Endodontie

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PROMOTING EXCELLENCE IN ENDODONTICS
Introduction
Perspective on pain control
and positive rapport
ASSOCIATE EDITORS
Julian Webber BDS, MS, DGDP, FICD
Pierre Machtou DDS, FICD
Richard Mounce DDS
Clifford J Ruddle DDS
EDITORIAL ADVISORS
Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI,
FIVCD
Professor Michael A Baumann
Dennis G Brave DDS
David C Brown BDS, MDS, MSD
L Stephen Buchanan DDS, FICD, FACD
Gary B Carr DDS
Arnaldo Castellucci MD, DDS
Gordon J Christensen DDS, MSD, PhD
B David Cohen PhD, MSc, BDS, DGDP, LDS
RCS
Stephen Cohen MS, DDS, FACD, FICD
Simon Cunnington BDS, LDS RCS, MS
Samuel O Dorn DDS
Josef Dovgan DDS, MS
Tony Druttman MSc, BSc, BChD
Chris Emery BDS, MSc. MRD, MDGDS
Luiz R Fava DDS
Robert Fleisher DMD
Stephen Frais BDS, MSc
Marcela Fridland DDS
Gerald N Glickman DDS, MS
Kishor Gulabivala BDS, MSc, FDS, PhD
Anthony E Hoskinson BDS, MSc
Jeffrey W Hutter DMD, MEd
Syngcuk Kim DDS, PhD
Kenneth A Koch DMD
Peter F Kurer LDS, MGDS, RCS
Gregori M. Kurtzman DDS, MAGD, FPFA,
FACD, DICOI
Howard Lloyd BDS, MSc, FDS RCS, MRD RCS
Stephen Manning BDS, MDSc, FRACDS
Joshua Moshonov DMD
Carlos Murgel CD
Yosef Nahmias DDS, MS
Garry Nervo BDSc, LDS, MDSc, FRACDS,
FICD, FPFA
Wilhelm Pertot DCSD, DEA, PhD
David L Pitts DDS, MDSD
Alison Qualtrough BChD, MSc, PhD, FDS,
MRD RCS
John Regan BDentSc, MSC, DGDP
Jeremy Rees BDS, MScD, FDS RCS, PhD
Louis E. Rossman DMD
Stephen F Schwartz DDS, MS
Ken Serota DDS, MMSc
E Steve Senia DDS, MS, BS
Michael Tagger DMD, MS
Martin Trope, BDS, DMD
Peter Velvart DMD
Rick Walton DMD, MS
Franklin S Weine DDS, MSD
John Whitworth BchD, PhD, FDS RCS
Helping people through comfortable, professional, and caring

endodontic therapy providing IV sedation, oral sedation, and
nitrous oxide analgesia
he glossy photos of happy people that grace dental magazine advertising are attractive, but
less than representative of the patients that face dental professionals in the chair, especially
with regard to their endodontic needs. One of the challenges we face on a daily basis is the
anxious patient. Such anxiety ranges from so mild that it is often unspoken, all the way to
patients who cannot have treatment without deep sedation. For both patient and doctor, having a
good endodontic experience is a function of both adequate pain control (from a pharmacological
standpoint) and a positive rapport, especially with anxious patients.
Patients may behave and say things under dental stress that they might never do in more
casual surroundings. For the endodontist, this is tough because we meet multiple patients per
day with the same issues with whom we must build trust, while often having only met the patient
once and having a limited amount of time to both make the patient comfortable and perform the
treatment. Its easy to get burned out.
Over the years, I came to appreciate that patients do the best they can in the dental
environment given their personal histories, and I do not take things personally when they are
uncooperative. Being personally frustrated at patients or the situation is unproductive. With time,
I gained perspective and developed several strategies for dealing with this common challenge, and
some of them are shared below:
1) My staff and I spend a lot of time listening. While we may hear the same story again
and again how past traumas have made patients fearful, we let patients tell us
their stories. It is our goal to let them feel heard.
2) Our informed consent is comprehensive; there is rarely a surprise, clinical or financial.
3) I assure patients that they are going to get profoundly numb, or we will not treat them
end of story. And we keep our promise. We never operate in the netherland of partial
anesthesia, regardless of the clinical situation. Using the STA device (Milestone
Scientific) and the X-tip (Dentsply Tulsa Dental Specialties) have been very
helpful in this regard. We routinely use the STA device for PDL injections along with
block and infiltration anesthesia. The X-tip is used less frequently, but when indicated,
it settles the issue once and for all.
4) In March of 2011, I took my IV sedation training at the Medical College of Georgia.
I have found IV sedation to be predictable, safe, and provide peace of mind.
In my hands, having provided oral sedation and IV sedation, I prefer IV because the
level of sedation can be titrated if the technique is performed correctly. One other
benefit to providing IV sedation is the additional training in medical assessment
and risk as well as algorithms for medical emergencies. Personally and for the staff,
while we make every effort to avoid such emergencies, should one occur, whether
the patient is sedated or not, our response is well rehearsed.
Regardless of how plush our offices are, whether we use heat-treated nickel titanium or
standard nickel titanium, have a cone beam or lack one, how patients feel about their experience
with us is essential for the prosperity of our practices. This prosperity has many components,
only one of which is financial. A happy patient is priceless. A happy patient also makes a happy
referring doctor and makes the experience of treating patients much smoother and more fulfilling
for the endodontist (and all clinicians) providing the service.
Rich Mounce, DDS
Dr. Mounce is in full-time practice as an endodontist in Rapid City, South Dakota. He is the owner
of MounceEndo, LLC, an endodontic supply company specializing in bulk purchases of rotary
nickel titanium and stainless steel hand files, opening November 1, 2012. RichardMounce@
MounceEndo.com. www.MounceEndo.com.
Volume 5 Number 5
Endodontic practice 1
Contents
8
13
16
!"#$%&$'()"*+&,'
Through the keyhole
Drs. James and Susan Wolcott: A dynamic duo in
endodontic practice
-*")*"#%'()"*+&,'
Gendex
Imaging excellence since 1893
-,&.&$#,
Irrigation: a critical step for endodontic
success
Dr. Daniel Flynn discusses the role of irrigation and its
importance during endodontic treatment
20
A novel endodontic cleaning and shaping

approach
Dr. James Prichard explains his preferred cleaning and
shaping methods
22
13
26
/.0*0*.%&$1(&.(+*$21
Top ten tips: Tip number 3 Radiography
In his third article of the series, Dr. Tony Druttman
discusses imaging methods
-*.%&.2&.3('02$#%&*.
Bioceramics in endodontic surgery: a
clinical review
Drs. Dennis Brave, Kenneth Koch and
Allen Ali Nasseh illustrate the benefits of bioceramics
32
The effectiveness of four irrigating

solutions in root canal cleaning after
rotary instrumentation
Drs. Jorge Paredes Vieyra, Jimnez Enrquez Francisco
Javier, Gaspar Nez Ortiz, and Alejandro Alcantar
Enrquez evaluate the debris removal ability of four
irrigating solutions during root canal instrumentation
16
2 Endodontic practice
Volume 5 Number 5
Contents
September/October 2012 - Volume 5 Number 5
MISSION STATEMENT
To be a practical journal promoting excellence in
endodontics by providing a full range of clinical,
continuing education, practice management, and
technology articles written by leading specialists.
38
42
NATIONAL SALES/MARKETING MANAGER

Drew Thornley
Email: drew@medmarkaz.com
Tel: (619) 459-9595
E-MEDIA MANAGER/GRAPHIC DESIGNER
Deidra Cole
Email: dcole@medmarkaz.com
CONTRIBUTORS
Julian Webber (Editor-In-Chief/UK Edition)
Email: jw@julianwebber.com
Richard Mounce
Email: RichardMounce@MounceEndo.com
46
48
Cliff Ruddle DDS

Email: ruddlec@aol.com
POSTAL ADDRESS
MedMark, LLC
15720 N. Greenway-Hayden Loop #9
Scottsdale, AZ 85260
Tel: (480) 621-8955
Toll-free: (866) 579-9496
Fax: (480) 629-4002
$99
$239
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Email: kmurphy@medmarkaz.com
Web: www.endopracticeus.com
FMC, Ltd 2012.
All rights reserved. FMC is
part of the specialist publishing
group Springer Science+Business Media. The publishers
written consent must be obtained before any part of this
publication may be reproduced in any form whatsoever,
including photocopies and information retrieval systems.
While every care has been taken in the preparation of this
magazine, the publisher cannot be held responsible for
the accuracy of the information printed herein, or in any
consequence arising from it. The views expressed herein are
those of the author(s) and not necessarily the opinion of
either Endodontic Practice or the publisher.
*"+,-#"./+&0-'"
Alternatives to third party
financing
1+&23#4./+&0-'"
A closer look at Seiler
microscopes and LED
illumination
46
Redefining endodontics:
Bioceramic technology
EndoSequence BC Sealer and Root
Repair Material (RRM)
Pierre Machtou DDS, FICD
SUBSCRIPTION RATES
Individual subscription
1 year
(6 issues)
3 years
(18 issues)
38
DentalBanc discusses its payment

model that can improve case
acceptance and increase profits by
10% or more by providing flexible,
no-interest payment options
PRODUCTION MANAGER/
CLIENT RELATIONS
Kim Murphy
Email: kmurphy@medmarkaz.com
PRODUCTION ASST./
SUBSCRIPTION COORDINATOR
Lauren Peyton
Email: lauren@medmarkaz.com
Three smart ways to upgrade

your radiography in todays
economy
Bryan Delano discusses creative
techniques for investing in innovative
technologies
44
ASSISTANT EDITOR
Kay Harwell Fernndez
Email: kay@medmarkaz.com
Cone beam CT and

endodontics
Dr. Richard Kahan
PUBLISHER
Lisa Moler
Email: lmoler@endopracticeus.com
Tel: (480) 403-1505
MANAGING EDITOR
Mali Schantz-Feld
Email: mali@medmarkaz.com
Tel: (727) 515-5118
!"#$%&'&()
50
51
RVG sensor technology

Carestream Dental celebrates 30 years
of RVG digital radiography
1+5#4-#".65%5("6"%4
51
Hiring the right people

Dr. Rick Steedle
54
55
56
Materials & equipment

Diary
Ruddle on the radar
Endo restorative considerations
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PAYING SUBSCRIBERS
EARN 24
CONTINUING EDUCATION
CREDITS PER YEAR!
PROMOTING EXCELLENCE IN ENDODONTICS
Cover image courtesy of

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

school, I knew that endodontics was my calling. Fortunately, I was
lucky and was accepted into an endodontic residency immediately
following completion of dental school and attended the Boston
University Goldman School of Dental Medicines post-doctorate
program.
4-%()*/%5/#&$6&+%,676$+2%$)%+'2)2)'$6&-3
()%"*& Yes, we are both board-certified endodontists. In our
previous community, some of the endodontists also placed
implants, including us. However, this is not the norm in our new
community. Thus, while we dont currently place implants, we
do offer our patients extractions, socket preservation grafts, etc.,
which can save them an additional surgical procedure, especially
when non-restorability is determined mid-procedure.
!"(%262%()*%2+&62+%$)%8)&*-%)'%+'2)2)'$6&-3
!"#$%& It was my sophomore year of dental school in the endodontic
pre-clinic lab where the class was working on extracted teeth.
Any dental student who has had to find good extracted teeth
knows how difficult this can be; suffice it to say I showed up
with a particularly curvaceous molar, to which one of the faculty
predicted I would screw it up. Well, Im a tad competitive, and
to make a long story short, it turned out nicely. At this point, it
occurred to me that I may have found my calling. Beyond that
however, being a specialist with its commensurate pros and cons
appeals to me. I am driven to try to be the best at something, even
if it is only one thing.
()%"*& As for me, as I already mentioned, I assisted in
an endodontic group practice before beginning dental school.
Witnessing a patients demeanor change from fear and anxiety to
happiness because his/her pain was alleviated by having root canal
therapy intrigued me. Of course, the question remained, Could
I do it when I was the one on the other side of the chair who
was responsible for rendering treatment? Luckily, that first root
canal in dental school went smoothly enough (as few things rarely
go smoothly in dental school) to solidify my desire to become
an endodontist. Everyone knows root canals get a bad rap. It is
Volume 5 Number 5
Practice profile
Truly the practices strength Annette (clinical assistant), Julie (clinical assistant), Lynda (financial coordinator), Veronica (seated) (office manager).
Reception area with hues, textures, and

tones that reflect our community
so gratifying for me to be able to ease patients fears about their

treatment and help them save their natural teeth. I want to do my
part to make root canal treatment a positive dental experience!
!"#$ %"&'$ ()*+$ ,"-$ .++&$ /0)12313&'4$ )&5$ #()2$
6,62+76$5"$,"-$-6+8
!"#$%& Well, Ive been a dentist for 20 years now, limited to
endodontics for the last 16 years. Meanwhile, Susan graduated
from dental school in 2003 and went directly to her specialty
training, and has done only endodontics since. I was a partner in a
large specialty practice, and upon completing her training, Susan
joined the same practice. However, in 2009, we were blessed with
a wonderful surprise, our son, Oliver. Shortly thereafter, it became
obvious that a large group practice is not right for everyone, and
we decided that it was time for a change. We chose New Mexico
because obviously, it is my home, but it is also much closer to a
set of grandparents! This also allowed us to start our own business
where we could practice at the highest level of our specialty and
not under group-setting restraints.
The rotary method that we use the most is the ProTaper
Universal system. We were both trained using the operating
microscope, so Zeiss plays a large role in our day-to-day
operating system. We are a paperless office so all of our charting
and radiographs are digital. We are very fortunate in that in our
community most of the referring doctors would prefer their
endodontist to place the necessary restoration after the root canal
therapy is complete. Our favorite fiber post and core system is a
new system that we are beta testing for Dentsply Caulk.
9()2$20)3&3&'$()*+$,"-$-&5+02):+&8
'(%")& Again, we are both Diplomates of the American Board of
Endodontics, which is to say we are committed to continuing
education. Aside from accumulating our own CEUs beyond local
requirements, we also periodically offer half-day courses to our
referring doctors on a variety of topics. We are invited occasionally
to lecture in academic settings. This year, James gave two lectures
at the AAEs Annual Session, as well.
Furthermore, while the majority of our CE hours are
endodontic specific, there are a fair number of hours gleaned from
other disciplines such as periodontics, surgery, prosthodontics,
etc., to make sure we maintain a functional awareness of what
others on the team are doing. In fact, a few years ago, both of us
completed, and continue to maintain, implant certification from
our liability carrier (an additional 64 hours of rigorous implantspecific CE) so that we are better positioned to help our patients
Volume 5 Number 5
Our attempt at the KISS principle and keeping

our patients field of view clutter free
faced with choosing between root canal treatment and implant

treatment.
Our commitment to lifelong learning enables us to
collaborate with our dental colleagues to provide the best treatment
plans in the best interests of our patients.
9("$()6$3&6/30+5$,"-8
!"#$%& I have been blessed with many exceptional mentors.
Taking the circuitous route in my dental education afforded me
the opportunity to form relationships with many exceptional
dental educators. Each was a mentor with a different story to tell,
including Drs. McCoy, Wilson, Averbach, Kleier, Himel, Rossman,
and Hicks. Each one of them encouraged me to develop my skills
as a teacher and a clinician, as well as give back to my profession.
I wanted to be just like them. Also, while I didnt have the same
personal relationship, there were three others I feel fortunate to
have as part of my endodontic program: Drs. Bender, Seltzer and
Trowbridge.
However, the person that pushes me every day to be the
best endodontist I can is my wife.
'(%")& I too, was fortunate enough to have Drs. Don Kleier
and Bob Averbach as mentors at a very early stage in my career,
dental school. In fact, these two were so encouraging, that from
a small graduating class of 37, they inspired six of us to become
endodontists! I also owe a great deal to Dr. Jeff Hutter for accepting
me into BUs endodontic program and to Dr. Lou Rossman who
helped me numerous times along the journey. Of course, I would
be remiss if I did not mention my husband. He was already an
endodontist by the time we met, and his reassurance and support
were invaluable to me while I was in my program. He still inspires
me today. He is one of the most passionate, knowledgeable, and
adept clinical endodontists that I have ever had the good fortune
to know, and I am lucky that I get to call him my partner!
9()2$36$2(+$7"62$6)236;,3&'$)6/+12$";$,"-0$/0)1231+8
!"#$%& Being able to pursue my profession with my spouse by my
side and having the autonomy to be able to choose to do it right.
'(%")& How do I say it any better than that?
<0";+663"&)%%,4$#()2$)0+$,"-$7"62$/0"-5$";8
!"#$%& Aside from the obvious, that I have the opportunity to help
others on a daily basis, I would say its a tossup between being
board certified and my appointment to the Journal of Endodontics
editorial board. Simply put, giving back to my specialty was
something impressed on me by several of my mentors, and as such
Practice profile
We were fortunate to be able to provide our staff a spacious

sterilization room
Intense case discussions (i.e., whose turn is it to make dinner?)
I have published, taught at both the pre- and post-doctorate level,

