as
long as they are not plastically deformed. All files kept their pre-bent shape during the pro-
cedure and moved safely in the centre of the canal.
The Hyflex CM-files respond to excessive resis- Even unexpected angles could be managed almost
tance with straightening of the spirals, which avoids effortlessly with the swift moving instruments. De-
binding to the walls. To create any form of steps in the spite the numerous steps that got sculptured into
canal shape is incredibly hard and instrument sepa- the root canal before a smooth shape was finally re-
ration is almost impossible, as long as the files are gained, which would ensure a tight and reliable ob-
applied correctly. A good preparation technique is to turation of the root canal system (Fig. 8).
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4 2016 29
| case report canal shaping
Fig. 4: Occlusal view on Successfully preventing re-infection tivation (cone pumping). Corresponding paper points
one of the steps. were inserted to dry the canals afterwards.
Fig. 5: Pre-bendable File 35/.06. As mentioned above, a thorough rinsing protocol
Fig. 6: Pre-bent File 35/.04. was performed throughout the whole nsRCT. The con- In the end a bioceramic sealer and gutta percha
Fig. 7: File 45/.04. stant copious irrigation helped to clear the canal of re- were used in the hydraulic condensation technique
maining debris or necrotic tissue. As cleaning irrigants for permanent obturation (Fig. 9). After curing, bio-
we used sodium hypochlorite (NaOCl) in a concentra- active filling material can form so-called hydroxyap-
tion of 5.25 % and citric acid (40 %). Both irrigants were atite crystals on the surface. The crystals help to stim-
activated by ultrasound as well as manual dynamic ac- ulate the regeneration of bone and dentin tissue in
Fig. 8 Fig. 9
30 roots
4 2016
canal shaping case report |
Fig. 10 Fig. 11
particular. The coronal restoration was topped off dodontists therefore can offer a lot of advice and help Figs. 10 & 11: Post-operative
with a composite and a core build-up of glass fibre with cases that are otherwise deemed to be untreat- radiographs.
reinforced composite. Further indirect restoration is able. A good working referral system can bring huge
planned to be done by the referring dentist. benefits for both general practitioners and endodon-
tists who know their way around the root canal.
The post-operative X-rays illustrate two interesting
aspects (Figs. 10 & 11): first of all, the obturation ma- Summary
terial was safe in place and together with the tight seal
of the coronal restoration should keep another re- Modern rotating instruments help the endodontist
infection at bay. Secondly, the steps were still visible. and general dentist to operate both confidently and
Especially the mesio-buccal and distal canals looked safely. Refined NiTi systems with “Controlled Memory”-
imposing in relation to their normal size. However, the effect are extremely flexible and fracture resistant due
composition as a whole appeared to be stable with to their special material properties. With pre-bendable
enough dentine surrounding the apex. We were able files root canals can be shaped efficiently without
to save the tooth and the patient left our endodontic making any concessions to the natural anatomy of a
practice with an uplifting prognosis despite his un- given root canal. Even referral cases with an eventful
fortunate entry. history can have a promising prognosis, if the RCT is
performed according to the rules, i.e step by step._
Experts for root canal treatment
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4 2016 31
| case report use of the new MTA
Figs. 1 & 2: Initial clinical and A 47-year-old female patient presented to our clinic straight tips (Irrisonic, Helse). The working length was
radiographic appearance of tooth #36. with a radiograph that showed an extensive iatro- then determined with the help of a foramen locator.
Fig. 3: O
bturation of the root canal. genic perforation of the furcation area at tooth #36 The final preparation of the canal was performed with
(Figs. 1 & 2) that was associated with radiographic the RECIPROC system (VDW).
bone loss, a vestibular fistula and pain on palpation.
The patient had previously received urgent interven- The prepared area was cleaned and refined with
tion concerning this tooth by another clinician owing an ultrasonic d iamond tip (E7D, Helse). In addition
to acute pain from pulpitis. The case was subse- to the intra-canal disinfection process, calcium hy-
quently recommended for endodontic therapy. droxide (Ultradent) placed in the furcation area was
exchanged every two weeks, during which time the
After an initial discussion with the patient, anaes- symptoms were alleviated.
thetic was administered and the tooth was isolated.
