Tạp chí Nội Nha tháng 10 2013 Vol 6 No5

Tạp chí Nội Nha tháng 10 2013 Vol 6 No5 Một tài liệu hay và quý cho các bạn yêu thích bộ môn nội nha trong chuyên ngành răng hàm mặt. Một tài liệu hay và quý cho các bạn yêu thích bộ môn nội nha trong chuyên ngành răng hàm mặt. Một tài liệu hay và quý cho các bạn yêu thích bộ môn nội nha trong chuyên ngành răng hàm mặt.

clinical articles • management advice • practice profiles • technology reviews October 2013 – Vol No Top ten tips # Preparation techniques Dr Tony Druttman Endodontic treatment of curved root canal systems Dr John Bogle Practice profile Dr Peter A Morgan Corporate profile Carestream Dental PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR! S IT D ! RE DE C I E NS C I Get up to 38% More Image Area 38% more image area with ScanX size phosphor sensor Image area of popular rigid sensor with square corners “Cover the complete coronal to apical length and provides more mesial-distal information.” EXCEPTIONAL DIAGNOSTIC CLARITY • Up to 38%* more image area―capture every root tip (even on maxillary canines) Howard S Glazer, DDS FAGD UNMATCHED PATIENT COMFORT • Flexible, cordless phosphor sensors for easy, comfortable placement, even for third molars CONVENIENT CHAIRSIDE WORKFLOW • Easy for your assistant; efficient for you EXCELLENT DIGITAL RADIOGRAPHY • Get 100% of the images you want, even for patients with small mouths, large tori, or gag reflexes Ask for a Product Demo in Booth# 1719 @ ADA SMART INVESTMENT • Less expensive than rigid sensors (and no insurance needed) Digital Imaging Without Limits * An Independent, non-profit, dental education and product testing foundation: Issue 9, September 2011 To order please contact your local dealer For more information, visit www.airtechniques.com IMAGING UTILITY ROOM MERCHANDISE No in a Series ASSOCIATE EDITORS Julian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICD Richard Mounce DDS Clifford J Ruddle DDS John West DDS, MSD D EDITORIAL ADVISORS Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A Baumann Dennis G Brave DDS David C Brown BDS, MDS, MSD L Stephen Buchanan DDS, FICD, FACD Gary B Carr DDS Arnaldo Castellucci MD, DDS Gordon J Christensen DDS, MSD, PhD B David Cohen PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen MS, DDS, FACD, FICD Simon Cunnington BDS, LDS RCS, MS Samuel O Dorn DDS Josef Dovgan DDS, MS Tony Druttman MSc, BSc, BChD Chris Emery BDS, MSc MRD, MDGDS Luiz R Fava DDS Robert Fleisher DMD Stephen Frais BDS, MSc Marcela Fridland DDS Gerald N Glickman DDS, MS Kishor Gulabivala BDS, MSc, FDS, PhD Anthony E Hoskinson BDS, MSc Jeffrey W Hutter DMD, MEd Syngcuk Kim DDS, PhD Kenneth A Koch DMD Peter F Kurer LDS, MGDS, RCS Gregori M Kurtzman DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd BDS, MSc, FDS RCS, MRD RCS Stephen Manning BDS, MDSc, FRACDS Joshua Moshonov DMD Carlos Murgel CD Yosef Nahmias DDS, MS Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot DCSD, DEA, PhD David L Pitts DDS, MDSD Alison Qualtrough BChD, MSc, PhD, FDS, MRD RCS John Regan BDentSc, MSC, DGDP Jeremy Rees BDS, MScD, FDS RCS, PhD Louis E Rossman DMD Stephen F Schwartz DDS, MS Ken Serota DDS, MMSc E Steve Senia DDS, MS, BS Michael Tagger DMD, MS Martin Trope, BDS, DMD Peter Velvart DMD Rick Walton DMD, MS John Whitworth BchD, PhD, FDS RCS oes your endodontics leave the footprints you want? Does your endodontics distinguish who you are? Do your clinical endodontic skills set you apart? Are you the endodontist that you would want to go to? What are your “measurables?” NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595 In today’s marketplace, it’s not good enough to be good enough, to have convenient hours, or to send referring doctors staff lunches In order to earn the transfer of referral trust, we have to something different We have to deliver something that exceeds expectation How is this done? Listed below are 10 measurables that influence the endodontic referral and create endodontic value: Quality The first step in becoming a masterful endodontic clinician is to slow down When we slow down, we better endodontic finishes, and we create more value to our patients and referring doctors With greater value, we are worth more to the community, and a higher fee has been earned If your fees are justifiably higher, you have a choice to slow down The successful cycle then continues Slowing down and skillful endodontic mechanics have been the focus and hallmark of my current Endodontic Practice US series entitled Anatomy Matters What is your finishing checklist? What matters to you? Only start what you can finish well Most of us attempt to finish everything we start This is the risk of the growth phase of endodontics We have no time to finish anything well Our quality and standards go down, and what once set us apart has been lost Be your dentists’ advocate/ally Let them know they can be safe with you no matter how bad they may have had technical difficulties Tell them their success is your job You have their back Transfer of trust Your referring dentists and their patients have granted you trust Now you have to earn it Be accountable for your results Referring dentists want an endodontist who has no excuses Take full responsibility for a successful patient experience and treatment outcome Present alternate treatment plans Sometimes endodontists have tunnel vision or diagnose based on their own needs Dentists need the security and confidence that you will tell them and their patients WWIDIIWM (What would I if it were me?) Learn the parts of the endodontic interdisciplinary mind: biology, structure, function, and esthetics Know these domains as well as, if not better, than your referring dentists Practice team endodontics Discover what it is in your day that you enjoy the most, and more of that and less of what you don’t enjoy For me, I am lost in the moment or in the Flow when I am Cleaning, Shaping, Packing, or in Surgery (Flow, Mihaly Csikszentmihalyi, 1991 by Harper Perennial) Delegate tasks that you enjoy less to trained and skilled hands Exceed your referring doctors’ and patients’ expectations Perform at a level of competence, consistency, and confidence that exceeds the expectations of the dentist and patients Mentor an Endodontic Study Club This study club should be designed to collaboratively learn knowledge and to make consensus diagnoses and treatment plans It should not be about “getting referrals.” 