and served on several AAE committees. In fact, I would argue
that the single best way for any endodontist to give back to the
specialty is become board certified. By definition, without a Board
there is no specialty, and without Diplomates there is no Board.
Personally though, of all these activities, the one that is arguably
the hardest, most time-consuming, and by far the most rewarding
is my role as one of 11 JOE associate editors worldwide. Indeed,
of the entire editorial board, only a couple of us are full-time
private practitioners. Thus, while all of us, clinicians, educators,
researchers, students, etc., all play a vital role in the health of the
specialty, I am in a unique position to help represent clinicians as it
relates to our Journal (might I add, the highest ranking endodontic
journal for the last 7 years and ranking in the top 10 of all dental
journals for that same time period. AAE members should be proud
of their journal!).
!"#$%& He keeps stealing my answers. I agree with James
assessment that the best way to give back to your specialty is to
become board certified. It is a long and arduous process, but the
reward is an overwhelming sense of pride. There is no monetary
payback. Most patients and referrers do not know (or possibly
care) that you are boardedbut YOU know. You have been
through the process and came out alive on the other side. I cannot
describe the feeling that you get when you receive that letter from
the ABE letting you know you have passed, but nothing else
(professionally) has given me the joy that becoming board certified
did.
Another thing that I am extremely proud of is our new
practice. It isnt the fanciest or the largest, but it is ours. Coming
out of a residency and going straight into a group practice left
me a little nave. The machine was already running, and I just
had to step in and start doing root canals. There was never any
brain damage as to whether or not I could provide for myself and
my family. All of that changes when you embark on setting up
your own practice. Will there be enough patients? Do we have
enough working capital? How in the world do you file insurance?
The logistics behind the things that I took for granted in a group
practice were a nightmare to circumnavigate! However, the reward
of this is so much more than I imagined, and I applaud all of those
who have done this before me!
!"#$%&'%(')%$"*+,%*-%)+*.)/%#0')$%(')1%21#3$*3/4
!"#$%& It is unique that we are spouses practicing in the same
office. Because there are two of us at start-up, we are able to fully
book one schedule and leave the other open for emergencies. Solo
practicing endodontists do not always have that luxury.
!"#$%"#-%0//+%(')1%0*55/-$%3"#66/+5/4
'$()#& Starting a new practice after already carrying the mantle of an
existing practice is not what most of us bargain for. Transitioning
from established endodontists back to the new kids in town in
such a tightly knit community is a tad humbling. Furthermore,
since my wife and I practice together, when we decided to relocate
to New Mexico, it meant introducing two endodontists to the
community simultaneously.
!"#$%& The biggest challenge I have is common to most
working parents, and that is balancing my career and raising
our child. The facts are simple: I love both of these, and I would
not change the path that I have chosen. Women are great at
multitasking!
!"#$%7')6&%(')%"#8/%0/3'9/%*:%(')%"#&%+'$%0/3'9/%
#%&/+$*-$4
'$()#& An architect. Ive been told some of them get to work from
home. There are days when that sounds pretty good
!"#$%& When I was very young, I thought I might go
into veterinary medicine. Now we have two very rambunctious
Viszlas, and I am glad I changed my mind (with much respect to
veterinarians)!
!"#$%*-%$"/%:)$)1/%':%/+&'&'+$*3-%#+&%&/+$*-$1(4
'$()#& While it is always hard to predict the future, the good news
is that endodontics historically has not rested on its laurels. The
AAE was very proactive years ago to establish the Foundation,
which is now paying dividends by helping support research
on the future of endodontics. Innovations such as regenerative
endodontics shine bright on the horizon. So while there seem
to be other treatment modalities that are perceived as being the
latest and greatest, endodontics has not been idle. Rest assured,
we do not perform root canal therapy the same way we did when
we graduated from our programs. A good, albeit dated, example
would be the advent of MTA, which has become commercially
available since I graduated from my program. A trend that we
find promising is the increasing focus on the biological aspect of
endodontics not just the mechanics (i.e., just another file design).
!"#$%#1/%(')1%$'2%$*2-%:'1%9#*+$#*+*+5%#%-)33/--:)6%
21#3$*3/4
'$()#& There seems to be a never-ending barrage of experts who
are willing to share their ideas about what makes a successful
practice. While some have merit (the AAEs practice promotion
resources as well as some top tier practice consultants), many are
simply presented as page filler between full page ads in non-peer
Volume 5 Number 5
Practice profile
reviewed journals. At
the end of the day, all
of the buzz words and
catch phrases aside, it
is the drive to deliver
the
best
ethical
patient care possible
that helps us sleep at
night and makes us
want to come to work
tomorrow.
!"#$%& We have been
very proactive in
getting our practice
up and running; we
know we cant just
Our pride and joy!
wait for patients to
walk through the
door! As James said earlier, we are the new kids in town, and were
working hard to build partnerships and trust throughout the Santa
Fe dental community. Were readily available for patient consults
and emergency treatments, and we welcome the opportunity to
provide specialized care that puts patients at ease, and allows
dentists to focus on the core parts of their practice they enjoy
most.
'$()#& With our new practice, every patient is an audition
for the next patient.
!"#$ %&'$ #"()*+,$ -",.-%.($ &'$ &$ %/'0&+1$ &+1$ #*2.$
-.&3$&22.4-.1$5"/($6(&4-*4.$'-57.8$
'$()#& I would say Susan helps temper me. Or to put it another
way, we complement each other nicely. We each have our strengths
and weaknesses, and fortunately they are different. Thus, we rarely
find ourselves butting heads as it relates to the practice. In fact,
without specifically assigning tasks, overseeing the remodel buildout fell to me, while the staffing and equipping found its way to
my wife.
!"#$%& Of course, I agree with the first statement above. As
I said earlier, I think James is one of the best clinical endodontists
that I know. We are all aware, of course, that there is more to
endodontics than seeing pretty white lines on a radiograph. If I
encounter a clinical situation that leaves me perplexed, I know
that I can go to James, and he will give me an educated opinion,
not an empirical one. The man knows the literature!
9%&-$&1:*4.$#"/71$5"/$,*:.$-"$0/11*+,$
.+1"1"+-*'-'8
'$()#& Always strive to improve. Compromise and complacency
are more beguiling than you think.
9%&-$&(.$5"/($%"00*.';$&+1$#%&-$1"$5"/$1"$*+$5"/($
'6&(.$-*3.8
'$()#& Im a gearhead, albeit on a budget. My dad and I restore,
drive, and race vintage Porsche 914s. We have several in various
states of repair from a Concours winning 914-6 to a fully-caged,
vintage club racer. Additionally, to get my fix of racing at the top
level, I volunteer with The Racers Group in Grand-Am Rolex
competition, where every year I am one of their extra driver
changer specialists for the Rolex 24 at Daytona. I also volunteer
for McMillin Racing, every year at the Baja 1000 as a chase crew
member. The McMillins are indeed a superlative team with
exceptional values. My annual trek to Baja every November is truly
the high point of my year.
!"#$%& Besides spending time with our son and two Viszlas,
I like to shop, although with the opening of this new practice, that
has been curtailed quite a bit. I like to travel, and since my family
is still in Florida, my son and I visit there several times a year. I
also like to garden, and I really hope to become more active with
the cultural activities in and around the Santa Fe area. EP
Top Ten List

The following are the top ten articles that have impacted how we practice, each in its
own unique way.
1. Abbott JA, Wolcott JF, Gordon G, Terlap HT. Survey of general dentists
to identify characteristics associated with increased referrals to
endodontists. J Endod. 2011 Sep;37(9):1191-6.
An evidence-based approach should apply to all that we do, including how we
interact with our fellow professionals.
2. Baumgartner JC, Xia T. Antibiotic susceptibility of bacteria associated
with endodontic abscesses. J Endod. 2003 Jan;29(1):44-7.
While probably dated even now due to the explosion of DNA techniques, the study
was still a strong reminder that newer doesnt necessarily mean better.
3. Bender IB, Seltzer S. Roentgenographic and direct observation of
experimental lesions in bone: I and II. J Am Dent Assoc 1961;62:152-60
and 708-16.
While imaging continues to progress, the underlying lessons of these two articles
remain valid: there are always limitations to our tools and technologies. Our best
diagnostic tool remains between our ears.
4. Bender IB, Seltzer S, Soltanoff W. Endodontic successa reappraisal of
criteria. I and II. Oral Surg Oral Med Oral Pathol. 1966 Dec;22(6):780-802.
More than 40 years ago, these authors proposed more pragmatic success criteria
based on function more so than radiographic. Yet, this concept has been seemingly
overlooked until recently when the implant literature touted its superiority to the
natural dentition using survival as its mantra. Subsequently, authors, such as Iqbal
and Kim (noted below), spoke to leveling the playing field as it relates to appraisal of
success.
5. Iqbal MK, Kim S. For teeth requiring endodontic treatment, what are
the differences in outcomes of restored endodontically treated teeth
compared to implant-supported restorations? Int J Oral Maxillofac
Implants. 2007;22 Suppl:96-116. Review. Erratum in: Int J Oral Maxillofac
Implants. 2008 Jan-Feb;23(1):56.
Although commissioned by the Academy of Osseointegration, this article shows the
exceptional service that quality endodontics can still provide our patients.
6. Penesis VA, Fitzgerald PI, Fayad MI, Wenckus CS, BeGole EA, Johnson
BR. Outcome of one-visit and two-visit endodontic treatment of necrotic
teeth with apical periodontitis: a randomized controlled trial with
one-year evaluation. J Endod. 2008 Mar;34(3):251-7.
In the face of a long-standing debate, these authors invested time and energy to
develop evidence at the highest level: a CONSORT Randomized Clinical Trial.
7. Roane JB, Sabala CL, Duncanson MG Jr. The balanced force concept
for instrumentation of curved canals. J Endod. 1985 May;11(5):203-11.
For us, this concept of balanced force opened the door to rotary instrumentation,
which has fundamentally changed how we do what we do.
8. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed
one year after apical microsurgery. J Endod. 2002 May;28(5):378-83.
We believe specialists should practice the breadth and scope of their specialty, which
means staying abreast of evolutionary changes with all the various techniques in our
armamentarium.
9. Seltzer S, Bender IB. Cognitive dissonance in endodontics. Oral Surg
Oral Med Oral Pathol. 1965 Oct;20(4):505-16.
Arguably our specialties first call to arms for an evidence-based approach.
10. Shabahang S, Goon WW, Gluskin AH. An in vivo evaluation of Root ZX
electronic apex locator. J Endod. 1996 Nov;22(11):616-8.
The researcher in us considers the design of this study elegant in its simplicity.
Beyond combining in vivo and ex vivo aspects, it managed to harness the best of both
worlds.
Volume 5 Number 5
Corporate profile
!"#$"%&
'()*+#*&"%,"--"#,"&.+#,"&/012
endex has a great accomplishment to celebrate in 2013 its

120th anniversary of excellence in imaging.
5.#3)3.',*$/
The Gendex legacy started in the late 1800s with the Victor X-ray
Corporation, which developed a device that yielded more consistent
exposure, and as a result, more consistent X-rays at
an affordable price point. In 1923, parent company,
Victor Electric was acquired by the General Electric
Company, and during those years, the GE Medical
Division began to develop intraoral and panoramic
imaging. Panelipse became the early benchmark
for panoramic performance. As the result of GE
dividing its medical and dental lines in 1983,
The Gendex Corporation was born, followed by
a series of innovative products such as the GXPan panoramic, and the GX-770 intraoral, the
AcuCam camera, Orthoralix 8500 and 9200
series of panoramic, DenOptix PSP system, and
VixWin imaging software.
As part of the celebration of its long-standing
history, Gendex is launching a program to reward its current loyal
panoramic owners by offering extraordinary savings when moving
up to the latest Gendex panoramic innovations. For a limited time
only, owners can trade-in any Gendex panoramic x-ray system
to receive exclusive savings on any new Gendex GXDP-300 or
GXDP-700 Series.
6-&7.,/)+$*(-#,'
The Gendex GXDP-700 brings the power of 3D to endodontic
treatment planning. Gendex is proud to note that the GXDP-700
offers a 4 cm x 6 cm scan size (along with its larger 6 cm x 8 cm
size) that is ideal as a diagnostic tool for endodontic procedures.
EasyPosition and PerfectScout features help operators to
concentrate on the exact location when scanning, while the 3D
software helps doctors zero in on such conditions as fractures,
perforations, and resorption from all angles.
The benefits of cone beam imaging have reached the
endodontic specialty. Recently, the American Academy of Oral and
Maxillofacial Radiography (AAOMR) and the American Association
of Endodontists (AAE) released a Joint Position Statement that
says, The advent of CBCT has made it possible to visualize the
dentition, the maxillofacial skeleton, and the relationship of
anatomic structures in three dimensions. The statement lists
many complex endodontic conditions that are appropriate for 3D
cone beam imaging.
The GXDP-700 Series is a three-in-one system that has the
ability to transform from 2D panoramics to cephalometrics to
3D. These images are integral to better diagnosis and treatment
planning of caries, root investigation, orthodontics, implants, and
other surgical procedures, as well as patient education. Besides 3D,
this flexible unit offers 33 panoramic options 11 projections for
three patient sizes, two 3D volume sizes plus a dose-saving scout
view, and the ability to add cephalometrics.
The GXDP-300 incorporates the most commonly used
imaging modes; a simple, three-step process; and a durable, sleek,
compact body design. Quality panoramic images are captured by
a simple three-step operation through a large LCD touchscreen
interface. The image is obtained by choosing the projection,
selecting the patient size, and taking the pan. Exclusive technologies
Volume 5 Number 5
ensure Gendex excellence FOX (Focus-Optimized X-ray)

technology increases the depth-of-field for optimized radiographic
image clarity, and the EasyPosition system stabilizes patient for
clear, consistent images in a short amount of time. With real estate
prices at a premium, the GXDP-300 is a space saver that can fit in
a small footprint.
Gendex also has invested years in sensor technology
research. The newest GXS-700 sensors are easy to use and have
advanced sensor technology that enhances image quality, elevating
technical and diagnostic capabilities. With sensors in size 1 and
size 2, rounded corners and smooth edges, children and adults
can have a more comfortable imaging experience. Ultra-portable,
the sensors have high-speed USB 2.0 connectivity and no need for
USB controllers, adapters, or docking stations.
!"#$%&'%()*++*$,-".,/
Filippo Impieri, Director of Marketing for Gendex, notes that
staying current with various digital imaging technologies can help
practices to differentiate themselves with patients in the current
competitive environment. He says, Digital radiographs and
3D scans, with their ability to be projected on a large computer
monitor, give the clinician the opportunity for improved patient
education and communication. Having a digital system cuts down
on the time the patient spends in the chair taking x-rays, speeding
up the office workflow and allowing for the doctor to spend more
time chairside. Dentists who have the additional information
obtained with 3D imaging also proceed into surgery with increased
confidence in a successful treatment outcome.
!0&1."1)2.,3)&)4.'.*"
For nearly 120 years, dental professionals have strived to advance
the quality of dental care by investing in Gendex panoramic x-ray
systems. Then and now, Gendexs mission has remained the same:
to deliver reliable and innovative imaging solutions to dental
professionals so that they can provide the quality of care their
patients deserve. EP
This information was provided by Gendex.
Clinical
!""#$%&#'()*%*+"#&#+%,*-&./*0'"*
.(1'1'(&#+*-2++.-3"4*3%(#.,*5,6((*1#-+2--.-*&7.*"',.*'0*#""#$%&#'(*%(1*#&-*#8/'"&%(+.*
12"#($*.(1'1'(&#+*&".%&8.(&
he goal of endodontic treatment is the prevention or treatment

of diseases of the dental pulp and the periapical tissues.
Endodontic treatment is a predictable modality. Clinicians can
enjoy success rates of up to 96% when sound biological approaches
are followed. Once the correct diagnosis has been made, and root
canal treatment has been initiated, irrigation is the key to success.
In vital cases, i.e., elective cases or where a diagnosis of reversible
or irreversible pulpitis has been made, the role of irrigation is to:
Ui>i
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In vital cases, the canal system is not infected; therefore,
it is imperative to use a rubber dam so that contaminants are not
introduced into the canal. Ideally, a four-walled chamber is created
so that the irrigant may be contained in the canal system. E. faecalis
is one of the most common isolates found in retreatment cases.
This bacterium is resistant to killing when present in very large
numbers, although it is easily killed in small numbers. It is possible
that many vital cases fail due to the introduction of bacteria during
treatment. Saliva has millions of bacteria which, when introduced
to the root canal system, can become pathogenic. If you are
obturating and can see saliva seeping into the canal system, this
means bacteria are contaminating the area despite your best efforts
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essential for the success of endodontic treatment.
!"#$%&'$()(
Sodium hypochlorite (NaOCl) is the irrigant of choice for
vital cases due to its tissue-dissolving ability. The higher the
concentration, the greater the dissolution capacity. For vital cases,
use 3% hypochlorite. You can also heat the hypochlorite to 60C
or use ultrasonics to activate it to increase its activity. In infected
cases, the role of irrigation includes the above, plus:
U/i`viVVi
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When using hypochlorite, it is vital to respect this chemical.
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rapidly. It has a foul taste if it leaks into the patients mouth. The
irrigating needle should never be bound in the canal, which forces
solution towards the apical tissues. This can cause a hypochlorite
accident leading to immediate severe pain and swelling, followed
by facial bruising. The idea that bacteria, causing apical disease are
free floating in the canal has been superseded by the realization
that, in reality, the bacteria are attached to the canal walls in a thick
Lw7iVi>}viVi`V>>]iVV>`>i
an image of the bacteria lining the canal walls. Studies have shown
endodontic instruments touch only around 50% of the walls.
Therefore, if 50% of the walls are not touched by the instruments,
it is only the irrigants that can disinfect these areas. Canals are not
round in cross section, and the preparation should be viewed as a
means of getting access for the irrigation to the source of infection.
I will open the canals to at least a size 25 apically before gauging to
Figure 1: Four-walled chamber, which contains irrigants and

prevents contamination
determine the optimum apical size. Sizes smaller than 25 do not

allow an adequate flow of irrigant to the apical areas. The wider
the taper, the better the flow of irrigant. This must be balanced
ii}V>>>>
Following preparation, I spend at least 20 minutes irrigating
the canals. I also use ultrasonics and the gutta-percha cones to
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not touched by instrumentation. Ultrasonics work by acoustic
streaming and cavitation, crashing the irrigant against the walls
where the bacteria are attached, like waves beating a coastline.
This has been shown to be more effective at bacterial removal than
passive irrigation alone. One should always realize that the irrigant
also only passes 1 mm beyond the tip of the needle. So, if the tip
viiiììiwVi]i}>>}
into the depths of the canal. I have never understood why some
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compared to sodium hypochlorite. It only works as an anesthetic
agent if it is applied under pressure, and the needle needs to be
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a 0.5% concentration, is effective at killing bacteria. Studies have
suggested that it is equally effective at removing bacteria at this
concentration as at higher concentrations. The tissue-dissolving
Daniel Flynn, BDentSc, MFDS, RCSI, MClinDent,