After creating a coronary access, we clinically verified The obturation was performed according to the
the presence of pulp necrosis and perforation. The root thermomechanical Tagger hybrid technique (Fig. 3)
Figs. 4 & 5: Clinical photograph and canal was disinfected (crown-down) with an irriga- using the GutaCondensor (Maillefer), TP gutta-percha
radiograph ofthe MTA Repair HP filling. tion agent (5 % NaOCl) and ultrasonic activation using cones (DENTSPLY) and the MTA-based sealer MTA-Fill
Fig. 4 Fig. 5
32 roots
4 2016
use of the new MTA case report |
about
Fig. 6 Fig. 7
apex (Angelus). After the thermomechanical compac- filling with the material (Figs. 4 & 5), and a glass
tion, the gutta-percha was cut and vertical conden- ionomer cement (3M) was applied to seal and pro-
sation was performed using a cold plugger. The area tect the area (Fig. 6).
of the perforation was then cleaned and refilled with
calcium hydroxide. After temporary restoration, we observed the Dr Fábio Duarte da Costa
tooth radiographically and found proper sealing of Aznar is a specialist in
After 15 days, we began to seal the prepared area the furcation area with MTA Repair HP. No post endodontics at the Hospital for
and initially verified that the area had dried properly. operative complications were reported. Rehabilitation of Craniofacial
The prepared area was filled with MTA Repair HP ac Anomalies at the University of
cording to the manufacturer’s instructions, applied At the two-month follow-up visit, bone forma- São Paulo in São Paulo, Brazil.
with the MTA Applicator (both Angelus). Clinical and tion in the furcation area was detected. No further He can be contacted at
radiographic criteria were used to determine correct symptoms were reported (Fig. 7)._ fabio@aznar.com.br.
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roots
4 2016 33
| case report use of Er,Cr:YSGG laser in endodontics
34 roots
4 2016
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Fig. 1: Clinical picture root canal system disinfection and to allow irriga- Case report
demonstrating aesthetic initial tion solutions to travel apically.22, 30–32 In addition,
appearance of tooth 11. Er,Cr:YSGG laser irradiation has been shown to pro- A 31-year-old female patient presented for con-
Fig. 2: Initial radiographic duce clinically safe temperature increments along sultation, complaining of recurrent swelling and
appearance of tooth 11 the root canal walls,32–35 together with absence of painful episodes related to tooth 11, which had been
demonstrating an extensive apical molecular dentine changes, signs of melting or car- treated with antibiotic prescriptions over the past
radiolucency and internal bonisation.18, 34, 36 few years. The patient’s medical history was not con-
root resorption. tributory. The patient reported trauma to her upper
Fig. 3: Immediate post-operative Previously, laser-assisted endodontic protocols teeth when she was 20 years old. After performing
radiograph of tooth 11. consisted of using plain fibres (with a straightforward clinical and r adiographic examinations, tooth 11 was
emission beam profile). Generally, these fibres were diagnosed with pulp necrosis with internal root re-
placed in the main canal and withdrawn from apical sorption and apical periodontitis. The tooth was
to coronal in a rotating motion. However, such tech- slightly tender to percussion, periodontal probing
nique is known to be sensitive and to produce incon- depths were considered normal (< 3 mm), and there
sistent results.18, 35, 37 was no discoloration (Figs. 1 & 2).
Designed to overcome such limitations, radial fir- Approval for the study protocol (N_682/068) was
ing tips (RFT) present a beam expansion pattern— obtained. Treatment options were discussed and the
promoted by the tip geometry—that favours a ho- required consent obtained (Helsinki Declaration, re-
mogeneous energy distribution along the root canal vised in Edinburgh 2000). No financial incentive was
wall. In contrast with plain fibres, RFT have been offered (i.e., patient was responsible for the usual
shown to produce consistently relevant in vitro re- root canal treatment fee).