10 Lead Leaders take people where they have never gone before Leaders keep their focus on the outcome they want in spite of pressure to otherwise They start with the answer PRODUCTION ASST./SUBSCRIPTION COORD Lauren Peyton Email: lauren@medmarkaz.com Tel: (480) 621-8955 Summary CE QUALITY ASSURANCE ADVISORY BOARD Dr Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com Tel: (480) 403-1505 MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Kay Harwell Fernández Email: kay@medmarkaz.com Tel: (386) 212-0413 EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com Tel: (727) 393-3394 DIRECTOR OF SALES | Michelle Manning Email: michelle@medmarkaz.com Tel: (480) 621-8955 MedMark, LLC 15720 N Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 Web: www.endopracticeus.com SUBSCRIPTION RATES year (6 issues) years (18 issues) $99 $239 © FMC, Ltd 2013 All rights reserved FMC is part of the specialist publishing group Springer Science+Business Media The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice or the publisher Volume Number If your endodontic practice is waning, does not represent you, if you are not as busy as you want to be, or you have lost the respect of your dentists, then commit to one, some, or all of these guidelines, and then observe the difference John West, DDS, MSD Founder and Director, Center for Endodontics, Tacoma, Washington Past President Academy of Microscope Enhanced Dentistry Past President of American Academy of Esthetic Dentistry Endodontic practice INTRODUCTION You are an endodontist: “how you measure up?” October 2013 - Volume Number TABLE OF CONTENTS Clinical Systematic adhesive core Practice profile Dr Peter A Morgan Hard work and attention to detail lead to smooth sailing in endodontics build-up Dr Ludwig Hermeler presents a clinical case using the Rebilda Post system 14 Case study Management of root resorptive lesions in maxillary incisors using computed tomography and MTA: 1-year follow-up Drs Anil Dhingra and Marisha Bhandari delve into the advantages of MTA and CBCT imaging 18 Endodontics in focus Top ten tips: Tip number Preparation techniques Continuing his series on endodontics, Dr Tony Druttman shows the importance of preparation 24 Corporate profile 12 Carestream Dental ON THE COVER A history of proven technology, a future dedicated to innovation Cover photo courtesy of Dr Ludwig Hermeler Article begins on page 14 For the August/September issue, the cover photo was courtesy of Dr Stanislav Geranin from Poltava, Ukraine Endodontic practice Volume Number simple, adaptable endodontic solutions A decade of success EndoREZ facts SaveS time For more than 10 years, EndoREZ has given you the ability to buy time When used conventionally, EndoREZ will be completely set in 30 minutes And when used with EndoREZ Accelerator, this time can be reduced to only minutes Compare this to the approximate 10-hour set time other sealers may require, and it’s clear: EndoREZ makes every RCT faster Unmatched hydrophilicity and adaptability EndoREZ contains a special hydrophilic organophosphate methacrylate monomer that increases its hydrophilicity and produces a resin with a strong affinity for moisture with resin penetration of 1200μ into the tubules EndoREZ penetrates into tubules and adapts to the walls like no other sealer on the market Don’t change your technique Make it easier with EndoREZ Scan to watch a short video about EndoREZ 800.552.5512 ultradent.com Use NaviTip to easily deliver EndoREZ to the entire anatomy of the canal in one step ©2013 Ultradent Products, Inc All Rights Reserved EndoREZ ® TABLE OF CONTENTS Practice management Growing the money tree William H Black, Jr discusses the financial advantages of having a good plan in place 48 Endospective One clinician’s means of obtaining patency and preparing the glide The big debate Continuing education Endodontic treatment of curved root canal systems Dr John Bogle offers some cases to treatment plan success for tooth retention .28 Root canal preparation: the path to success Dr Omar Ikram explains the principles of taper and apical preparation and how they relate to clinical practice .32 Endo essentials The big debate Drs Michael Norton and Julian Webber discuss — implants or endodontics? 