MRD, qualified from the Dublin Dental
Hospital, Trinity College, in 2002. He has joined
the EndoCare team, headed by Dr. Michael
Sultan. Dr. Flynn teaches endodontics at the
Eastman Dental Institute for Oral Healthcare
Sciences in London, England. For more information, contact
EndoCare at 011 20 7224 0999, email reception@endocare.
co.uk, or visit www.endocare.co.uk.
Volume 5 Number 5
Clinical
Figures 2 and 3: Early colonization of dentin by bacteria. Note the way they can grow into the tubules
Figure 4: Smear layer and debris present on dentin
power increases as the concentration increases, and a concentration

of 1% is required to dissolve necrotic tissue and around 3% to
dissolve vital tissue. This dissolving capacity depends on:
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nEndodontic practice
Figure 5: The effects of NaOCl and EDTA on dentin
/
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when we achieve good technical results; however, cases where the
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Clinical
!" #$%&'" &#($($#)*+" +'&,#*#-" ,#("

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uccessful endodontics requires mechanical preparation of the

root canal system and an efficient method of removing pulpal
tissue and microorganisms.
Traditionally, stainless steel hand files have been used;
however, they are time-consuming, laborious, and prone to causing
procedural errors. The advent of nickel-titanium instruments
has helped the practitioner consistently produce nice tapered
preparations.
But this is only part of the equation. Irrigant flow in root
canals is fraught with problems and, as yet, there is no consensus
of opinion of the correct canal parameters (apical size and canal
taper) that should be prepared to give the best clinical results.
Fluid dynamic research has shown that the larger the canal
dimensions, the easier it is to get the irrigant to penetrate apically,
which is logical. This does not, however, address the complex
anatomy that is often seen in cleared teeth that was originally
demonstrated by Dr. Hess, and can also lead to unnecessary loss of
tooth dentin, making it more susceptible to fracture.
It is now becoming accepted that to simply use syringe
delivery of the irrigant is not sufficient, but that the irrigant must
also be dispersed or agitated within the canal space to make it
more effective.
Using rotary nickel-titanium instruments produces a large
amount of debris that can be packed laterally into isthmi and
lateral anatomy, thereby blocking it. The use of ultrasonic agitation
of the irrigant has been shown to aid in removing this debris, thus
rendering root canals cleaner.
!"#$#%&"'%&()'
The patient was referred following a bout of acute toothache that
culminated in receiving antibiotics from his GP. On presentation,
he was no longer in pain and complained of a swelling on his
gum on his lower right side that occasionally swelled up and
discharged.
The tooth was occasionally tender to bite on, but he was
eating comfortably and had not had any significant pain since
completing the antibiotic course.
Clinical examination revealed a small swelling adjacent to
the lower right second premolar. There was no pocketing of note,
and the tooth had recently had a provisional crown placed, and
did not respond to sensibility tests compared to adjacent teeth.
Radiographically, the root canal showed some widening
of the lamina dura both apically and about 5 mm short of the
radiographic apex on the mesial aspect. The primary canal was
obvious in the coronal and middle third, but became less apparent
in the apical 5 mm, suggesting a bifurcation.
*+),&+&-#.$
Anesthesia was achieved via buccal and lingual infiltration, the
provisional crown removed, and the tooth isolated with rubber
dam. On removal of the provisional crown, there was an apparent
exposure of the pulp horn.
The access cavity was prepared with a 541 diamond bur and
refined with a safe-ended access cavity bur (Schottlander). Rotary
shaping was performed with RaCe nickel-titanium instruments.
Figure 1: Photograph showing 2 ISO size 10 steel hand files with

different curvature applied
The working length (WL) was determined electronically as 22.5

mm, and the master apical size was ISO 30 (the canal was prepared
to an ISO size 35). Copious amounts of 3% NaOCl (Schottlander)
were used during the preparation phase.
!")&$#$/
Once the shaping of the primary canal was completed, the
IrriSafe (Satelec) instrument was used on power setting seven
on the P5 Newtron (Satelec).
Three intermittent flushes of 3% NaOCl via a 3ml
Monoject syringe fitted with a 27g needle were made. After each
flush of irrigant, the IrriSafe was inserted to 21 mm and activated
for 20 seconds.
Recapitulation was performed after each cycle with a precurved size 10 K-Flex file. During this process, the tip was rotated
incrementally and advanced apically to feel for additional anatomy.
Another canal was found, which exited buccally and
measured electronically to 17 mm. This was subsequently enlarged
to a size 25, and the cleaning procedure repeated with 3% NaOCl
and IrriSafe.
Seventeen percent ethylenediaminetetraacetic acid (EDTA)
was introduced, allowed to soak for 60 seconds, and was also
agitated for 20 seconds with IrriSafe, prior to a final flush with
NaOCl.
01-2+&-#.$
The master cone (size 35/.04) was fitted to length and shortened
by 0.5 mm to allow for thermoplastic displacement. The main
canal was dried with paper points (Schottlander) and AH Plus
sealer (Dentsply) applied to the apical 3 mm of the GP cone. This
was seated to length in the canal in one single movement.
An incremental downpack was performed (warm vertical
James Prichard, BDS, LDSRCS, MFGDP, DRDP, MSc, is an
endodontist at James Prichard Endodontics in Coventry,
England.
He completed his undergraduate dental
training at the Royal London Hospital in 1994. He

subsequently returned to general practice. Dr. Prichard
is an associate clinical teacher in endodontics and clinical
supervisor in endodontics at the University of Warwick.
Volume 5 Number 5
Clinical
JOR_EP_AD_0912_Layout 1 8/7/12 9:29 AM Page 1
One tough foam...
Figure 2: Preoperative radiograph
Introducing e-Foam Rotary HD

Our new e-Foam Rotary HD inserts are specially
designed for cleaning rotary instruments. A rotating file
secured in a hand piece can be placed directly into the
high density foam to assist in cleaning debris from
rotary flutes. Our Rotary HD foam minimizes tearing
or shearing of the foam while a file is in motion.
Precisely engineered to fit Jordcos Endoring II organizer.
Jordco e-Foam Rotary HD, endodontic foam inserts,
REF: ERFBHD-s (48 high density blue inserts)
Figure 3: Postoperative radiograph showing lateral anatomy and

a well-condensed filling
Joins the endodontic assistant

youve come to trust.
condensation technique as described by Schilder) with System

B (Obtura Spartan), and the apical plug of GP was condensed
with manual pluggers. The backfill was performed with Obtura
II (Obtura Spartan) in three separate increments; condensing of
the GP was performed as before.
The final coronal seal was achieved with a composite
restoration (Venus Diamond, Heraeus Kulzer) bonded in with
Clearfil SE Bond (Kuraray Dental).
The provisional crown was recemented with flowable
composite (Venus Diamond Flow, Heraeus Kulzer), the dam
was removed, and the occlusion was checked.
!"#$%##"&'
The final radiograph reveals a well-condensed filling in the
primary root canal, which appears flush with the radiographic
apex. There are two lateral canals in the middle third of the root:
one exiting distally and one exiting buccally.
The presence of the mesial radiolucency had suggested a
lateral portal of exit, but the distal was less obvious. The tissuedissolving ability of the NaOCl has clearly helped in this case;
however, it needed to be dispersed in to the spaces in order to be
effective, which is much more difficult when syringe irrigation
only is employed.
The use of IrriSafe to agitate the irrigants has, in this
situation, significantly improved their effect within the root
canal space. There has been good penetration of the irrigants to
allow improved cleaning compared with filing alone. This has
allowed the obturation material to flow well in to the accessory
anatomy.
This challenging case would appear relatively
straightforward from the preoperative radiograph, but a
combination of meticulous cleaning and shaping has hopefully
allowed for a successful result. EP
Volume 5 Number 5
The Endoring II organizer enables the clinician to directly

place, store, measure and clean endodontic hand and
rotary instruments within the operating field. It reduces the
risk of cross-contamination and minimizes the passing of
sharps between dentist and staff. Using the Endoring II
organizer helps make endodontic procedures safer, faster
and reduces patient chair time.
Endoring II, hand-held endodontic assistant,
REF: ERK2-s (Premium Kit), ER2SK-s (Starter Kit), ER2-s (with metal ruler)
Manufactured by Jordco, Inc.

www.jordco.com TEL 800-752-2812 FAX 503-531-3757
To order, please contact your dental supply dealer.

Or visit us @ www.jordco.com or call
800-752-2812
To view a video on Jordcos new e-Foam Rotary HD

point your smartphone here:
Endodontics in focus
!"#$%&'$%(#)*
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here is no doubt that radiography is one of the cornerstones

of endodontics. We use radiographs to aid diagnosis, during
endodontic treatment, to judge the quality of the root treatment
we have just completed, and to monitor healing.
We live in exciting times in dental radiography. Having
moved from the bisecting angle technique to the long cone
paralleling technique for periapical radiography, in the last decade,
there has been a shift from wet film radiographs to digital, with the
quality of the digital image improving all the time. Most recently,
cone beam CT scanners have been introduced to dentistry and
have proven to be an invaluable aid to diagnosis.
Whatever the purpose of the radiograph, the aim is to get
consistently high quality images, with the minimum radiation
dose, and nowhere is that more important than in endodontics.
There are many ways that this can be achieved with an existing
X-ray set. Interpreting the information from a radiograph is
notoriously subjective; different examiners wont always agree
when examining radiographs at different times, let alone with each
other.
In endodontics, it is crucial that we get the best possible
image (Figure 1), and that is usually achieved with the long cone
paralleling technique, using some form of receptor (film or sensor)
holder and aiming device.
Lets look at the variables that can help you achieve that
goal:
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!"#"$%&'()*+"(,-.(&'*"-%,%*&When using films for intraoral periapical radiography, all the
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or landscape orientation for the posterior teeth. There are many
situations when deviating from those recommendations can prove
very advantageous. Where there is a large lesion associated with an
anterior tooth, the complete lesion may not be captured on a small
receptor, so if there are no anatomical constraints, a large film can
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receptor because of their position in the arch, the shape of the
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the vertical orientation will often overcome these difficulties
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larger receptors very uncomfortable, and with some their use is
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because a more parallel image can be achieved, and it may well
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The position of the receptor can be fine tuned by altering its
Endodontic practice
Figure 1: Long cone periapical image using a sensor holder
Figure 2A: Size 1 sensor shows

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

the complete lesion
specialist
Tony
Druttman,
MSc, BChD, BSc, has extensive expertise

in treating dental root canals, resolving
difficult endodontic cases, and saving teeth
from being extracted. His two London,
England practices, one in the West End and the other
in the City of London are restricted to endodontic
treatment. www.londonendo.co.uk.
Volume 5 Number 5
Figure 3A: Size 2 horizontal orientation
Figure 5A: Periapical of tooth No. 27

using a size 2 sensor
Figure 3B: Size 2

vertical orientation
Figure 4A: Periapical of tooth No. 15

using a size 2 sensor
Figure 4B: Periapical

of tooth No. 15 using
a size 1 sensor
Figure 5B: Periapical of tooth No. 27 using a

size 1 sensor
Figure 6: Slight change
of horizontal angulation
shows both mesial canals
of tooth 46
Volume 5 Number 5
Endodontic practice
Figure 7A: Long cone periapical

view of tooth No. 26 using a size 2
sensor
Figure 9: Digital image shown on a

monitor
Figure 7B: A slight

change of vertical
angulation and
using a size 1
sensor. Note the
lesion over the
MB root is less
prominent than
in 7A
Figure 8A: Radiograph

underexposed
Figure 10A: Preoperative radiograph of

tooth No. 25 using Schick CDR
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changed when root separation is desired (Figure 6), i.e., looking
at both roots of an upper premolar or both canals of a lower
molar without superimposition. If the front of the receptor is
angled mesially, the palatal or lingual root is thrown mesially, and
the buccal root is thrown distally. Vertical angulation is changed
to get a parallel view of a divergent root. Upper molars are the
classic example: when the paralleling device is lined up with the
buccal roots, the palatal root is foreshortened, the root tip may be
cut off, and its relationship with the periradicular bone may be
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be a few degrees. Excessive alteration will obscure the image,
because the X-rays have to penetrate too much bone.
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The only setting on the X-ray set that is likely to be altered for
every patient is the exposure timer, and the guide on the control
panel is used to adjust the time. This will only give a dose based
on an average for the tooth type, without taking into account bone
density. The X-rays are likely to have penetrated through far more
bone in the maxilla of a 6-foot rugby forward than a small 70-yearold lady, so the timer should be adjusted accordingly. Often the
exposure has to be increased slightly to improve image quality for
endodontics.
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The number of practitioners using digital radiography is
increasing. I see that in my own practice as the number of films
sent by referrers is reducing. Film has always been the benchmark
of image quality and is obviously cheaper. There is, however, a
continuous supply of chemicals to be bought and disposed of
{Endodontic practice
Figure 8B: Radiograph at correct

exposure. Note the lesion on the
distal root of tooth No. 46 is now
clearly visible
Figure 10B: Postoperative radiograph of

tooth No. 25 using Schick Elite
responsibly. Digital radiography, on the other hand, requires a

significant capital investment, but has so many advantages over
film. The image quality is continuously improving. Radiographs
can be read instantly and are a great communication tool. There
is nothing better than showing the pre-op and post-op together
or the pre-op and review image that shows healing to convince
your patient that endodontic treatment is worth the investment.
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a film.
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be considered to be easier than CCD/CMOS, because the sensors
have the same dimensions as film, they do not last and get easily
scratched, making them progressively more difficult to read. For
endodontics, and to my mind all radiography, the power of digital
radiography is in the ability to read the image instantly while the
holder is still in the mouth and make changes accordingly.
I am an unashamedly enthusiastic user of Schick Sensors.
I have used both CDR and more recently Elite sensors, and I use
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The technique I use is a follows:
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teeth in relation to other anatomical structures, shape of the palatal
vault, curvature of the arch, presence of tori, etc.
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have to be much more accurate).The patients height is sometimes
a good indication of the length of the roots.
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density.
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the timer.
5. While the device is still in the same position (tell the patient not
Volume 5 Number 5
Figure 12A: Periapical

radiograph of tooth No.
27 shows an impacted
tooth No. 28
Figure 11A: Periapical radiograph
of tooth No. 27 shows a normal
appearance
Figure 11B: Cone beam

CT image of tooth No. 27
shows a periapical lesion
to remove it until you are ready), assess the image.