sults. They are known to spread their energy in the
direction of the dentinal tubules,22 to produce lower Under local anaesthesia (2 % lidocaine with
temperature increments,27 to increase cavitation ef- 1:100,000 epinephrine, Scandonest, Saint Maur
fects towards the root canal walls without harming des Fossés, France) and rubber-dam isolation (Hy-
periapical tissues,38 to be highly efficient in bacterial genic Non-Latex Rubber Dam, Coltène/Whaledent,
and biofilm reduction39, 40 and to allow irrigating Germany), an access cavity was prepared with a
solutions to travel apically by overcoming the airlock high-speed carbide bur (SS White, Lakewood, NJ)
effect.41 and Zekrya Endo burs (DENTSPLY Maillefer, Ballai-
gues, Switzerland). The working length (WL) was
Although some clinical studies have demonstrated electronically established (Root Zx mini, Morita,
the potential benefits and long-term outcomes after USA) as 1 mm short of the biological apex of the root
laser-assisted treatments,42, 43 there is no mention of and confirmed by radiography. No bleeding was
any IRR case treated with a laser-assisted technique. noted from the root canal. Patency was confirmed
The report of distinct clinical cases with long-term with an ISO#20 K-file and root canal preparation
follow-ups may be an additional support for an evi- was performed with the Protaper system (DENTSPLY
dence-based proof of concept. Maillefer, Ballaigues, S witzerland) up to an F5 (#50.05)
36 roots
4 2016
use of Er,Cr:YSGG laser in endodontics case report |
instrument. Root canal irrigation was performed a final rinsing of sterile saline solution (3 ml) was
between each file with 3 ml of sterile saline solution performed, and the canal was dried with sterile pa-
(Monoject 27G, Kendall-Covidien, USA). No chemical per points, checking for the absence of any suppu-
irrigants or inter-appointment dressings were used. ration or exudate. Filling was performed with a
#50.05 auto-fit gutta-percha cone (DENTSPLY
For smear layer removal and root canal disinfec- Maillefer, Ballaigues, Switzerland) using a down
tion, a previously reported laser-assisted protocol pack-backfill technique (Calamus, DENTSPLY
was adopted.42, 43 Following root canal preparation, Maillefer) and a resin-based endodontic sealer
the main canal was filled with distilled water and (Topseal, DENTSPLY Maillefer). Both down pack mo-
laser irradiation was performed with the 2,780 nm tion and gutta-percha injection were performed
Er,Cr:YSGG laser (Waterlase MD; Biolase Technol- with low pressure and extreme caution due to the
ogy, San Clement, CA) and radial firing Tip (RFT2 En- root weakness. Radiographic images were taken
dolase, Biolase Technology; calibration factor of immediately (Fig. 3) and after one (Fig. 4), two
0.55) which was 270 µm in diameter, with panel set- (Fig. 5) and three years (Figs. 6 & 7). Over this
tings of 0.75 W, 20 Hz (37,5 mJ), 140 µs pulse, 0 % follow-up period, the tooth remained completely
water and 0 % air. The tip was placed at the working asymptomatic and periapical healing was noticed.
length and irradiation was performed, approxi-
mately, at the speed of 2 mm/s until it reached the Discussion
most coronal part of the canal. The irradiation pro-
cedure was repeated four times: 2x with the canal Due to its insidious pathology, the following clin-
filled with distilled water (for smear layer and gran- ical findings enabled the establishment of the diag-
ulation/pulp tissue removal) followed by 2x in dry nosis of IRR:44 initial absence of bleeding from the
conditions (to achieve deep dentine penetration root canal confirming a necrotic pulp, normal prob-
and disinfection), with approximately 15 seconds ing depth (< 3 mm) and the complete resolution of
between each irradiation. Afterward, a sterile cot- apical radiolucency after endodontic treatment,
ton pellet was placed in the pulp chamber, and the followed by the cessation of the progression of re-
access cavity was sealed with a reinforced zinc-ox- sorption.
ide eugenol intermediate restorative material (IRM,
DENTSPLY). Given that there is insufficient clinical data sup-
porting the superiority of any chemical irrigation reg-
At the second appointment after seven days, the imen and no guidelines for the management of low-
patient reported pain, tenderness to percussion occurrence pathologies such as IRR, case reports may
and swelling upon questioning. Under local anaes- be of special relevance while adequately reporting new
thesia and rubber dam isolation, the canal was disinfection techniques and their clinical o utcomes.3, 45
re-accessed. The main canal was filled with distilled
water and laser irradiation was performed using a The present protocol adopted the use of an Fig. 4: Twelve-month follow-up.
320 µm radial firing tip (RFT3 Endolase, Biolase Er,Cr:YSGG laser and innocuous irrigants (e.g. saline Fig. 5: Two-year follow-up.
Technology: calibration factor of 0.85), with panel solution as irrigation and distilled water for laser ac- Fig. 6: Three-year follow-up from
settings of 1.25 W, 20 Hz (62.5 mJ), 140 µs pulse, tivation). The decision was primordially based on the the mesial direction.
0 % water and 0 % air. The irradiation protocol was assumption that IRR lesions may perforate external Fig. 7: Three-year follow-up from
identical to the first appointment. After irradiation, root surfaces without being detectable on conven- the distal direction.
roots
4 2016 37
| case report use of Er,Cr:YSGG laser in endodontics
tional radiographic images,46 and that anatomic vari- tion.19, 38 Then, to achieve its maximum bactericidal
ations are known to significantly contribute to the properties, the Er,Cr:YSGG laser should work on a dry
occurrence of sodium hypochlorite accidents.47 canal, allowing the energy to be transmitted deep
into the dentinal tubules22 and to instantaneously
While trying to achieve significant bacterial reduc- interact with the water molecules trapped into the
tions, our protocol contrast with that recently re- bacterial membrane and within endodontic biofilms.39
ported by Christo et al. which used low concentra-
tions of NaOCl and a Er,Cr:YSGG laser-activation RFT have been shown to overcome several limita-
technique. In fact, this protocol has been shown not tions attributed to bare fibres, distributing the emit-
to improve the antibacterial effects of NaOCl48 and, ted laser energy in a uniform ring-shaped pattern.33, 59
therefore, the activation of NaOCl may seem inade- In similarity with any other innovative root canal
quate for the management of such conditions. In treatment strategies, there are few reports demon-
accordance, it was shown that the use of Er,Cr:YSGG strating the prospective, long-term clinical out-
laser with relatively high output powers to activate comes associated with the use of Er,Cr:YSGG laser,
irrigants such as NaOCl or EDTA may result in a high namely with RFT. However, Martins et al. have shown
magnitude of pressure changes capable to induce ir- that RFT can be considered predictable as the con-
rigants extrusion during laser-activated irrigation.49 comitant use of 3 % NaOCl and CH for the endodon-
tic treatment of single-rooted teeth with apical peri-
In order to obtain adequate microbial control cal- odontitis.42, 43 Our findings may provide further
cium hydroxide (CH) is often recommended for the evidence that RFT can be considered safe in cases of
management of IRR lesions.50–52 However, the use of teeth with wide apical foramina while being ade-
CH as an intra-canal medication consistently fails to quate to effectively reach all the contours of the re-
present improved clinical outcomes.53–55 In the pres- sorption lesion.
ent report we may support that CH medication should
not be considered crucial as antimicrobial agent and The prognosis for the conservative treatment of
neither as essential to stop the IRR progression. IRR should increase due to the report of alternative
endodontic techniques along with the use of new
In fact, the decision process for not using CH as technologies (Al-Momani & Nixon 2013, Khojaste-
intra-canal medication during the endodontic treat- pour et al. 2015, Nilsson et al. 2013).2, 44, 46 Therefore,
ment of IRR was also supported by the following cri- clinicians may consider this laser-assisted technique
teria: (1) no irrigation technique is completely able to while selecting an appropriate endodontic disinfec-
remove CH from simulated internal root resorption tion strategy for the management of IRR.
cavities14 and (2) the long-term exposure to CH can
cause a significant reduction in the mechanical prop- Conclusion
erties of radicular dentine.56
Despite their intrinsic methodological limitations,
Due to their biophysical properties, lasers have the adequate report of single clinical cases may either
long been seen as a promising disinfection tool in help the understanding of unusual presentations of
endodontics. However, each wavelength demon- common diseases or assist in guiding new treatment
strates different biophysical interactions with the concepts into clinical practice.45 This case report pres-
main radicular dentine components.15 The high ab- ents potential benefits towards the use of Er,Cr:YSGG
sorption coefficients in both water and hydroxyap- laser and radial firing tips in endodontics. Further ran-
atite may justify the selection of the Er,Cr:YSGG laser domised clinical trials should be conducted to clearly
(=2,780 nm) for both smear layer removal and dis- demonstrate its effectiveness._
infection purposes.18 Conflicting evidence while us-
ing other wavelengths can be found consistently.57, 58 Editorial note: A list of references is available from
the publisher.
In the present report, the laser protocol consisted
in two irradiations with distilled water in the main contact
canal followed by two irradiations in dry conditions,
respectively for smear layer removal and disinfec- Dr Miguel Rodrigues Martins, DDS, MSc, PhD
tion purposes.42 The rationale was that in wet condi- Endodontic Department, Faculty of Dental Medicine,
tions the Er,Cr:YSGG laser can promote beneficial Universidade do Porto, Portugal
cavitation effects inside the main canal without in- Rua Dr. Manuel Pereira da Silva,
creasing the extrusion of irrigants.38 Moreover, wa- 4200-393 Porto, Portugal
ter-mediated cavitation has been shown to be highly Tel.: +351 914610046
effective for the removal of dentin debris in compar-
ison with conventional or passive ultrasonic irriga- miguel.ar.martins@gmail.com
38 roots
4 2016
| industry report role of the microscope
Fig. 1a Fig. 1b
40 roots
4 2016
role of the microscope industry report |
Fig. 2 Fig. 3
Preparation of root canal system of lower molars remained in the canal system after Fig. 2: Oval shaped canal in the apical
irrigation. third of the distal root of a lower molar.