6. If it gives an acceptable, but not an ideal result, make a note of
which parameters to change for the next radiograph. If it is not
>VVi>Li]V>}ii>>Liiii]ii]>`
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The radiation dose with the CCD/CMOS sensors is
considerably reduced compared to the dose required for a film,
and it is perfectly justifiable to repeat an exposure while adhering
i , }ìi v i i v `>}V >i
Make a note of the exposure used so that when you review the
endodontic treatment, the radiographs can be compared like for
i > i i>i i Livi >i
review radiograph so that you can set the aiming device in the
same position.
Volume 5 Number 5
Figure 12B: CBCT

images show the
presence of a
supernumerary tooth
overlying buccally tooth
No. 27 as well as the
impacted tooth No. 28
!"!#
The most recent addition to the radiographic armamentarium in
endodontics is the cone beam CT scanner. For use in endodontics,
i>iV>iii>VV>iVii
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that were previously unimaginable. The full extent of resorptive
lesions can be assessed, and lesions and structures that are hidden
on the conventional periapical are fully visible (Figures 11 and
EP
Next issue: Rubber dams
Endodontic practice x
Continuing education
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t has been approximately 3 years since we introduced

bioceramics (for both surgical and non-surgical use) to the
endodontic community. The response has been excellent, and
we sincerely believe that we have changed the way obturation
is performed and, more importantly, the way we think about
obturation. In this article, we want to concentrate specifically
on the surgical applications of bioceramics and to share with you
some of the impressions of your endodontic colleagues.
Through the years, dental specialists have used all kinds
of material for retrofills following apical surgery and for root
perforation repairs. The introduction of mineral trioxide aggregate
(MTA) [Dentsply Tulsa] more than a decade ago, was a significant
advancement in surgical endodontics, particularly in perforation
repairs. Recently, there have been other new materials introduced
into surgical endodontics, although we view some of them as
being more in the pulp capping space. So, when we wish to
compare bioceramics as a surgical material, we really need to
compare it to MTA. Both of these materials are excellent, and they
have produced outstanding results, but there are some significant
differences.
While we are all familiar with the success of MTA, we
must also realize that it is basically a modified Portland cement.
Consequently, there are some real challenges in its handling
characteristics. The first is that MTA does not come premixed
either in a syringe or in a jar. This can be a problem because any
hand mixing of a powder and liquid may result in inconsistencies.
This inconsistency of mix can lead to erratic setting times. This
can be especially troublesome when the material is hand mixed by
a new assistant.
Secondly, MTA, just like Sakrete is difficult to control and
can be a challenge to place into retrofill preparations. Nonetheless,
there are numerous endodontists who have overcome these
challenges and continue to use MTA in their retrofills. However,
it would be preferable if we had a material that could be used
successfully by a great majority of dentists, not just a few talented
ones.
This lack of handling ability can be a significant challenge to
general practitioners, particularly when they attempt a perforation
repair. The good news is that dentistry is moving in the direction
of premixed materials, but this is still going to be an issue with
mineral trioxide aggregate. The particle size of MTA is too large
to be extruded through a reasonable-sized syringe. It should
be noted, however, that it has a number of favorable properties
including a pH of 12.5 which is strongly antibacterial. However,
with the introduction of a true medical-grade bioceramic material,
we now have, for the first time, the opportunity to employ a
material that has all the benefits of MTA but none of its handling
issues. But, prior to a discussion of bioceramic technology in
surgical endodontics, a quick review of bioceramics, in general,
would be helpful.
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When evaluating bioceramic technology over a 3-year period, we
really must ask ourselves, Why has there been such excitement
associated with its use? The answer is clearly related to its physical
Educational aims and objectives
The purpose of this article is to:

Discuss the surgical applications of
bioceramics and show how colleagues have
used these materials for specific cases.
Expected outcomes
Correctly answering the questions on page

31, worth 2 hours of CE, will demonstrate
that you can:
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between MTA and bioceramics.
r 0KLU[PM`[OLRL`WO`ZPJHSWYVWLY[PLZVM
bioceramics.
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bioceramics.
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Figure 1: Biocompatibility (fibroblast adhesion) of ProRoot MTA (left

image) and ESRRM (right image)
Figure 2: EndoSequence Root

Repair Material putty
properties as well as to its superior handling characteristics.

Similar to MTA, bioceramics are very biocompatible and are
chemically stable within the biological environment. Also, true
bioceramics do not shrink upon setting. In fact, they expand
slightly upon completion of the setting process (0.002). A further
advantage of this material is its ability (during the setting process)
to form hydroxyapatite and to ultimately establish a chemical
bond with dentin. Being hydrophilic in nature, not hydrophobic,
is a significant advantage and makes this material very unique1
(Figure 1).
The bioceramic material that we recommend is the
EndoSequence Root Repair Material (RRM) [Brasseler USA],
which comes premixed in a syringe and premixed as a putty
(Figure 2). Note, that in the very near future, the putty will be
available in unit dose packages. This will be even more cost
effective and will enhance sterility.
Volume 5 Number 5
Figure 3: ESRRM putty on a plastic instrument
Figure 4A: Pre-op X-ray
Figure 4B: Cortical bone was intact
Figure 4C: Retro-preparation connecting

MB-ML
Figure 4D: Immediate post-op X-ray
Figure 4E: 1-year recall X-ray
The ability to come premixed in a syringe or in a unit dose

package is a tremendous help, not just in terms of assuring a
proper mix, but also in terms of ease of use. Finally, we now have
a root repair material that is associated with an easy and efficient
delivery system. This is a serious upgrade from MTA because it
allows all clinicians to take advantage of its properties.
EndoSequence RRM has all the attributes of MTA, but is a true
medical-grade bioceramic. It (ESRRM) has a compressive strength
of 50-70 MPa, which is similar to that of MTA and BioAggregate,
but its small particle size (approximately one micron) allows it to
be extruded through a syringe.2 The nanotechnology associated
with its development allows this material to be very user friendly.
In fact, the highly acclaimed CLINICIANS REPORT (CR)
recently (November 2011) published its findings on EndoSequence
RRM. Some of its noted advantages as an RRM were:
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Furthermore, the final conclusion was that 95% of 19 CR
evaluators stated that they would incorporate EndoSequence RRM
into their practice. Also, 95% rated it excellent or good and worthy of
trial by colleagues.3
Drs. Karen Lovato and Christine Sedgley also published
a very significant piece of research in the Journal of Endodontics
that investigated the antibacterial activity of EndoSequence RRM
material against Enterococcus faecalis. The aim of their study was
to determine whether EndoSequence RRM possessed antibacterial
properties against a collection of E. faecalis strains. As a standard,
they compared the EndoSequence RRM to MTA. Their conclusion
was that EndoSequence RRM, in both the putty and syringeable
forms and ProRoot White MTA demonstrated similar antibacterial
efficacy against clinical strains of E. faecalis. They also noted that
clinical strains varied in their susceptibility to the root repair
materials.4
This research again validated earlier studies that found
that EndoSequence RRM putty and EndoSequence RRM paste
displayed similar in vitro biocompatibility to MTA. Additionally,
Volume 5 Number 5
other studies have found that the EndoSequence RRM had cell
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set and fresh conditions.5
Furthermore, recent research concerning cytotoxicity was
conducted at the Case School of Dental Medicine. The purpose of
this study was to compare the cytotoxicity and cytokine expression
profiles of EndoSequence Root Repair Material and ProRoot MTA
using osteoblast cells. Their conclusion was that ESRRM and
MTA showed similar cytotoxicity and cytokine expressions. They
also made the astute observation that more clinical studies are
needed to assess if the elevation of cytokines is relevant clinically.6
As we have mentioned previously, the bioceramic material
to use in surgical cases is the EndoSequence RRM, and it is
available in two different modes; there is a syringeable RRM (very
similar to the basic BC Sealer in its mode of delivery), and there
is a RRM putty that is both stronger and more malleable. The
consistency of the putty is similar to Cavit -* /i
RRM in a syringe is obviously delivered by a syringe tip, but the
technique associated with the putty is different.
When using the putty, simply remove a small amount from
the room temperature jar and knead it for a few seconds with a
spatula or in your gloved hands. Then start to roll it into a hot
dog shape. This is very similar to creating similar shapes with
desiccated zinc oxide eugenol or SuperEBA (Bosworth). Once
you have created an oblong shape, you can pick up a section
of it with a sterile instrument, and use this to deliver it where
needed (Figure 3). This is an easy technique for apico retrofills,
perforation repairs, and even for resorption defects. After placing
the putty into the apical preparation (or defect), simply wipe with
a moist cotton ball, and finish the procedure.
While the above mentioned technique is very much user
friendly, we must keep in mind the results of the aforementioned
study that agreed with a previous study. The study, which compared
the biocompatibility of MTA and ERRM putty and paste, reported
that all specimens displayed similar biocompatibility to MTA in
human gingival fibroblasts. So, if the products are essentially
the same, which technique should you employ? We believe the
technique that works most predictably and easily in your hands is
the preferred technique.
Figure 5C: Immediate perforation repair
Figure 5D: Healing underway
Figure 6C: Immediate post-op
Figure 5E: Recall X-ray showing complete

healing
Figure 6B: Pre-op X-ray
Figure 6D: 3-1/2 month recall
As evidence of how beautifully this technique works, and

the salubrious properties associated with its use, we would like to
show the following surgical case by Dr. Allen Ali Nasseh in Boston,
Massachusetts. This case is so significant because it again clearly
demonstrates the extraordinary healing capability of bioceramics,
when used as a surgical repair material. The radiographs display
excellent healing and bone fill (in 1 year) in the mandible!
Concerning the case itself: this specific case was seen
previously by an endodontist who attempted retreatment but who
was unfortunately prevented from instrumenting the final apical
curvature. As one can see from the pre-op X-ray, it appears that
there may have been a slight perforation during the retreatment
process. The case was then referred to Dr. Nasseh who proceeded
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Figure 5B: Post removed
Figure 6E: 9-month recall X-ray
to cut the root too short (to incorporate the transportation of

the canal), but to only address the lesion at the apex and fill the
isthmus (he found) between the two mesial canals. The 1-year
postoperative radiograph shows excellent healing following this
conservative apicoectomy (Figures 4A-4E).
We have been excited about the use of bioceramics for a
number of years, but the question we must ask ourselves is, What
has been the experience of other specialists? Lets begin with a
perforation repair case from Dr. Art Lane in Florida.
All too often, endodontic teeth are condemned, the tooth
extracted, and a bridge or implant placed without a thorough
evaluation of the possibilities to retreat and salvage a tooth that
appears to have a poor prognosis. This case is representative of
an open-minded dentist and patient who were willing to think
Volume 5 Number 5
Figure 7A: Pre-op
Figure 7D: Post-op X-ray
Figure 7B: Fistula traced
Figure 7E: Recall showing

healing
outside the box and to trust the endodontist.

A 50-year-old female presented to Dr. Lanes office with a
chief complaint of a dull ache in tooth that had received root canal
treatment 2 years previously. She also complained of swelling and
sensitivity of the gum area when she rubbed her finger over the
tooth. Her dentist told her that her symptoms were related to a
post perforation, and she was consequently sent to his office for
further evaluation.
Clinical examination revealed tenderness to palpation on
the distal aspect of the buccal gingival. However, there was no
probing in the gingival sulcus, and the tooth was not sensitive to
percussion. Radiographic examination revealed tooth No. 30 to
have an extensive post perforation, as well as bone loss along the
distal aspect of the root. Dr. Lane advised the patient of the risks,
alternatives, and benefits of treatment, and thereafter, the patient
expressed a desire to try and save the tooth. He then proceeded
with the appropriate treatment to repair the post perforation.
The tooth was isolated with a rubber dam, and the access
cavity filling material was removed and dissected from around
the post. With the aid of ultrasonics and the Masserann Kit, the
post was uneventfully removed. The post perforation area was
lavaged with sodium hypochlorite, and the Biolase Waterlase
MD was used to further disinfect the defect. EndoSequence Root
Repair Material putty was used to seal the perforation utilizing
a small Messing gun. A moist cotton pellet was placed over the
EndoSequence RRM, and then Cavit was used to seal the access
cavity. One week later, a permanent composite filling was placed.
We had the patient return on a regular basis and noticed,
Volume 5 Number 5
Figure 7C: High magnification shot
almost immediately, resolution beginning. As one can see from the

radiographs, we now have total resolution of the post perforation
defect. Periodic radiographs will continue to be taken (Figures
5A5E). This is extraordinary healing and demonstrates how
dedication to the preservation of the natural dentition can actually
pay off in big dividends for the patient. Too often we are seeing
dentists rush to an extract and replace with an implant decision.
We can do better.
Dr. Nasseh has contributed another case (tooth No. 19)
where the patient presented with a chief complaint of some aching
in the jaw bone (Figures 6A-6E). The tooth was slightly percussion
sensitive, but there was no significant probing. After analyzing
the pre-op X-rays, Dr. Nasseh elected to perform an apicoectomy
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X-rays), because we can see some healing being established at the
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the 9-month recall. A very important point to remember is that
this excellent healing at 9 months is occurring in the mandible!
Another terrific example of how this material works for
lateral perforations (whether iatrogenic or natural) is the following
case done by Dr. Brad Trattner of Maryland. Well let Dr. Trattner
describe it.
A patient presented with a sinus tract over tooth No. 8,
which was traced with gutta percha to a lateral lesion on the
mesial aspect of the tooth. A flap was reflected during endodontic
microsurgery revealing a bony lesion, with an associated lateral
canal on the mesial. A preparation was made with the Varios 350
ultrasonic (Brasseler USA), and we then filled the preparation
with EndoSequence RRM. A decision was made to use the
EndoSequence RRM due to its ease of use and physical properties.
(Ease of placement, manipulating ability, cleanup, and working
time are paramount with microsurgery.) A 1-year followup
shows complete radiographic healing with an intact periodontal
ligament (Figures 7A7E).
The last surgical case we would like to present was performed
by Dr. Samuel Kratchman of the University of Pennsylvania. Dr.
Kratchman is an accomplished endodontic surgeon, and we can
see how beautifully he was able to work with the bioceramic
material and the outstanding result he achieved in this surgical
case (Figures 8A8E).
So, where are we after 3 years of bioceramic use in
endodontic surgery? There are a few points worth mentioning.
a)
There is more than ample research to demonstrate that both
EndoSequence Root Repair Material and ProRoot MTA work well
from a biological perspective. There will be advocates of both
Figure 8A: Pre-op
Figure 8C: High magnification showing

ESRRM retrograde fill
Figure 8B: High magnification after resection
Figure 8D: Immediate post-op X-ray
MTA and ESRRM, but dentists should make their own personal
decisions as to which material works best in their hands.
b)
Yes, as endodontists, we are better trained to repair
perforations, but the truth is many general dentists also want to
be able to repair minor perforations when they occur. (And we all
know how critical time is in the long-term success of perforation
repair.) We now finally have a material (and technique) that will
work in all capable hands.
Dennis Brave, DDS, is a Diplomate of the American

Board of Endodontics and a member of the College
of Diplomates. Dr. Brave received his DDS degree from
the Baltimore College of Dental Surgery, University of
Maryland and his certificate in Endodontics from the
University of Pennsylvania School of Dental Medicine. He
is an Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas
Odontologic Honor Society Member. In endodontic practice for over
25 years, he has lectured extensively throughout the world and holds
multiple patents, including the VisiFrame. Dr. Brave was voted one of
Baltimores Best endodontists by Baltimore Magazine. Formerly an
associate clinical professor at the University of Pennsylvania, Dr. Brave
currently holds a staff position at The Johns Hopkins Hospital. Along
with having authored numerous articles on endodontics, Dr. Brave is a
co-founder of Real World Endo.
Kenneth Koch, DMD, received both his DMD and
Certificate in Endodontics from the University of
Pennsylvania School of Dental Medicine. He is the
founder and past Director of the New Program in
Postdoctoral Endodontics at the Harvard School of Dental
Medicine. Prior to his endodontic career, Dr. Koch spent
Figure 8E: 1-year recall X-ray
c)
Its about saving the natural dentition whenever possible.
Having a user friendly (and predictable) technique for surgical
repair is a big asset for all of us.
d)
Dont be misled by false, contrived, or managed information
from competing dental companies. We are the providers of our
patients care. Your patients have every right to expect the best that
is available; be critical in your thinking and demanding in your
expectations. EP
10 years in the Air Force and held, among various positions, that of
Chief of Prosthodontics at Osan AFB and Chief of Prosthodontics at
McGuire AFB. In addition to having maintained a private practice,
limited to endodontics, Dr. Koch has lectured extensively in both the
United States and abroad. He is also the author of numerous articles on
endodontics. Dr. Koch is a co-founder of Real World Endo.
Allen Ali Nasseh, DDS, MMSc, received his Masters in
Medical Sciences degree and Certificate in Endodontics
from the Harvard School of Dental Medicine in 1997.
He received his DDS degree in 1994 from Northwestern
University Dental School. He maintains a private
endodontic practice in Boston, Massachusetts (MSEndo.
com) and holds a staff position at the Harvards postdoctoral
endodontic program. Dr. Nasseh has done research in the areas
of bone biochemistry and has lectured extensively nationally and
internationally on such diverse topics as endodontic diagnosis,
anesthesia and sedation, treatment planning, efficiency of care, and
microsurgery. Dr. Nasseh is the endodontic editor for several dental
journals and periodicals and serves as the Alumni Editor of the Harvard
Dental Bulletin. He serves as the Clinical Director of Real World Endo
and maintains an educational website www.Nasseh.net.
References
1. Koch KA, Brave D (2009). Bioceramic technology the game changer in
endodontics. Endodontic Practice US. 12:7-11.
V] >i Vi>V]>\/iVV>i
Dent Today. Vol.31; No. 2: 118-125.
3. (2011). Premixed root repair material is easy to use, biocompatible,
hydrophilic, and radiopaque. Clinicians Report. Nov: 6.
4. Lovato KF, Sedgley CM (2011). Antibacterial activity of EndoSequence root
repair material and ProRoot MTA against clinical isolates of Enterococcus faecalis.
J Endod. 37:1542-1546.
5. AlAnezi AZ, Jiang J, Safavi KE, et al (2010). Cytotoxicity evaluation of

EndoSequence root repair material. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 109: e122-e125.