The cause of failure of endodontic treatment has Fig. 3: Debris accumulated after
been attributed to the presence of microorganisms Failure of endodontic treatment in maxillary mo- preparation in the isthmus between
persisting in the apical part of the root canal (Siqueira lars has been attributed to the failure to locate and the mesial canals of a lower molar.
2001). Much attention has therefore been focused on treat the mb2 canal (Weine, 1969; Wolcott et al., 2005).
preparation and obturation of the apical part of the Various studies have shown the presence of the mb2
canal thereby depending on the apical seal to prevent canal in up to 90 % of maxillary first molars. A study
toxins from leaking out into the periradicular tissues. by Somma et al. (2009) showed that in 58 % of teeth,
While success rates of endodontically treated teeth the mb1 and mb2 merge apically into one canal. In a
without periradicular lesions is very high, there can be proportion of these failed cases where the mb1 canal
a significant reduction in success in both teeth with has been located, cleaned, shaped and obtruded well,
periradicular periodontitis and in those teeth where the question should be asked, “Was the failure due to
endodontic treatment has failed (Ng et al., 2011). This inadequate treatment of the apical part of the mb1
is predominantly due to the failure to remove mi- canal, or because the mb2 canal and isthmus between
crobes form the root canal system. The quest is to find the two canals had been missed?” Identification and
more effective irrigants and irrigation techniques, as treatment of the mb2 canal with concommitant
well as rotary files and preparation techniques to re-treatment of the mb1 canal often leads to healing.
overcome these difficulties. This suggests that the seals are not always good
enough to “entomb” the bacteria. Indeed coronal
An ideal preparation shape with a rotary instru- microleakage has been implicated as a major cause
ment can only be achieved in a canal with a matched of failure of endodontic treatment (Saunders and
cross section. Many canals are variable in shape. They Saunders, 1990). Undoubtedly tracts of debris run-
may have irregular and oval cross-sections and while ning along side root fillings are conduits for bacteria
much of the debris is captured within the flutes of the to cause failure by this method.
instruments, some is compacted into those spaces
between the instrument and the canal wall (Fig. 2). The In an in vivo study by Nair (2005) the mesial canals
incidence of isthmuses in both maxillary and mandib- of sixteen lower molars with infected root canals were
ular first molars is very high (von Arx 2005). They are root treated by conventional techniques in a single
particularly liable to have an accumulation of com- visit and the apical portions removed by flap surgery
pacted debris after preparation and the inability to and evaluated by corrective light and transmission
clean these areas effectively has been implicated as a electron microscopy. In the majority of cases residual
major cause of failure of root canal treatment, partic- microbes were located in inaccessible recesses, unin-
ularly in both mandibular and maxillary first molars strumented areas of the main canals, accessory ca-
(Fig. 3) (Hsu & Kim, 1997; Tam & Yu, 2002). nals and intercanal isthmuses.
The more the debris is compacted, the more dif- If the lateral extensions feed into the apical part of
ficult it is for chemicals such as sodium hypochlo- the canal, then removing bacteria and nutrients from
rite and calcium hydroxide to penetrate through these areas reduces the bacterial load and this has to be
the interface. Paque et al. (2010) reported that ap- beneficial for the outcome of treatment. A variety of
proximately half of the debris that accumulated techniques have been proposed to overcome the inad-
during rotary instrumentation of the mesial canals equacies of mechanical preparation in non-circular ca-
roots
4 2016 41
| industry report role of the microscope
nals including circumferential filing using both hand to remove debris utilising a combination of acoustic
and rotary files and the use of a rotary self-adjusting microstreaming and and cavitational energy (Ahmad
file that adjusts to the shape of the canal. The SAF sys- et al., 1987a, b; 1988; 1992) (Fig. 4).