>V>]>>i] ]i>V>vi
cytotoxicity and proinflammatory cytokine production of EndoSequence root
repair material and ProRoot mineral trioxide aggregate in human osteoblast cell
culture using reverse-transcriptase polymerase chain reaction. J Endod.
38:486-489.
Volume 5 Number 5
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Bioceramics in endodontic surgery: a clinical review

1. Bioceramics are:
a.
b.
c.
d.
hydrophobic
hydrophilic
able to form hydroxyapatite upon setting
both b and c
2. The introduction of MTA more than a

decade ago, was a significant advancement
in surgical endodontics, particularly
in_______.
a.
b.
c.
d.
perforation repairs
pulp capping
bone grafting
replacing gutta percha for filling canals
3. While we are all familiar with the

success of MTA, we must also realize that it
is basically a _______.
a.
b.
c.
d.
new type of amalgam

intracanal lubricant
modified Portland cement
derivative of gutta percha
4. Consequently, there are some real

challenges in its handling characteristics.
The first is that MTA _______either in a
syringe or in a jar.
a. is usually premixed
b. is already packaged
c. does not come premixed

d. none of the above
5. The particle size of MTA is _____to
be extruded through a reasonable-sized
syringe.
a.
b.
c.
d.
too small
just the right size
easily altered
too large
6. It should be noted, however, that

it (MTA) has a number of favorable
properties including a pH of _____, which
is strongly antibacterial.
a.
b.
c.
d.
7
8
9
12.5
7. Similar to MTA, bioceramics are

______within the biological environment.
a.
b.
c.
d.
very biocompatible
chemically stable
overly reactive
both a and b
and BioAggregate, but its small particle size

(approximately one micron) allows it to be
extruded through a syringe.
a.
b.
b.
c.
5-10 MPa
10-20 MPa
50-70 MPa
500-750 MPa
9. Once you have created an oblong shape,

you can pick up a section of it with a sterile
instrument, and use this to deliver it where
needed (Figure 3). This is an easy technique
for ______.
a.
b.
c.
d.
apico retrofills
perforation repairs
resorption defects
any of the above
10. The purpose of this study was to

compare the cytotoxicity and cytokine
expression profiles of EndoSequence Root
Repair Material and ProRoot MTA using
osteoblast cells. Their conclusion was
that ESRRM and MTA showed ______
cytotoxicity and cytokine expressions.
a.
b.
c.
d.
similar
vastly different
ESRRM to have higher
MTA to have higher
8. ESRRM has a compressive strength of

______, which is similar to that of MTA
To provide feedback on this article and CE, please contact Endodontic Practice US
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Volume 5 Number 5
!"#$#%%#&'()#*#++$,%$%,-.$(..(/0'(*/$
+,1-'(,*+$ (*$ .,,'$ &0*01$ &1#0*(*/$
0%'#.$.,'0.2$(*+'.-3#*'0'(,*
4.+5$6,./#$70.#8#+$9(#2.0:$6(3;*#<$=*.>?-#<$@.0*&(+&,$60)(#.:$A0+B0.$
CDE#<$F.'(<:$0*8$G1#H0*8.,$G1&0*'0.$=*.>?-#<$#)01-0'#$'"#$8#I.(+$
.#3,)01$0I(1('2$,%$%,-.$(..(/0'(*/$+,1-'(,*+$8-.(*/$.,,'$&0*01$
(*+'.-3#*'0'(,*
he cleaning and shaping of the root canal system are considered

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

removal ability of EDTA, MTAD, 1.0% NaOCl
and chlorhexidine (4.0%) when used as
irrigants during root canal instrumentation.
Expected outcomes
Correctly answering the questions on page

36, worth 2 hours of CE, will demonstrate
you understand:
r;OH[[OLHWPJHS[OPYKZOV^LKTVYLKLIYPZ
than the middle third.
r;OH[UVULVM[OLPYYPNH[PUNZVS\[PVUZSLM[[OL
root canal walls totally free of debris.
active at a concentration of 15 to 17%, and pH of 7 to 8 (Naenni,

et al, 2004)
U
V>V`]i`>VVi>v]x]>`x
(Senia, et al, 1971; Garberoglio, Becce, 1994).
Although sodium hypochlorite appears to be the most
desirable single endodontic irrigant, it cannot dissolve inorganic
dentin particles, and thus prevents the formation of a smear
layer during instrumentation (Ferrer, et al, 1996). In addition,
calcifications hindering mechanical preparation are frequently
encountered in the canal system.
ii>}>}iV> /}ivwViV
in removing the smear layer (Lester, Boyde, 1977). In addition to
their cleaning ability, chelators may detach biofilms adhering to
root canal walls.
/>i>> /}>i`Li}
superior to saline in reducing intracanal microbiota (Zehnder, et
al, 2005), despite the fact that its antiseptic capacity is relatively
limited (Yoshida, et al, 1995). Antiseptics such as quaternary
>V` /
Q*>i]Ri>VVi
>LV/Q"L]xR>iLii>`ì` />`
citric acid irrigants, respectively, to increase their antimicrobial
capacity. The clinical value of this, however, is questionable.
/
> i>i} ivwV>V > /]
L i V>V />Li>`] i >] v /]
Volume 5 Number 5
17%
EDTA
MTAD
2.5%
NaOCI
2% CLX
Cervical third
Middle third
Apical third
Figure 1: Typical SEM photomicrographs showing the cervical, middle, and apical thirds of root canal dentin surface in 17% EDTA, MTAD,
2.5% NaOCl, and 2% chlorhexidine (1,000x-5,000x)
resistance to tetracycline is not uncommon in bacteria isolated

from root canals (Torabinejad, et al, 2003). Generally speaking,
the use of antibiotics instead of biocides such as hypochlorite or
chlorhexidine appears unwarranted, as the former were developed
for systemic use rather than local wound debridement, and have a
v>>iiV>i>i>j]i>]
Chlorhexidine is a strong base and is most stable in the
form of its salts. The original salts were chlorhexidine acetate and
hydrochloride, both of which are relatively poorly soluble in water
Vi] ,i] iVi] i >i Lii i>Vi` L
chlorhexidine digluconate.
Chlorhexidine is a potent antiseptic, which is widely used
for chemical plaque control in the oral cavity (Foulkes, 1973;
Addy, Moran, 2000). Aqueous solutions of 0.1 to 0.2% are
recommended for that purpose, while 2% is the concentration
of root canal irrigating solutions usually found in the endodontic
literature (Zamany, et al, 2003).
Several new nickel-titanium instruments have been
developed to facilitate the difficult and time-consuming process
of cleaning and shaping the root canal system, and to improve the
quality of root canal preparation.
Volume 5 Number 5
The new designs of hand and rotary instruments include

non-cutting tips, radial lands, and varying tapers. These features
are meant to improve the safety of canal preparation, shorten
working time, and create a greater flare preparation. Most are used
in a crown down sequence.
The purpose of the present study was to evaluate the debris
i>>Lv /] >"
]/>`Viì
(4.0%) when used during root canal instrumentation.
!"#$%&"'(")*(+$#,-*.
} vi i>Vi` > >> Vi> > }i]
straight root canal extracted from 40- to 60-year-old patients
with periodontal disease were randomly selected, radiographed
buccolingually and mesiodistally, then placed in individual
containers with 2% formalin and stored in a refrigerator at 10C.
The average root length was 12 mm. At the time of use, the
teeth were removed from formalin, washed in running water for
30 minutes, and randomly separated into four groups of 20 teeth
r >V}>ìwi`Li}>}i`
(Table 1).
The scoring procedure was carried out by the operator who
could not identify the specimen, using the following five score
system (Hlsmann, et al, 1997):
U-Vii\
i>V>>>qiviìL>Vi
U-Vi\i>V}i>
U -Vi ii\ > V}i> q i > x v V>>
wall covered
U-Viv\i>xvV>>>Vii`
U-Viwi\
iii>ViiVi}vV>>>
by debris.
!""#$%&'&($)*+)&*&#,"'
After preparing a conventional access preparation for each tooth,
> V>Lì L] > i wi i >ivi]
Switzerland) was used to determine the working length (WL) by
penetrating the apical foramen and pulling back into the clinically
visible apical foramen. WL was established 0.5 mm coronal to the
apical foramen and confirmed radiographically.
All the root canals were then explored and prepared by
rotary instrumentation with a #25 LightSpeed LSX instrument
V i>] 1-] i>L} > i i> 7 i `>Vi
measured up to 0.5 mm below the root apex. All WLs were
confirmed radiographically.
Rotary instrumentation was performed with #25 to #80
LightSpeed LSX instruments in the apical third. They were used
with a constant speed of 2000 rpm (LightSpeed electric handpiece,
V i>] 1- } > >` ii /i
instruments were changed every six canals, and instrumentation
was performed according to the manufacturers instructions.
Gates Glidden drills (Mani, Japan) #2 to #4 were used
on the body of the root canal walls (cervical and middle thirds).
Apical stops prepared with LightSpeed instruments were shaped
to size 80 respectively.
-**,.&#,"'
} >i] i V>> > }>i` n v i
irrigating solution. The same method was used with all of the 20
teeth of each group, only changing the irrigating solutions tested.
In all groups, irrigation was performed using a plastic syringe with
30 gauge closed end needle (Hawe Max-i-Probe, Hawe Neos,
Bioggio, Switzerland).
In all cases, the needle was inserted as deeply as possible
into the canal. After cleaning and shaping, all root canals were
finally flushed with 5cc with their corresponding irrigant and
ì`>LLi>ii>ivi
/01$+2&3,'&#,"'
All were separated longitudinally and evaluated from cervical,
middle, and apical third. Roots were split longitudinally in the
buccolingual plane. To facilitate fracture into two halves, all
roots were grooved longitudinally on the external surfaces with
a diamond disk, avoiding penetration of root canals. The half of
each root in which the entire canal was visualized was selected.
Root surfaces were grooved to three levels at 3, 6, and 9 mm from
the root apices using a diamond bur. Canal halves were secured on
metal stubs, desiccated, sputter-coated with gold, and viewed with
>V>}iiVVVi- Q "{6*]
><i
/-L]"LiVi]i>R
The cleanliness of each canal wall was evaluated in three
thirds and photographed at 1500-2000 of magnification at the
same height as the groove that defined each third.
/#&#,4#,%&($&'&(54,4
The experimental data used in this study consisted of four groups
with a Q-Cochran test (Siegel, Castellan, 1998). The Q-Cochran
test showed statistical significance between the four groups. The
Kolmogorov-Smirnov test was used for checking the normality of
the data distribution.
As the results for each group did not follow a normal
distribution, the variables were analyzed using a non-parametric
test. The level of statistical significance was set at p less than 0.05.
!+46(#4
The results showed that the increase in the percent of debris
always occurs in the same direction, i.e., from the middle region to
the apical, no matter which solution is utilized. Table 2 shows the
debris findings and the comparisons among irrigating solutions.
To define which of the irrigation solutions was significantly
different from the others, the complementary Tukey test was used
for this factor of variation. The Tukey test showed a statistical
`vviiVi Liii i i> v { Viì >` /
7 i /i i] i v` i / >` *i /
i/>i>Li>V>i>
iL i> } i` }wV> `vviiVi

Liiiiivi} />iivviViìL
removal than the rest of the irrigant solutions (Table 2).
7,4%644,"'
Chemical-mechanical preparation forms the key requisite for the
success of root canal instrumentation. The objective of these two
interdependent factors consists of the cleaning of the canal and its
eventual ramifications, removing the largest possible amount of
debris in order to establish ideal conditions that allow a functional
recuperation of the dental organ and a regeneration of tissues
eventually injured by infection.
iìi>`>]i>]>iV>i`
the performance of irrigating solutions in root canal treatment,
V`}`vviiVVi>v >"
]VV>V`>` /
(OConnell, et al, 2000; Olmos, et al, 2000).
/>ì`vvii>vVi>iv>i`
are effective chelating agents to smear layer removal. Numerous
authors (Yoshida, et al, 1995; Patterson, 1963; Ostby, 1957)
ii`>>i>i>V> >"
>` /i>i`
both organic and inorganic components.
No significant differences were found by Hulsmann, et al,
(2001; 2003a; 2003b) in either debris or smear layer removal,
when using 3% NaOCl as initial and final irrigation, and 17%
/ >vi i>V wi V>}} > i>
techniques.
/iiL>iìii`> /
>` *i/ivi>i>viì
in the interior of the canals, followed by NaOCl and finally,
chlorhexidine, which left the greatest amount of debris.
With the rotary instrumentation technique, the results for
/>ìivi}>ii>>}iii
previous reports (Cervio Vzquez, et al, 2002; Wayman, et al,
-Vi>]i>]]>`L />`/
Volume 5 Number 5
are recommended.
/iv>V> />iLiVi>ivi
canal confirms the findings of Tanomaru, et al, (2003). This may
be due to the potentiation of the solvent action when energized by
temperature (Senia, et al, 1971).
Irrigating solutions used in endodontic treatment not only
present antimicrobial action, but they also clean the pulp chamber
(Sarbinoff, et al, 1983). None of the irrigating solutions studied
in the present study were capable of eliminating all of the debris
in the root canal walls, since none of them left the root canals
completely free of debris.
In the present study, no significant differences in presence
of debris were observed among root canal thirds in the manually
and rotary instrumented groups irrigated with NaOCl. Similar
results were found by Tucker, et al, (1997) who compare the
rotary instrumentation with the hand technique, using 1% NaOCl
as irrigating solution; and Ahlquist, et al, (2001) who compare the
rotary instrumentation technique, ProFilei]>`
instrumentation with S-files using 0.5% NaOCl.
The removal of debris and smear layer depends not only on
the irrigation method, but also on the endodontic instrument, the
way the instrument is used, and the preparation technique. The root
References
canal cleaning capacity of manual versus rotary instrumentation

techniques with NaOCl is somewhat controversial (Hlsmann, et
al, 1997).
!"#$%&'("#
1. The apical third showed a greater amount of debris than the
middle third, regardless of the solution used.
2. None of the solutions used for irrigation of the root canals
allowed full removal of the debris from the interior of the canal.
/ >` *i / > }>} iv i
canals with less debris than 1% NaOCl and chlorhexidine. EP
Jorge Paredes Vieyra is a full-time lecturer of endodontics at the
Autonomous University of Baja California, Tijuana Campus, Mexico.
Jimnez Enrquez Francisco Javier is a lecturer of oral surgery and
endodontic surgery at the Autonomous University of Baja California,
Tijuana Campus, Mexico.
Gaspar Nez Ortiz is an endodontist as well as chairman of the
endodontic program at the School of Dentistry, Mexicali, Mexico.
Alejandro Alcantar Enrquez is chairman of the School of Dentistry,
Mexicali, Mxico.
Addy M, Moran JM (1997). Clinical indications for the use of chemical adjuncts to
plaque control: chlorhexidine formulations. Periodontol 2000 15: 52-4.
"]
?ì>]>V*}>Vì>ì>>`V>]
]VVìì>i `VVViiVVì
barrido. Endodoncia 18: 207-14.
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V>>>>vii>> />i\>V>>i-
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i6?i]> i`> ]6>i>*>*]i> i`

V>>ì>>VVì`}>ii ``V>Rev Eur Odont
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-VBvi ]> vwViVv>Vi>i>i

instruments compared with stainless steel hand K-Flexofile. Part 2. Cleaning
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>j]->i7]>ì],i
ìwV>>`>VL>
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>`x /}>i>>ii> Int Endod J 33:46-52.
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VivviVvVV
>V`>` //i`>V>>}>\>>>J Endod 27: 741-3.
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Tanomaru JM, Leonardo MR, Tanomaru Filho M, Bonetti Filho I, Silva LA (2003).
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7>> ]7]*i]>> *
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7ii-]i,] > vviVvi>>i``V>ìVi
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Yoshida T, Shibata T, Shinohara T, Gomyo S, Sekine I (1995). Clinical evaluation of the
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Nygaard stby B (1957). Chelation in root canal therapy. Odontol Tidskr 65: 3-11.
<iì]V]ì]-ii ]7>//i`}V>>V

and antimicrobial effect of buffered and unbuffered hypochlorite solutions. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 94: 756-62.
OConnell MS, Morgan LA, Beeler WJ, Baumgartner JA (2000). A comparative study of
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Zehnder M, Schmidlin P, Sener B, Waltimo T (2005). Chelation in root canal therapy

reconsidered. J Endod 31: 817-20.
Volume 5 Number 5
Endodontic Practice CE
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!"#$%&'()*
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+,-%$)./01$'1/"2%2"*
Each article is equivalent to two CE credits. Available only to paid subscribers. Free
subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits
for only $99. To receive credit, complete the 10-question test by circling the correct answer,
then either:
</=)20)%2"*
Post the completed questionnaire to:
+33$)00*
Endodontic Practice US CE
15720 N. Greenway-Hayden Loop. #9
>/1?@%A1'1)%'23%B/7%>"3)*
Fax to (480) 629-4002.
4('/5*
Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The
CE provider, however, does not independently verify the content or materials. Any opinions expressed in
the materials are those of the author and not the CE provider. The instructional materials are intended
to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained
healthcare professional.
6)5)78"2)9:';*
Please allow 28 days for the issue of certificates to be posted.
The effectiveness of four irrigating solutions in root canal cleaning

after rotary instrumentation
1. Many canals have ________ that make
them susceptible to procedural accidents
such as ledges, zips, perforations and
blocked canals.
a.
b.
c.
d.
moderate curvatures
severe curvatures
abrupt curvatures
any of the above
2. The effectiveness of endodontic space

cleaning depends on ________________.
a.
b.
c.
d.
instrumentation
irrigation
curvature of the canal
both a and b
3. The most widely used irrigant for root

canal treatment is ______at concentrations
of 0.5 to 5.25%.
a.
b.
c.
d.
EDTA
citric acid solutions
sodium hypochlorite (NaOCl)
quaternary ammonium compounds
4. Demineralizing agents such as EDTA

show ______ in removing the smear layer.
a. low efficiency
b. high efficiency
c. no effect
d. difficulty
5. Generally speaking, the use of _______
instead of biocides such as hypochlorite
or chlorhexidine appears unwarranted, as
the former were developed for systemic
use rather than local wound debridement,
and have a far narrower spectrum than the
latter.
a.
b.
c.
d.
antibiotics
sodium hypochlorite
BioPure
Miltons solution
6. Chlorhexidine is a potent antiseptic,

which is _______for chemical plaque
control in the oral cavity.
a.
b.
c.
d.
not currently used

widely used
used in very high concentrations
a time-consuming method
7. The new designs of hand and rotary

instruments include ______.
a.
b.
c.
d.
8. Chemical-mechanical preparation
forms the ________ of root canal
instrumentation.
a.
b.
c.
d.
debris particles
least ideal element
key requisite for the success
average length
9. _____used in endodontic treatment not

only present antimicrobial action, but they
also clean the pulp chamber.
a.
b.
c.
d.
Irrigating solutions
Manual instruments
Rotary instruments
Gates Glidden drills
10. _____ depends not only on the

irrigation method, but also on the
endodontic instrument, the way the
instrument is used, and the preparation
technique.
a.
b.
c.
d.
Conventional access preparation

The removal of debris
The removal of the smear layer
Both b and c
non-cutting tips
radial lands
varying tapers
any of the above
To provide feedback on this article and CE, please contact Endodontic Practice US
15720 N Greenway Hayden Lp. #9, Scottsdale, AZ 85260 | fax: (480) 629-4002 | email: education@endopracticeus.com
Volume 5 Number 5
Technology
!"#$%&$'(%!)%'#*%$#*"*"#+,-.
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adiography has an important role in the assessment of

morphology and the diagnosis of pathology of the pulp
and root canal system, but conventional planar radiography
only provides a two-dimensional representation of this complex
anatomy. The limited 2D representation might not yield sufficient
information for the clinician to fully diagnose pathological states
and therefore effectively treatment plan.
Limited volume cone beam computed tomography (CBCT)
provides high-resolution three-dimensional undistorted images
of the maxillofacial skeleton, including the teeth and their
surrounding tissues. Although the effective radiation dose used in
CBCT is higher than that of conventional radiographic techniques,
it is substantially lower than conventional CT1. The advantages
of this relatively new technology in all fields of dentistry have
not been overlooked, and guidelines for its safe use have been
prescribed by SEDENTEXCT (http://www.sedentexct.eu/content/
guidelines-cbct-dental-and-maxillofacial-radiology).
CBCT has a demonstrated efficacy in a large number
of endodontic applications, including, but not limited to, the
investigation of complex dental anatomy and hidden pathology2.
I have been using CBCT for diagnosis, treatment decisionmaking and planning, along with surgical guidance for the past
5 years in my specialty practice. I believe that the advantages
of the extra dimension and superior resolution substantially
enhances the level of advice and treatment offered to patients,
reducing failure with effective diagnosis, and increasing success
and efficiency through the accurate identification of canal anatomy
and the surrounding tissues.
This series of case discussions highlight the use of CBCT
in clinical endodontics and how it is used to enhance diagnosis,
decision making, treatment planning, and the treatment itself.
!"#$%&'#()##'*+%,%-%"%.'&&$+%/$#'*+%
Clinical details
A 56-year-old female patient with no relevant medical history was
referred to the practice by a restorative consultant for root canal
treatment of her lower right second molar (LR7). The patient had
presented a week earlier to the referring dentist complaining of an
intermittent pain in her lower right jaw. The dentist had identified
the LR7 as the source of the pain and carried out a pulpectomy. He
was only able to identify and negotiate a distal canal and a single
mesial canal. A week following the emergency treatment, the pain
was still present, and the referral requested further treatment
through the location of a missed mesial canal.
At the time of consultation, the patient described the pain
as intermittent, and moderate to severe. The timing was mostly
random, lasting for hours, occasionally disturbing sleep, and it
would invariably follow eating. It was poorly localized toward
the posterior part of the right mandible with the pain radiating
up toward the right ear. It was controlled with regular analgesics.
Following the pulpectomy, the pain had worsened briefly but was
now similar to that prior to the emergency procedure.
Clinical examination revealed a temporary filling in the
LR7, which was slightly tender to percussion (TTP). The tooth did
not respond to vitality tests (Endo-Ice [Hygenic] and electric
pulp testing [EPT]). The lower right first molar (LR6) had a well
fitting bonded precious metal full veneer crown, and the lower
right second premolar (LR5) was a bonded precious metal full
Figure 1: Preoperative periapical radiograph. Widening of the PDL

observed around the mesial root of the LR7. PDL intact around the
mesial and distal roots of the LR6
veneer crown on an implant. Neither LR5 or LR6 was TTP, and

without visible dentin around the LR6, it was not possible to carry
out an electric pulp test. Periodontal probing depths around all
lower right posterior teeth were within normal limits, and there
were no discernible occlusal issues.
A periapical radiograph (Figure 1) showed a deep restoration
in the LR7 with widening of the periodontal ligament (PDL) space
associated with the mesial root apex. Apart from some sclerosis in
the distal canal of the LR6, the PDL is clearly intact around this
root, and no other pathology was noted.
A limited volume (4 cm x 4 cm) cone beam computed
tomograph was taken of the lower right mandible using a Morita
Epochs 3D (80kV, 5mA, 9.4 sec). The scan confirmed widening of
the PDL at the mesial root of LR7 (Figure 2), but also revealed a
2.5 mm diameter lesion associated with the distal root of the LR6
(Figures 3 and 4). The scan also showed the presence of a single
canal in the mesial root of the LR7 (Figure 5).
A diagnosis of chronic periapical periodontitis (CPP)
associated with pulpal inflammation and necrosis was made for
the LR7 and also CPP for the LR6 associated with likely necrosis or
partial necrosis. As the LR7 had already been opened and dressed
without pain resolution, a pulpectomy of the LR6 was carried out
through the crown. The pulpal tissues in both mesial and distal
canals were found to be necrotic, and the canals were dressed with
Richard Kahan is an endodontist working
in Harley Street and the former director of
endodontic courses at UCL Eastman CPD. He
has lectured on endodontics and technology
and has set up the Academy of Advanced
Endodontics to teach the fundamentals of endodontics
to GPs through extended mentoring within his practice.
With years of experience in endodontic CBCT, his clinic
has become a referral center for complex cases used by
both endodontists and GPs. For more information visit
www.endodontics.co.uk.
Volume 5 Number 5
Technology
Figure 2: CBCT Saggital

slice widening of the PDL
space around the mesial
root of the LR7 (arrowed) can
be observed. Also arrowed
at the LR7 is a distal vertical
periodontal defect. The width
of this defect (seen axially)
suggests it is likely to be of
periodontal etiology and not
a vertical root fracture
Figure 3: CBCT Saggital

slice a 2.5 mm diameter
periapical lesion is
associated with the distal
root of the LR6. There is also
widening of the PDL space
around the distal root of the
LR7
Figure 4: CBCT Coronal slice

the lesion associated with
the distal root of the LR6
is positioned between the
buccal and lingual cortical
plates and therefore invisible
on a traditional 2D periapical
radiograph
Figure 7: The ability to

detect a periapical lesion
on a standard periapical
radiograph will be
dependent on its proximity
to the cortical plate, most
usually determined by the
position of the root apex in
the maxilla or mandible
Figure 6:
Postoperative
periapical
radiograph
calcium hydroxide.
Within 2 to 3 days, the patient reported a resolution of her
pain symptoms. Endodontic treatment of both the LR6 and LR7
was subsequently completed without complication (Figure 6).
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The limitations in standard radiographic detection of apical lesions
have been known for many years3 noting that a lesion will only be
visible with involvement of the overlying cortical plate of bone.
There is no literature evidence for the proportion of apical lesions
that do not involve the cortical plate, and it is unlikely that we
will ever know this figure. The ability of a standard periapical
radiograph to accurately detect apical pathology (diagnostic
sensitivity) is therefore dependent on the size of the lesion and the
proximity of the root apex to its closest cortical plate (Figure 7).
This can explain the historically low scores seen in the literature
for the diagnostic sensitivity and specificity of standard periapical
radiography.
In this case, a periapical lesion had formed beneath the
distal root of the LR6, and as clearly seen in the CBCT coronal slice
(Figure 4), it is positioned in the cancellous bone space between
the cortical plates of the mandible. No matter how hard we peer
at the 2D periapical radiograph, digitally enhance it, or take views
from different angles, this lesion will not be visible.
Unfortunately for the dentist, the pain suffered by the
patient in this case was poorly located, there were no clinical signs
or symptoms associated with the LR6, and it was impossible to
carry out a vitality test.
No retrospective judgement could be made on the veracity
of carrying out the pulpectomy at the LR7, as there certainly was
widening seen in the periapical radiograph and TTP, but this could
have been as a result of the procedure carried out the week before.
Certainly the fact that the pain had not resolved was a powerful
indicator that the source of the problem had not been addressed.
The appearance of a lesion associated with the LR6, along with
confirmation of a single mesial root canal in the LR7, despite any
further evidence of pathology associated with the LR6, provided
Figure 5: CBCT Axial slice

this slice confirms the
position of the lesion at the
LL6 distal root between
the cortical plates and also
shows the presence of a
single canal in the mesial
root of the LR7
the confidence to make a diagnosis and therefore to logically

proceed with treatment.
We can speculate as to what would have occurred without
the benefit of a CBCT scan and the third dimension. In the absence
of any other pathology, an attempt would have been made to locate
a second canal in the mesial root of the LR7. Although symmetry
of the canal system would have dictated a cautious approach to the
location of a second mesial canal, the continuing pain would have
been a motivator to go drilling into the root hunting the elusive
(and nonexistent) pulp tissue, removing structural dentin, and
damaging the root. Having not found any further canal anatomy,
the tooth would have been dressed (or filled), with the patient
returning, no doubt on numerous occasions, still complaining of
pain.
This unfortunate situation would have continued until
either the pain located itself more specifically to the LR6, or with
the lesion increasing in size leading to cortical plate involvement,
it would finally become visible on a standard radiograph. Without
these two confirmatory signs, the patient would have been moved
from specialist to specialist, possibly losing the LR7 after a few
unsuccessful treatments and being referred for atypical facial
pain. This is not an uncommon scenario. As it was, the problem
was quickly identified and dealt with successfully in a single
appointment, as the patient and the referrer would have expected.
EP
References
1. Patel S, Dawood A, Pitt Ford T, Whaites E (2007). The potential
applications of cone beam computed tomography in the management of
endodontic problems. Int Endod J, 40, 818830.
2. Nair MK, Nair UP (2007). Digital and advanced imaging in endodontics: a
review. J Endod 33, 1-6.
3. Bender IB, Seltzer S (1961). Roentgenographic and direct observation of
experimental lesions on bone: J Am Dent Assoc. 62:152 Feb.
Volume 5 Number 5
Technology
!"#$$% &'(#)% *(+&% ),% -./#(0$% +,-#%

#(01,/#(."+%12%),0(+3&%$4,2,'+
5#+(2%6$7(2,8%4,9:,-20$#%,:%;$2$*%61/1)(78%01&4-&&$&%4#$()1<$%
)$4"21=-$&%:,#%12<$&)12/%12%122,<()1<$%)$4"2,7,/1$&
odays high-tech world demands advanced state-of-theart equipment both inside and outside the general
dental and specialty practice. Numerous studies have shown
that dental professionals who reinvest in their practices with
modern technology tend to be leaders in their respective fields
with increased production and higher profits. The challenges of
our current economy, however, can often limit a practitioners
practical and financial ability to adopt these innovative products
and services. The use of creative purchasing techniques and tools
such as Section 179 tax deductions and financing, trading in your
current X-ray, or purchasing used or refurbished systems can help
minimize the impact of upgrading and keeping up with current
imaging technology.
!"#$#%&'()*$+,-$.%./&'()*
Historically, one of the easiest ways to realize immediate savings on
capital dental equipment purchases is through the IRS Section 179
deduction. This incentive allows business owners to deduct the
full price of purchased, financed or leased qualifying depreciable
equipment and software for the current tax year. The equipment
purchased or leased must be within the specified Section 179 dollar
limits and must be placed into service in the same tax year that
the deduction is taken. In recent years, the size of the deduction
provided an exceptional opportunity for dental practitioners to
upgrade, modernize, and invest in their practices.
Prior to the economic downturn following the 9/11 tragedy,
Section 179 allowed for a deduction of up to $25,000 of qualifying
depreciable property used in trade or business activities. To help
boost the economy through increased spending in manufacturing
and technology, the Jobs and Growth Tax Relief Act of 2003
increased the Section 179 deduction limit from its annual ceiling
of $25,000 to $100,000. The annual deduction limit was further
increased in 2007 to $125,000 and then again in 2008 to allow for
an annual deduction of up to $250,000. It was revised significantly
in 2010 to allow a maximum annual deduction of up to $500,000
for tax year 2011 and then dramatically reduced the deduction
back to an inflation-indexed $125,000 ($139,000) in 2012.
Starting in 2013, the annual deduction limit under Section 179 is
scheduled to return to its pre-2003 $25,000 level (see Figure 1).
As a result of these significant upcoming changes to Section
179 deductions at the end of this year, dental practitioners should
contact their tax advisors to discuss the benefits of acquiring
depreciable business assets, such as dental X-ray and cone beam
systems in the remaining months of 2012.
Figure 1
012.%3(*
The introduction of dental
cone beam and the release
of newer generations of
these systems have created
a previously unprecedented
trade-in value for 2D
panoramic digital X-ray
and first generation cone
beam units. Due to this
demand, several reputable
companies have surfaced
that purchase, refurbish,
and sell used dental X-ray
equipment, allowing practitioners to recoup a portion
of their initial investment
by selling or trading their
panoramic or cone beam
systems. Often, these funds
can be provided to the
practitioner directly upon removal or sent to the equipment dealer
or vendor to apply to the down payment of the new unit. Used
equipment dealers can also work directly with the new equipment
vendor to coordinate removal of their existing system with the
implementation of the new unit, minimizing office down time
or loss of production.
The fair market value of used dental X-ray and cone beam
equipment, like that of used vehicles, depends on several factors
such as the units make and model, age, condition, and exposure
count. Included hardware and networking components such as
cephalometric capabilities, ethernet connectivity, and multiple
sensors can affect the systems value. Additional features such as
extraoral bitewings, touch panel controls, and other upgrades can
also impact the purchase price.
Some practitioners opt to sell their existing equipment on
their own in an attempt to achieve the greatest profit. However,
these transactions often result in improperly licensed software,
missing parts, and non-transferable warranties. Plus, delicate
X-ray components can be easily mishandled in removal, shipment
Bryan Delano is a co-founder of Renew
Digital, the leading provider of refurbished
dental X-ray systems. With more than a dozen
years in dental technology experience, he has
held key management positions at Carestream Dental
(KODAK Dental Systems), 360imaging, and topsOrtho.
His extensive background includes practice management
software, dental X-ray technology, implant planning and
patient education. Mr. Delano lives in Atlanta, Georgia
with his wife and two children.
Volume 5 Number 5
Technology
or installation, resulting in expensive repairs. All of

these issues, combined with lost production while
managing the process, can be more costly and time
consuming than initially anticipated.
!"#$%&'()"*+",$'-."/0
Many practitioners have chosen to purchase used or
refurbished equipment that is current generation or
only one generation behind. This strategy can offer a
significant cost savings on more advanced 2D digital
panoramic systems, 2D/cone beam 3D-hybrid units,
or cone beam 3D scanners.
Companies that offer used and refurbished
dental X-ray systems can often provide the new
product experience with up to 50% savings off the
cost of new equipment. This equipment is typically
inspected at time of pick up, refurbished as needed
at the companys warehouse, thoroughly tested
again, and resold in an almost new condition.
They then coordinate product delivery and
installation including the latest imaging software,
conduct on-site training, and provide after-purchase
service and support. Some companies even include
comprehensive product and manufacturers
warranties.
Because refurbished X-ray companies are
vendor neutral and have access to a wide variety of
models, they can help practitioners select systems that best fit
their practices, regardless of manufacturer. They can also help
find previous generation models to match X-ray systems
in primary offices for secondary locations, minimizing staff
learning curve and software integration issues. Because
they are equipment resellers, these companies are also often
willing to take existing 2D digital equipment as trade-ins for
more advanced 2D or cone beam systems, further reducing
the purchase price.
For increased affordability, used or refurbished X-ray
equipment is eligible for certain low-interest financing
programs and Section 179 tax deductions.
There are many ways in which modern dental and
dental specialty practices can benefit from innovative
imaging technologies and numerous ways to incorporate
them, even in todays tough economic landscape. Implement
your smart X-ray upgrade plan today! EP
About Renew Digital
Renew Digital is the leading provider of quality
refurbished panoramic X-ray and cone beam 3D systems
to dentists and dental specialists throughout the U.S. and
Canada. Since all systems include delivery*, installation,
training, and a comprehensive warranty, Renew Digital
offers dental professionals the features and reliability they
need to deliver superior patient care more affordably.
Visit www.renewdigital.com or call 888-246-5611 for
more information.
Max-i-Probe
Endodontic/Periodontal Irrigation Probes
Care for your patients with

the irrigating probe named
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in the Journal of Endodontics.
... the Max-i-Probe removed significantly more
bacteria ... the unique side vent of these safetyended needles produces upward turbulence that
enhances complete cleaning of root canals.
Journal of Endodontics, Vol.33, No. 6, June 2007
Request a FREE sample at www.RinnCorp.com