tem has been shown to be more effective in cleaning
oval canals that conventional rotary nickel titanium in- PUI was found to be effective in apical part of
struments, however in the study by De Deus et al. (2011) curved canals and in the isthmus area between two
using mandibular canines, even this technique did not canals. The technique has been shown to remove tis-
render the canals completely clean. They showed that sue more effectively than hand irrigation and does
rotary files were unable to access the recesses of oval not cause damage to the canal wall (Gutarts et al.,
canals and that sodium hypochlorite had a “limited 2005). Variation in the efficacy of PUI reported in
ability to compensate for the inadequacy of the file it- some studies were explained by difficulties in stan-
self”. They further suggested that the common belief dardising the position of the instrument in the centre
that “the file shapes; the irritant cleans” is based more of the canal (van der Sluis, 2007).
on wishful thinking than on experimental facts. In a re-
view article by Metzger (2014), it was recognised that Since the introduction of the operating micro-
SAF was unable to prepare the narrow isthmus of less scope, it has been possible to carry out endodontic
than 0.2 mm. In the case of the narrow isthmus the treatment at varying magnifications up to approxi-
challenge is to deliver sufficient quantities of irrigant mately 25x with the aid of direct light that can pene-
effectively into a very small area in which debris has trate into the depths of the root canal. This means that
been compacted during preparation. visual inspection of the prepared root canal is possi-
ble. Once the canal has been shaped by conventional
techniques and dried, the canal can be visually in-
spected both apically and laterally into the extensions
of the canal. Straight canals can be inspected to the
apical constriction. Since the rotary files straighten
the coronal and middle thirds of curved canals, most
of these prepared canals can be inspected to within a
few millimetres of their full working length.
42 roots
4 2016
role of the microscope industry report |
Fig. 5 Fig. 6
A very effective solution is to use an ultrasonically interchangeably just by varying the lateral pressure
energised K-file (UEFK), the very instrument that was placed on the ultrasonic handpiece.
discarded after the problems identified with ultra-
sonic instrumentation in the 1980s. The difference In endodontic retreatment cases both the UEKF and
between then and now is that in conjunction with the the dedicated ultrasonic tips can be used to great effect
use of the operating microscope the instrument can to remove endodontic obturation materials, separated
be used with a great deal of control. Also power set- instruments and posts using minimally invasive tech-
tings have been considerably reduced to minimise the niques. While the UEKF has to be used at low power set-
possibility of instrument separation. In many situa- tings to minimise the possibility of fracture, it allows for
tions the UEKF overcomes many of the limitations excellent visual control. The dedicated ultrasonic tips
presented by other ultrasonic instruments. The file such as the EndoSucess ET 25 tip can be precurved to
can be curved in multiple directions so that the head improve visual access and can be used at higher power
of the ultrasonic handpiece does not impair visual ac- settings. It is however only effective at its end. This tip
cess and the file can be shaped to follow the curvature is particularly useful for removing separated instru-
of the canal. When used in conjunction with the op- ments. Other ultrasonic tips that cannot be pre-curved
erating microscope, the file can be directed to the part can only be used in straight parts of the canal.
of the canal that has not been prepared by the rotary
files. A size 20 UEKF with a 2 % taper is an optimal size The removal of gutta-percha from oval canals of-
although occasionally a larger file may be used. Be- ten presents a challenge as rotary instruments are not
cause the file is relatively flexible and removes only completely effective. A rigid ultrasonic tip is more like
0.2 mm of tissue, unnecessary removal of dentine is to plasticise the gutta-percha, while the UEKF with its
kept to a minimum (Fig. 6). increased tip amplitude, fragments the material.
roots
4 2016 43
products
new endo products
innovative instruments
FKG Dentaire SA
MaxWire alloy, it features extreme flexibility and remarkable fatigue strength, Crêt-du-Locle 4
compared with competing instruments that achieve the same final size. It has the 2304 La Chaux-de-Fonds
capacity to expand, from its initial 0.01 taper to a minimum taper of 0.04, and the Switzerland
ability to progress with agility along the canal, reducing the risk of torsional fatigue. info@fkg.ch (XP-endo Shaper is a registered
Featuring the Booster Tip, which has six cutting edges, the XP-endo Shaper www.fkg.ch trademark of FKG Dentaire.)