Closed-end
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Others claim a closed
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Volume 5 Number 5
The RINN Max-i-Probe tip is welded

closed to protect your patient from
fluids expressing past the apex.
Service profile
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5$&#'"6'&3+.(*37**$*+(#*+0'18$&#+8,.$"+#-'#+3'&+(80%,)$+3'*$+
'33$0#'&3$+'&.+(&3%$'*$+0%,2(#*+91+:;<+,%+8,%$+91+0%,)(.(&4+
2"$=(9"$>+&,/(&#$%$*#+0'18$&#+,0#(,&*
entalBanc has designed a solution to help dentists offer

monthly payment options to their patients without creating
extra work for their staff. As an alternative to third-party financing,
DentalBanc has saved practices thousands of dollars each year that
would otherwise be lost to these third-party companies.
!"#$%&'#$()"#*+,$(--"&)#'$,+-+./(01+$2,"3,(4
Through the use of DentalBancs credit recommendations, practices
can easily identify patients who represent a low financial risk and
offer them the right payment plan. This helps practices build
an accounts receivable portfolio without giving up 10% of their
treatment fee. In addition, DentalBanc fully manages the payment
plan while leaving the staff free to provide excellent dental care.
5"6(78'$2(#.+)#'$(,+$2,.-+$'*"22.)3
Patient trends are changing. Whitening used to be just for the
super-wealthy, and braces were just for teenagers. Today, many
American adults are willing to spend thousands of dollars to
improve their smiles. These changes in patient trends have allowed
dental professionals to increase revenues by offering a wide
variety of treatments to a new generation of appearance-conscious
consumers. Just as patient care preferences are changing, so
are patient payment preferences. Cost-conscious patients are
exploring their options, literally price shopping costly dental
procedures, by obtaining several quotes and researching payment
options offered by various providers. As a result, consumers with
good credit ratings expect no interest financing even on their
dental treatments.
9.)(117:$()$(1#+,)(#./+$#"$#*.,6;2(,#7$<.)()-.)3
While some finance companies boast a 12 months, no interest
payment plan, they are charging practices an administrative fee as
high as 10% for these plans. Meanwhile patients, believing they
are receiving an interest-free option, find that only one missed
payment results in retroactive interest as high as 23.99 percent.
Third-party finance companies have done their homework and
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Many practices feel that these plans are detrimental to the
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DentalBanc will completely manage those accounts. Payments are

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The funds are deposited directly into the practices bank account
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Step 3: DentalBanc will deposit collected payments, four times
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Consider your current payment options. Are you being flexible
with your low-credit risk patients by offering them a true nointerest payment plan? Do you have an accounts receivable
program? Are you collecting 100% of the treatment fees? Are
you working with a professional payment management company
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late payments?
If you answered no to any of these questions, call 1-888758-0584 to learn more about how DentalBanc can work for your
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OrthoBanc LLC (DBA OrthoBanc, DentalBanc, and PaymentBanc) is a
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This information was provided by
DentalBanc.
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Step 1: DentalBanc provides a credit recommendation to help an
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level along with a payment plan recommendation. DentalBancs
credit inquiry does not affect the patients credit score. With
DentalBanc, a practice can determine the risk associated with each
patient and offer the appropriate payment plan.
Step 2: Once a practice decides to offer payment terms to a patient,
Volume 5 Number 5
Do you offer expensive

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Product profile
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W
ith more than 67 years of optical experience, Seiler

Instrument is a worldwide leader in the field of microscopy.
Seiler offers a full line of dental and medical microscope products
including its newly designed dental operating microscopes:
Evolution ZOOM, Evolution XR6, and Seiler IQ, featuring
technical advances in their illumination systems, an innovative
fluid design, and all Apochromatic lenses for superior optics.
The new line of Seiler Dental Microscopes has truly
revolutionized the way the dental microscope performs and
operates with a greater depth of field, higher levels of magnification,
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specifically engineered for the dental professional. They all
provide superior visualization and have been specially designed
for ergonomic positioning.
In addition, Seiler Instrument Company has recently
launched its much anticipated revolutionary illumination systems:
the LED and Plasma.
Seiler is the first dental surgical microscope company to
incorporate Plasma Illumination into its dental product line. The
Plasma technology is the next generation in illumination, with
over 100,000 LUX and 10,000 hours of bulb life. It has been
introduced as an alternative to the expensive Xenon light source,
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LED or 10,000 hours.
In addition to the Plasma light, Seiler has also launched
the new LED system. With over 3 years of research into LED
illumination, Seiler has achieved the perfect solution for dental
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spectrum and are not as bright when increasing the magnification
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Along with the introduction of the new illumination
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into focus at the same spot, which in turn, reduces or eliminates
chromatic aberration and sharpens the image.
Another feature of the Seiler Microscope is the option of
video and digital documentation, which has become extremely
vital in the dentistry field. With the use of documentation, one is
able to educate the patient and help to facilitate the process. Seiler
offers a full line of documentation tools such as the new HD CCD
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Each of these can be easily attached to any of the firms dental
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In addition to the many benefits of owning a Seiler
Microscope, Seiler Instrument Company offers a wide range of
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$10,000. The Evolution ZOOM is equipped with motorized
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sales representative in every state. As part of its commitment to
excellence, the firm stands behind all of its products by offering a
free, no obligation opportunity to demo a Seiler Microscope. Seiler
also offers a lifetime warranty on the mechanics and optics of
each microscope. For additional information, please contact Seiler
Instrument and Manufacturing Company, Inc. at 800-489-2282,
or visit www.seilermicro.com. EP
This information was provided by Seiler Instrument and Manufacturing
Company, Inc.
Volume 5 Number 5
Product profile
!"#"$%&%&'("&#)#)&*%+,
-%)+"./0%+(*"+1&)2)'3
4&#)5"67"&+"8(-9(5"/2".:(/&#(!))*(!";/%.(</*".%/2(=!!<:>
ndoSequence BC Sealer and Root Repair Material are redefining

the way many specialists approach endodontic obturation and
root repair procedures. For years, scientists and practitioners alike
have been in search of a root canal sealing and repair material
which contains the following characteristics:
Biocompatible
Antibacterial
Optimal handling (user friendly consistency and premixed)
Osteogenic (healing)
Non-shrinking (dimensionally stable)
Chemical bond to dentin and filling material
Excellent flow (small particle size)
Radiopaque
Sets in the presence of moisture
Recent advancements in Bioceramic Nano-Technology have
allowed for the creation of two novel materials (EndoSequence BC
Sealer and Root Repair Material) which contain all of the above
characteristics.
!"#$%&'(&")&*+,-+%&./&01
Unlike conventional base/catalyst sealers, BC Sealer utilizes the
moisture naturally present in the dentinal tubules to initiate its
setting reaction. The canal should be dried, but unlike other
sealers, the set will not be inhibited by moisture. This highly
radiopaque and hydrophilic sealer forms hydroxyapatite upon
setting and chemically bonds to both dentin and to our bioceramic
points (EndoSequence BC Points). BC Sealer is antibacterial
during setting due to its highly alkaline pH (+12), and unlike
traditional sealers, BC Sealer exhibits absolutely zero shrinkage
and is extremely biocompatible! BC Sealer can either be syringed

directly into the coronal third of the canal or delivered via a hand
file or point. BC Sealer can be used with cold or heated methods.
However, many specialists have come to the conclusion that heat
is not necessary with BC Sealer because of its slight expansion
(.02%) and its ability to bond to dentin. This truly revolutionary
sealer has remarkable healing properties and is designed
specifically to be non-resorbable. In the event of a slight overfill
(puff), an anti-inflammatory reaction will not occur because the
sealer is essentially a root repair material with a flowable viscosity.
!"#$%&'(&")&*+2$$3+2&4.50+6.3&05./+722618
EndoSequence Root Repair Material (RRM) is available in
two specifically formulated consistencies (syringable paste or
condensable putty) and contains many of the same characteristics
as BC Sealer. Like BC Sealer, the setting reaction of RRM is driven by
the moisture naturally present within the dentinal tubules so there
is no mixing required. The favorable handling properties, increased
strength and shortened set time (~1.5-2 hours), make RRM highly
resistant to washout and ideal for all root repair and pulp capping
procedures. The putty consistency is ideal for retrofills, one step
apexifications (apical barrier technique), external resorptions,
and pulp capping. The syringable version is recommended for
retrofills, perfs, internal resorptions, and pulp capping. Many
specialists employ a retrofill technique that involves syringing
some of the flowable RRM into the prep and following it up with
pre-formed cones of the RRM putty. The consistency of RRM putty
is similar to that of Cavit, and it is extremely resistant to washout
making it ideal in difficult fields. The unique properties of RRM
putty allow the practitioner to adjust the consistency to his/her
liking. The more the material is manipulated (via kneading it with
a sterile instrument within the jar provided), the more flowable
it will become. RRM is antibacterial (12+ pH) and is extremely
biocompatible and osteogenic. Join the thousands of specialists
that have set their spatulas aside and joined the RRM revolution! EP
For more information or to order, contact Brasseler USA: 800-8414522 or visit www.brasselerusa.com
Cavit is not a trademark of Brasseler USA or Endodontic Practice US.
This information was provided by Brasseler USA.
Volume 5 Number 5
Product profile
!"#$%&'%()$*&+,'(-(./
01)&%*)&12$3&'*1-$+&-&4)1*&%$56$/&1)%$(7$!"#$89.9*1-$)189(.)1:,/$
hirty years after the advent of RadioVisioGraphy (RVG) in

1982, Carestream Dental is celebrating 3 decades of providing
dental practitioners worldwide with unparalleled image quality.
Invented and patented by visionary French dentist Dr. Francis
Mouyen, RVG imaging delivers digital images instantly, creating
a more efficient workflow for practices and improving patient
communication.
Since its introduction, RVG has established a continuing
tradition of innovation in digital radiography, including
milestones such as offering the first sensor to provide >20
lp/mm resolution and a wireless sensor that can easily
be shared between operatories. Today, Carestream
Dentals RVG family features three sensor options for
practitioners.
Serving as entry point into

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

seamlessly with the companys various imaging software programs.
Additionally, Logicon Caries Detector Software serves as a
computer-aided diagnostic tool that helps practitioners locate and
diagnose interproximal caries using a database of known caries
problems.
Carestream Dentals RVG sensors are built with rounded
corners and rear-entry cables to ensure patients are comfortable.
All sensors are also built with shock-resistant casing, providing
maximum durability for a long lifespan.
For more information on Carestream Dentals RVG product
family, call (800) 944-6365 or visit www.carestreamdental.com. EP
This information was provided by Carestream Dental.
Volume 5 Number 5
Practice management
HIRING
)"#$;*.")$A#23,#
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.%#+)$#63,27##'8$9%:$;*40$/)##<,#$
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ltimately, the success of your practice is not limited by the

economy, competition, or any other external factor. It thrives
(or simply just survives) on your ability to hire, train, and retain
an excellent staff. With an exceptional staff, you are able to
consistently deliver outstanding service, which gives your practice
a powerful competitive advantage.
But, how do we find good people? Whats the best way to
select the right person? And, how do we decide if we should keep
a new employee?
This article will take a detailed look at the hiring process,
reviewing the key steps, suggesting ways to improve and, thereby,
increasing your chances of choosing the right person.
!"#$!"%##$&''#()*+,$-*%*(.$/0*,,'
All of us have experience hiring staff, and no one can presume to
know the unique situation or specific challenges you might face
in finding good employees. Nonetheless, under all circumstances,
hiring the right person for your practice comes down to three basic
skills:
U find the right person
U /ichoose the right person
U ` w>] employ and retain only those who are
right for your practice
So, what are the best strategies to add someone who will
become an asset to your practice?
Finding the right person
Actually, we dont really find the right person; instead, the best
practices attract the right person. Good employees will not even
consider your office unless its a great place to work. So, the
best way to find the right person is to make your practice highly
attractive to the kind of employee you want. You must get your
house in order first if you expect the best applicants to apply.
So, even before youre actively hiring someone, the best way
to attract the right person is to make your practice the employer of
choice for potential staff in your community. The best people will not
even consider your practice unless your present staff raves about
your office and encourages others to apply.
Volume 5 Number 5
Finding Strategy #1: Become the employer of choice

To attract great employees, focus on making your practice the
employer of choice in four key areas:
U
ii Vi> A good salary and benefits
package is merely the price of admission to be considered by the
best person. Since the best people in other offices are usually being
paid well already, it will take more than a good financial package to
attract them to your practice.
U `>V >VVi i >` ìV1 Is
your practice staying current and constantly adapting to new
technologies and ways of serving your patients? Is your leadership
inspiring and your purpose clear? The best people dont want to
remain stagnant; they want opportunities to learn and grow. At the
end of the day, they want job satisfaction and the feeling that they
have made a meaningful contribution.
U } ii What are the key
frustrations that staff feel when working in any dental practice?
Have you solved these problems in your office? The best employees
J. Richard (Rick) Steedle, DMD, MSEd, MS, received
his dental degree with honors from the University
of Pennsylvania, concurrently completing a Masters
Degree in Education. He received his Masters Degree
in Orthodontics at The University of North Carolina at
Chapel Hill where he was awarded the Morehead Fellowship in
Post Graduate Dentistry and a NIH research training fellowship.
After orthodontic residency, he served on the faculty of the
Wake Forest University School of Medicine for 4 years before
entering private practice. During the next 20 years, he and
Dr. Bruce McLain built a three-office orthodontic practice with
a staff of more than 25 employees in Winston-Salem, North
Carolina. In 2005, Dr. Steedle joined the part-time faculty at
the Department of Orthodontics in Chapel Hill. Since then, he
has developed a 3-year curriculum in Practice Management for
the residents, complementing the work of Dr. Robert Scholz
there. UNC now has one of the most comprehensive Practice
Management residency courses in the country. Contact Dr.
Steedle at DrSteedle@gmail.com.
Practice management
are looking for a great working environment that includes a
manageable work schedule, a compassionate, yet fair, leave policy,
great office systems, sufficient training, and the necessary support
to do their jobs well.
U Vii}i>qHow are the interpersonal
relationships in your office? Do all staff members work as one
team, or do they often annoy each other with petty squabbles? The
best people want co-workers who care for each other, a doctor
who appreciates them, and a voice in improving the operations of
the practice.
When you do begin to look for a new employee, how
then do you find and attract the best person? Where are the best
potential applicants working now, and what type of advertisement
would attract them?
Finding Strategy #2: Write an appealing ad
A standard ad will not get the attention of the best people.
Invest your time and money in an ad that appeals to an excellent
applicant by wording it to attract the type of person you want. Be
sure to include which personal traits are desirable, what makes
your practice unique, and how they may have opportunities to
grow. It may take a little more time and possibly cost a little more
money, but what is the value of finding a great employee?
`}->i}\
`V>ì>}}i>V
>>ìiiivw`}iLiiLi
staff, design a classified ad to attract applicants outside the dental
profession. Applicants with the right attitude and outlook are
often employed in other customer service jobs. Although Craigslist
is a popular and inexpensive way to advertise for a position,
consider that the best applicants may be more inclined to read the
classifieds in the local paper and scan online services like Monster.
com or CareerBuilder.com when choosing new employment.
Ask your staff to refer others like themselves. If youve
made your office the employer of choice, they will not hesitate to
encourage other great potential employees to join your team.
>] V> Li i v }i> iii