44 roots
4 2016
dental imagining
Sendoline
Box 7037 Tillverkarvägen 6
18766 Täby
Sweden
www.sendoline.com
roots
4 2016 45
| meetings IDS
The scientific and technological progress in the field models enable a particularly relaxed view even in the
of endodontics has considerably improved the chances case of very small-structured areas. If necessary, the
of long-term tooth preservation and also turns this practitioner choses a colour corrected lens system
specialised field into a relevant part of prophylaxis- and a correction to suit his spectacles.
oriented dentistry. Because the success rates are sig-
nificantly higher today than twenty years ago. Whereby The endodontic X-ray—more and more frequently in
the methodical spectrum ranges from the conserving the form of a digital 3-D X-ray—delivers essential ad-
therapy with manual or mechanical root canal treat- ditional information on the precise course of the root
ment, disinfection and obturation, to the possibly canal. In the further process, X-rays frequently serve
necessary root canal revision, through to minimally the purpose of determining the exact length, whereby
invasive, microsurgical concepts for the treatment of the combination with an electro-metrical determina-
specific endoperiodontal lesions. The International tion with an endometric device proves to be helpful in
Dental Show (IDS) from 21 to 25 March 2017 will pres- many cases. Electrical resistance represents the actual
ent the entire palette of endodontic instruments and measuring sizes here. In the case of more recent endo-
materials necessary for this purpose. metrical devices, a reference point between the fora-
men physiologicum and the foramen apicale is deter-
Getting to know the root canal system: mined. The actual measurement of the resistance is
Glide path and diagnostic tools thus only dependent on the conductivity of the canal
wall dentine. State-of-the-art developments work
This begins with systems for the production of the according to the principle of the impedance quotient
gliding path as a basis of every successful endodontic measurement: These apex locators determine the
treatment. To this end both hand files and chelation alternating current resistance in the case of two dif-
gels as well as machine-driven alternatives are avail- ferent frequences (multi-frequency technology). For
able. A trend towards the use of a single rotating sin- practical use, devices that communicate the message
gle-use file is noticeable, because modern instruments “apical section reached!” or “Beware, danger of over-
made of nickel titanium display high resistance to instrumentation!” using acoustic and/or optical sig-
breakage, can reduce the treatment time and are thus nals are recommended. Modern apex locators work in
also advantageous from an economic point of view. both dry and moist root canals and are in some cases
even available in compact small formats.
In this stadium of the treatment the dentist al-
ready gets a precise picture of the anatomy of the root Less and less filing
canal -not least thanks to a multitude of diagnostic needed to achieve the goal
aids. For the visual examination with the bare eye,
the dentist can use a magnifying glass for the inspec- In order to prepare the root canal, sequences of co-
tion, whereby today extremely lightweight high-tech ordinated filing are required—however this is tending
46 roots
4 2016
IDS meetings |
to become less all the time or—an important develop- a separate head (two-piece), conically cylindrical or
ment of our era—only one sequence of filing is needed with a double taper design with a slightly less conical
even. Depending on the individual case and personal lower third. Several posts behave like a chameleon and
experience, the practitioner decides between classic display a colour coding at room temperature to enable
rotating filing with a high degree of flexibility and if a safe recognition, only to take on the colour of the
necessary increased breakage resistance (continually natural tooth at body temperature.
rotating movement) and an effective and simple pro-
cess (reciprocal file movement). Last, but not least: After the “endo“ is before the
“post-endo“. The final coronal care has to be hermeti-
Depending on the filing system, classic endo mo- cally sealed and must remain stable long-term. Here
tors can be implemented or advanced systems that the practitioner can choose between the conventional
can work either continually or reciprocally. Alterna- prosthetic materials, classic filling materials and (ex-
tively to the usual touch-screen operating surface, in cept for the formation of posts) bulk filling composites.
some models it is possible to steer them per Bluetooth
via an app from the iPad Mini. This can make the stor- Borderline:
age of filing sequences, the graphic representation of Special area endo/perio lesion
treatment scenarios to the patient much easier.
The endoperiodontal lesions generally constitute a
With the subsequent rinsing of the treated canals significant borderline case because in the individual
(i.e. with NaOCI, EDTA) numerous details have been cases the therapy is strongly dependent on the cause.
optimised over the past years—one of them: The for- If it is primarily due to a periodontal inflammation,
mation of and the related limited flow of fluid around both endodontic treatment and a curettage will be re-
it is avoided by activating the rinsing fluid. This is quired. However, if the cause of the disease in the re-
made possible by a pressure/vacuum rinsing or by spective tooth is primarily endodontic, root canal
combined vibrating and swaying movements with treatment could suffice and a curettage should not be
selectable sequences. The suitable devices normally carried out. Comprehensive probing and a high-per-
comprise of a handpiece (possibly cordless) and spe- formance microscope aid the differential diagnosis.
cial inserts/attachments. In some cases these can be
bent to suit the canal anatomy and then inserted. This Whereas in the case of endodontic treatment a
can lead to the achievement of the desired clean sur- host of individual decisions have to be taken. Manual
face with open dentine tubules. or mechanical production of the glide path? Prepa-
ration with multi-filing or one-time filing systems?
The next partial goal is the hermetic sealing of the Root post or not? Restauration of the crown using
canal system. Usually this is carried out using gut- composites or prosthetics? A series of predecisions
ta-percha, whereby both systems for the lateral con- could be taken at the International Dental Show in
densation or the multi-fill technique as well as for the Cologne from 21 to 25 March 2017, because the dif-
one post, two material method (flexible plastic carrier ferent processes, products and ultimately an abun-
+ heated gutta-percha) can be implemented. Thanks dance of endo experts will be available.
to the obturation options available today, they can
frequently be carried out in such a forward-looking “The desire to preserve one's own teeth up until an
way that a possible revision is even facilitated. advanced age is growing within the population. Thanks
to the progress of the past years, there have been shifts
Strongly co-decisive: in the borders in the field of endodontics: What was
Posts and coronal provision considered to be a healing attempt or even a “risk“ five
or ten years ago, has often become a challenge today
Finally, the quality of the coronal restauration also that can be mastered. As the leading trade fair for den- Image courtesy of Koelnmesse.
plays a decisive role for the overall success of the tistry and dentist technology, IDS, from 21 to 25 March
“endo“. If after the preparation a small amount of nat- 2017, shows which innovations are carrying on this
ural tooth substance remains (i.e. no more cavity wall trend -the entire spectrum of modern endodontics and contact
or at the most one single wall), it is worth considering the current therapy and diagnostic developments,“
implementing a post to stabilise the tooth, if necessary said Dr. Martin Rickert, Chairman of the VDDI. Koelnmesse GmbH
after applying a dentine pin (usually 2 mm high). There Messeplatz 1
is a wide selection here: Posts made out of zirconium IDS (International Dental Show) takes place in Co- 50679 Köln
oxide fibreglass with a 10–20 % resin content, out logne every two years and is organised by the GFDI Germany
of different fibreglass/resin mixtures, out of pre-si- Gesellschaft zur Förderung der Dental-Industrie mbH, Tel. +49 221 821-2486
lanized fibreglass reinforced composites, etc. and in the commercial enterprise of the Association of Fax +49 221 821-3544
different geometrical executions, for example conical, German Dental Manufacturers (VDDI) and staged by j.mader@koelnmesse.de
cylindrical, optionally with an activated thread or with Koelnmesse GmbH, Cologne._ www.koelnmesse.de
roots
4 2016 47
| meetings events
International Events
2016 Irish Endodontic Society—
Annual Scientific Meeting
26–27 January 2017
Greater New York Dental Meeting
Dublin, Ireland
25–30 November 2016
www.irishendodonticsociety.com
New York, USA
www.gnydm.com
AEEDC 2017
7–9 February 2017
ROOTS Summit
Dubai, UAE
30 November–3 December 2016
www.aeedc.com
Dubai, UAE
www.roots-summit.com
IDS
21–25 March 2017
Austrian Society of
Cologne, Germany
Endodontology Annual Meeting
www.ids-cologne.de
2–3 December 2016
Vienna, Austria
Asia Pacific Dental Congress (APDC)—
www.oegendo.at
9th Scientific Congress of Asia Pacific
Endodontic Confederation and
2017 18th IACDE & IES PG Convention
5–8 April 2017
New Dehli, India
Swiss Society for Endodontology—
www.apec2017.in
Annual Conference
20–21 January 2017
Libanese Society of Endodontology—
Bern, Switzerland
12th International Scientific Meeting
www.endodontology.ch
7–8 April 2017
Beirut, Lebanon
www.lse-lebanon.org
Finnendo 2017
11–12 May 2017
Helsinki, Finland
www.finnendo.fi
48 roots
4 2016
submission guidelines about the publisher |
roots
4 2016 49
| about the publisher imprint
roots
international magazine of endodontics
Copyright Regulations
roots international magazine of endodontics is published by Dental Tribune International (DTI) and appears in 2016 with four issues. The magazine and
all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable to
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50 roots
4 2016
The Dental Tribune
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