even when youre not hiring. This way you can create a pool of
potential applicants for when you need it. When you encounter
people who give you great service, hand them a business card,
and ask them to call if they are considering a job change. Were
always looking for excellent people like you. Theyll be flattered
by the compliment, and you may have found an excellent future
employee.
Choosing the right person
The best way to choose the right person is to have a highly selective
hiring process that involves the entire team. In order to choose
the best employees, first you need to be clear on what type of
individuals are best suited to work in your practice and, second,
have an effective way to identify them.
}->i}\-iiVi}ivi
Its natural to think that you need applicants with experience
who can step right in and wont need much training. However,
practices that over-value and hire only the skilled employee
may discover that these are the same people who later create
interpersonal problems with the staff and patients. We can usually
train someone to perform the skills needed to do well, but we cant
train people to have strong interpersonal skills.
A better way is to choose self-motivated people who share
your core values, can learn their jobs quickly, and who, by their
very nature, are caring and compassionate. Therefore, hire and
retain good heads and good hearts, not necessarily just good
hands. When hiring, its great if you can get all three, but its
essential that you get the first two.2
}->i}\Vì>vvi}
If you are the only one who interviews applicants and
independently makes the hiring decision, you have created an
environment in which your present staff is not fully invested in
helping the new employee succeed. In the best practices, the staff
is deeply involved in the interview process, and guides the final
decision about who to bring on the team.
Once applicants have met with your approval, let the final
selection be made by a consensus of your staff. If everyone has a
voice, then everyone can commit to welcoming the new employee
and training him/her to be a productive member of your team.
}->i}\>i>}}Vi
To be highly selective, you need a systematic approach for
choosing the best applicant rather than counting on just a
favorable impression from an application and interview. This
should include:
U iii i>V Vi prepare an attractive
advertisement, and conduct a wide-ranging search.
U ivviVi Vii} Vi identify applicants whose
resumes display the qualities desired, and have a trained staff
member prescreen them on the phone, inviting for an office visit
only those applicants whose telephone interview meets your
standards.
U }iiVi have the applicant meet with
the staff who will work closely with the new employee and schedule
a short interview with you to get a preliminary impression. If the
initial impression is favorable, invite the applicant for a one-half
to full day in the practice to better assess the fit. Even though first
impressions are important, several hours with the applicant is a
better way to gauge his/her true nature.
U }ìVVi hire someone only when there
is consensus among the staff that this is a person who is selfmotivated, shares your core values, and has a good head and heart.
If there are reservations among the staff, dont hire, keep looking.
Taking some additional time to find the right person is preferable
to endlessly spending time managing the wrong person.
Retaining the right person
The best way to employ the right person is to have a highly discriminating
probationary period, so that an applicant is retained only when you are
100% certain that he/she is right for your practice.
Even if you attract and select the right person, you still
must be absolutely certain that this new employee can become a
productive and harmonious member of your team. Both the team
and the new hire need a probationary period of at least 90 days to
evaluate the fit. During this time, the new employee is considered
a temporary hire, and either party can walk away without giving
advance notice.
,i>}->i}\*ì>ì>i>}
Even the best new employees need a thorough training program.
The program should include several key elements. It should:
U i V`Vi` L i` i] L L
best trainer (someone who can give clear guidance and emotional
support to the new employee).
U-i>V>}ivi>iiVi
U i }ì` L > >} >>] V V v i
protocols documenting your processes and procedures.
U*}iiii>iivìiìViìiìVi
(using direct observation of the trainer, followed by the trainee
performing the task with the trainer observing, progressing to
executing the position with a ready backup, and finally leading to
independent performance).
Volume 5 Number 5
Practice management
,i>}->i}\iviivii`L>V
During the probationary period, frequent and specific feedback
from the trainer is essential. Is the new person learning quickly,
displaying professional behavior, demonstrating a caring and
compassionate attitude, and taking the initiative to become a team
member?
At least monthly, the trainer should take some time with the
new employee to honestly assess progress and offer suggestions
for improvement. Any reservations about the new hire should be
communicated immediately to the doctor and team. Everyone
should be given a fair chance, but the best future employees will
clearly demonstrate their value as high performers and excellent
teammates in the first 3 months.
Retaining Strategy #3: Be 100% certain
If you have done your job well in the selection phase, the
probationary period usually goes well. In some cases, however,
the new employee may learn that the position is not what he/she
expected. In other cases, you may discover that he/she is not all
that you thought. If you or your team has any doubts, its best that
you dismiss the new person during the probationary period.
As difficult as this might be, you should retain a new hire
only when everyone is 100% certain that the employee is right for
your team. Its not a question of whether everyone likes the new
person. Usually everyone will. The decision is based purely on the
fit for your office. Not being decisive at this point only sets the
stage for problems later on.
!"#$%#&$'()(*+$,)(*-(./#0
Developing an outstanding staff starts with hiring good people
6 /" -
" 1
/"
Volume 5 Number 5
and then forming them into an All-star Team. Unfortunately, as

Jim Collins points out in his classic book, Good to Great, If you
have the wrong people on the bus, it doesnt matter whether you
discover the right direction; you still wont have a great company,3
or a great practice.
>VVi>>}iiLiiiii
bus, the key hiring principles then are:
U Attracti}i
By becoming the employer of choice for the best people and
conducting a wide-ranging search to locate them.
U Selecti}i
Through a rigorous selection process in which team members
participate in the decision to choose the right type of person, not
just the one with the right skills.
U Retaini}i
By using a well-designed training program with frequent feedback
and retaining the new employee only when you and your staff are
100% certain that he/she is right for the team. EP
References
1. Steedle JR (2011) Becoming the successful, not stressful practice:
*>q
}i}ìVOrthodontic Practice US 2 (2):
45-47.
2. Steedle JR (2010) Leading an all-star staff, J Clin Orthod, 44(8):
487-494.
3. Collins, J (2001) Good to Great: Why Some Companies Make the
Leap... and Others Dont>i
*Li] i9
1-/ /
" /
/
Materials & equipment

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

Enac Model OE-F15
New version of Logicon Caries Detector

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

cutters from KOMET
USA
Osadas latest model Piezoelectric

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

KOMET USA provide maximal
substance removal and virtually vibration-free, smooth operation
due to innovative, geometric toothing. Engineered for use on
non-precious metals and model cast alloys, the cutters are
particularly suited for techniques requiring efficient substance
removal, such as shape corrections and occlusal-surface
trimming. In addition, the cutters facilitate operation in
interdental and hard-to-access areas where working space is
limited. Easily identified by their golden shanks, laser marks, and
distinctive green rings, user-friendly NEX cutters are gentle to the
users wrist, facilitating tactile, intuitive operation.
For more details visit www.komet-usa.com.
Introducing the Evolution xR6 LED

dental operating microscope from Seiler
Versa Brush rotational utility brush for

a variety of endo procedures
The all-new illumination system comes with a 50,000 hour bulb

guarantee, which equates to nearly 20 years without changing a
bulb. Seilers LED is one of the brightest on the market with
nearly 80,000 LUX providing a clear, sharp image every time.
Seiler has developed the LED light to attain a 5800 Kelvin
temperature, which will remove the blue spectrum found in
many other LED lights.
The Seiler Evolution xR6 has truly revolutionized the way the
dental microscope performs and operates.
Seiler continues to stay at the forefront of fine optics and stands
behind their products with a lifetime warranty on the optics and
mechanics. To experience the Seiler advantage, call 1-800-4892282 to schedule a demo or visit www.seilermicro.com
In response to
growing demand
in the endodontic
c o m m u n i t y,
Vista
Dental
Products has just
reintroduced its popular Versa Brush, an incredibly strong and
bendable spiral utility brush that can be adapted to any low speed
rotary device. Exclusively available from Vista, the Versa Brush
is ideal for use in a wide variety of endo procedures including
removal of cement, post hole cleaning, and cleaning coronal
access openings. The Versa Brush is designed to fit a low speed
rotary handpiece for use at 250 rpm or less.
For more information, call 1-877-418-4782 or 262-636-9760 or
visit www.vista-dental.com.
Volume 5 Number 5
Diary
!"#$%&'%('%)*+,-%(,(.)
/01,&%
Dr. Jaime Morgan
September 2-9, 2012
Cabo San Lucas, Mexico
800-520-6640
2&&%(-,#$)2(34
Dr. Jorge Vera
September 7, 2012
Miami, FL
September 14, 2012
Salt Lake City, UT
November 2, 2012
Grapevine, TX
Dr. Joseph D. Maggio
September 7, 2012
Wichita, KS
September 28, 2012
Minneapolis, MN
October 5, 2012
Phoenix, AZ
October 12, 2012
Covington, KY
October 19, 2012
Des Moines, IA
Dr. John S. Olmsted
September 7, 2012
Amarillo, TX
September 28, 2012
Birmingham, AL
October 5, 2012
Westminster, CO
Dr. Garry L. Bey
September 7, 2012
Moorhead, MN
September 14, 2012
Little Rock, AR
October 19, 2012
Albany, NY
October 26, 2012
Bismarck, ND
Dr. Fred Barnett
September 14, 2012
Providence, RI
Dr. Thomas Jovicich
September 14, 2012
Albuquerque, NM
September 21, 2012
Houston, TX
October 5, 2012
Austin, TX
October 12, 2012
Seattle, WA
November 2, 2012
Fresno, CA
Dr. Brett Gilbert
September 21, 2012
Ft. Wayne, IN
September 28, 2012
St. Louis, MO
October 26, 2012
East Elmhurst, NY
Volume 5 Number 5
Dr. Garry Glassman

September 21, 2012
New Orleans, LA
October 5, 2012
Boston, MA
October 19, 2012
Novi, MI
800-395-9929
SybronEndoCED@sybrondental.com
/100%(-)5',%(-,6,')27,3%('%)
,()2(3434(-,')8+%0#"9
Dr. Sergio Kuttler
September 8, 2012
Honolulu, HI
October 5, 2012
Redding, CA
Dr. Ryan Facer
September 14, 2012
Boise, ID
Dr. George Bruder
September 14, 2012
Long Island, NY
Dr. Karam Ashoo & John Peters
September 14, 2012
Moncton, NB (Canada)
Dr. Diwakar Kinra
September 14, 2012
Seal Beach, CA
October 26, 2012
Cleveland, OH
Dr. Kevin Calzonetti
September 21, 2012
Kitchener, ON (Canada)
Dr. Jeffrey Coil
September 22, 2012
Regina, SK (Canada)
September 29, 2012
Parkville, BC (Canada)
Dr. Frank Cervone
September 28, 2012
Rochester, MN
October 12, 2012
Portland, OR
October 19, 2012
Milwaukee, WI
Dr. Donnie Luper
October 6, 2012
Cincinnati, OH
October 12, 2012
Atlanta, GA
November 2, 2012
Minneapolis, MN
Dr. Larry Farsakian
October 12, 2012
Concord, NH
Dr. Manor Haas
October 19, 2012
Montreal, QC (Canada)
October 26, 2012
Toronto, ON (Canada)
Dr. Troy McGrew
October 19, 2012
Seattle, WA
Dr. Michael Ribera

November 2, 2012
Pittsburgh, PA
800-662-1202 (press option 1)
Register.tulsadentalspecialties.com
:%&&4(&)46)-+%);4<(-10(=)
>4&,-,4(,(.)640)-+%)?1-10%
Dr. Dan Fischer & Carol Jent
September 14, 2012
Austin, TX
September 28, 2012
Dearborn, MI
October 13, 2012
Philadelphia, PA
November 2, 2012
Los Angeles, CA
www.ultradent.com
@%#$,A,(.)51''%&&),()
2(3434(-,'&B)C)5',%(-,6,')
C""04#'+
Dr. William Nudera
September 13, 2012
Bloomington, MN
800-662-1202 (press option 1)
>#-+<#9&)-4)51''%&&B)
2(3434(-,')!1-'4D%&)E#&%3)
4()5',%(-,6,')27,3%('%
Dr. Sergio Kuttler
September 14-15, 2012
Detroit, MI
Allen, TX
Dr. Donnie Luper
Naperville, IL
Dr. Frank Cervone
Modesto, CA
October 5-6, 2012
Rochester, NY
Dr. Troy McGrew
Lubbock, TX
Dr. George Bruder
October 5-6, 2012
Denver, CO
October 19-20, 2012
Wilmington, DE
Dr. Michael Nimmich
October 5-6, 2012
Richmond, VA
October 26-27, 2012
New Orleans, LA
Dr. William Nudera
October 12-13, 2012
Kansas City, MO
800-662-1202 (press option 1)
Ruddle on the radar

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here are many factors that influence the long-term retention

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

we compromised disinfection and the potential to fill root canal
systems. On the contrary, when the shapes were overprepared, we
invited root thinning, fractures, or strip perforations. The Holy
Grail of endodontic canal preparation is not too small, not too big,
just right.
Recently, the late Dr. Schilder, one of the greatest minds,
clinicians, and endodontic educators our profession has ever
witnessed, was attacked in absentia. In an astonishing published
statement that completely misrepresented Schilders classic article,
the dental author wrote, The big aggressive canal-flaring party is
officially over. He is apparently unaware of the strong relationship
that exists between general dentists and endodontists by further
stating, Restorative dentists can reclaim endodontics.*
In a recent dental publication, a CEO proclaimed that his
companys recently launched file really is unique because it has
a patented variable taper that at the top of the file is much more
conservative and allows for the preservation of cervical dentin to
a higher degree than any file system on the market.* There is
no scientific evidence to support this statement. For the record,
the ProTaper NiTi rotary file system came to market more than a
decade ago, offering a unique, patented, and decreasing percentage
tapered design over the active portion of a single Finishing file. In
other words, what the CEO claimed as innovative is exactly what
the ProTaper system brought to endodontics in 2001.
What the ProTaper development team recognized so many
years ago is that a file with a decreasing percentage tapered design
would conserve coronal and peri-cervical dentin and improve
flexibility compared to a file of the same D0 diameter and apical
one-third taper. For example, a 25/08 ProTaper Finishing file
has a tip diameter of 0.25 mm and an 8% fixed taper from D1D3. However, because the 25/08 ProTaper file has decreasing
percentage tapers from D4-D16, the D16 diameter is 1.05 mm vs.
a dangerous 1.53 mm if, in fact, this same file had a fixed taper of
8% over its entire active portion.
I have noticed that an increasing number of recently
launched products are marketed through unsubstantiated claims
or positioned as new discoveries. Clinicians need to make the
critical distinction between this marketing hype and the clinical
reality that predictably successful endo restorative treatment is
achieved through knowledge, skill, and experience, combined with
the integration of the most proven technologies and techniques
into everyday practice. Keep this on your radar! EP
*References available upon request.
Clifford J. Ruddle, DDS, FACD, FICD,

is founder and director of Advanced
Endodontics
(www.endoruddle.com),
an international educational source, in
Santa Barbara, California. Additionally, he
maintains teaching positions at various
dental schools. Dr. Ruddle can be reached at
info@endoruddle.com.
Volume 5 Number 5
TDO IS COMMITTED TO EDUCATION

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At TDO, we believe mentoring is

the best way we can give back to
the endodontic community. For a
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residents can join TDO Clinical, an
online forum where they can see
and participate in inspiring cases
and join in discussions between
top clinicians, educators, and
residents from around the world.
This EHR Module is 2011 compliant and has been certified by an ONCATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and
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PROMOTING EXCELLENCE IN ENDODONTICS

Helping people through comfortable, professional, and caring

A novel endodontic cleaning and shaping

The effectiveness of four irrigating

NATIONAL SALES/MARKETING MANAGER

Cliff Ruddle DDS

Toll-free: (866) 579-9496

Pierre Machtou DDS, FICD

DentalBanc discusses its payment

Three smart ways to upgrade

Cone beam CT and

RVG sensor technology

Hiring the right people

Materials & equipment

PROMOTING EXCELLENCE IN ENDODONTICS

Cover image courtesy of

treatment on a real patient at the end of my second year of dental

Reception area with hues, textures, and

so gratifying for me to be able to ease patients fears about their

Our attempt at the KISS principle and keeping

faced with choosing between root canal treatment and implant

We were fortunate to be able to provide our staff a spacious

Intense case discussions (i.e., whose turn is it to make dinner?)

I have published, taught at both the pre- and post-doctorate level,

Top Ten List

endex has a great accomplishment to celebrate in 2013 its

ensure Gendex excellence FOX (Focus-Optimized X-ray)

he goal of endodontic treatment is the prevention or treatment

Figure 1: Four-walled chamber, which contains irrigants and

determine the optimum apical size. Sizes smaller than 25 do not

Daniel Flynn, BDentSc, MFDS, RCSI, MClinDent,

Figure 4: Smear layer and debris present on dentin

power increases as the concentration increases, and a concentration

Figure 5: The effects of NaOCl and EDTA on dentin

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uccessful endodontics requires mechanical preparation of the

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

The working length (WL) was determined electronically as 22.5

He completed his undergraduate dental

training at the Royal London Hospital in 1994. He

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

One tough foam...

Figure 2: Preoperative radiograph

Introducing e-Foam Rotary HD

Figure 3: Postoperative radiograph showing lateral anatomy and

Joins the endodontic assistant

condensation technique as described by Schilder) with System

The Endoring II organizer enables the clinician to directly

Manufactured by Jordco, Inc.

To order, please contact your dental supply dealer.

To view a video on Jordcos new e-Foam Rotary HD

here is no doubt that radiography is one of the cornerstones

Figure 1: Long cone periapical image using a sensor holder

Figure 2A: Size 1 sensor shows

Figure 2B: Size 2 sensor shows

MSc, BChD, BSc, has extensive expertise

Figure 3A: Size 2 horizontal orientation

Figure 5A: Periapical of tooth No. 27

Figure 3B: Size 2

Figure 4A: Periapical of tooth No. 15

Figure 4B: Periapical

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