36 Endodontic practice 36 Legal matters Harassment – crossing the professional line Dr Bruce H Seidberg discusses the consequences and complications of harassment 38 Product profile PROTAPER NEXT™ delivers performance refined 42 path Dr Rich Mounce discusses a method for obtaining patency and preparing the glide path with hand files 50 Anatomy matters “Could it all simply be a coincidence?” Part Dr John West considers the mysteries of endodontic success or failure 52 Industry news 56 Materials & equipment 56 Air Techniques’ all new ScanX Swift™ Digital imaging without limits 44 Practice development Apply current tax laws to improve patient care Bob Creamer explains Section 179 and Bonus Depreciation .46 Volume Number ORTHOPHOS XG 3D The right solution for your diagnostic needs Implantologists Endodontists Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement General Practitioners will achieve greater diagnostic accuracy for routine cases ORTHOPHOS XG 3D “With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, fractures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients Combine that with the metal artifact reduction software that reduces distortions from metal objects, my treatment process is a lot less stressful My patients benefit from the technology and my referrals appreciate the value.” ~ Dr Kathryn Stuart, Endodontist - Fishers, Indiana The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977 www.facebook.com/Sirona3D PRACTICE PROFILE Dr Peter A Morgan Hard work and attention to detail lead to smooth sailing in endodontics What can you tell us about your background? I grew up in a small town on the Allegheny River in Western Pennsylvania just 20 miles outside of Pittsburgh I attended the University of Pittsburgh for college and dental school Because it was during the Vietnam War, I had been deferred from military service, and so I entered the U.S Army after I graduated from dental school I was fortunate to have a very good dental internship at Fort Bragg in North Carolina and then spent additional years as a Captain in the U.S Army Dental Corps doing general dentistry at Fort McNair in Washington DC Why did you decide to focus on endodontics? Because of extensive exposure to oral surgery in the military, I originally thought of specializing in oral surgery However, as I approached the end of my Army service, I began to think about endodontics as I enjoyed saving teeth over extracting them I visited what was then the School of Graduate Dentistry at Boston University (BU) and met Dr Harold Levin He eventually became a mentor and my partner in practice We first met by chance when I walked into the school, and he was kind enough to take considerable time to explain the school and the specialty of endodontics to me I left that meeting with tremendous excitement about the possibility of having a career in endodontics and training at BU Not long after that, I was fortunate to have an interview with Dr Herb Schilder That led to a residency at BU, training under Dr Schilder and many other talented and dedicated endodontists who were teaching there at the time What training undertaken? have you I received a Certificate in Endodontics and a Masters of Science and served as Associate Clinical Professor at the school for many years I am a Diplomate of the American Board of Endodontics (AAE) I have served two terms as a Trustee to the American Association of Endodontics and am currently serving as a Trustee to Endodontic practice In sailboat racing and in practice, all members of the crew need to focus on every detail to get a good outcome the American Association of Endodontics Foundation I am currently the managing partner of North Shore Endodontics and Brookline Endodontics in Boston and suburbs It is my association with the AAE Foundation that has been a real eye opener to me on the real world of endodontics I have seen that there is a tremendous need for endodontic teachers in all of the dental schools and an equally important need for research to further our understanding of the biological and technical processes that affect the outcome of the care we deliver This revelation has only been topped by the fact that the Foundation funding to date has been a result of a tremendous outpouring of support from endodontists and from corporate partners who see the commitment our endodontist members make and value their judgment The Foundation is the only organization exclusively dedicated to supporting endodontic research and education It provides support to every endodontic residency program in the U.S and Canada The Foundation provides over million dollars yearly to support research and faculty positions in endodontics Who has inspired you? Dr Schilder was the best teacher I have ever encountered He was exceptionally smart, very demanding, and capable of explaining complex concepts in a clear way His educational protocol allowed for little deviation from his prescribed technique I have realized the tremendous value of this approach on countless occasions in my career when faced with difficult diagnostic and treatment cases Herb knew that the oddities of anatomy and biology were looming out there By giving his residents a solid understanding of diagnosis and disciplined treatment objectives, he equipped us for the real world of endodontic practice Herb trained clinicians in an era when the specialty of endodontics was just beginning to grow Dr Schilder’s legacy continues at BU through the BU Endo Alumni Association, which provides a forum for all BU trained endodontists to collaborate Tell us about your practice My career in practice began when I joined Dr Harold Levin and Dr Robert Rosenkranz Over many years together, we grew the practice to a multi-office, multidoctor practice Both of those doctors have retired from practice, and I am now fortunate to have Dr Yuri Shamritsky and Dr Fiza Singh as partners Together we have continued to grow the practice, which Volume Number What is the most satisfying aspect of your practice? There are many aspects of Endodontic Volume Number practice that I find satisfying The most rewarding feeling by far is the satisfaction of meeting a patient with significant symptoms that are life-interrupting and reversing those symptoms quickly and painlessly Every endodontist experiences this, and I hope they all realize what a unique service it is in the health care world It is very common in our offices for an emergency patient to be seen very soon after we get the call from his/her dentist Not long after that, members to take responsible roles in the practice We have a great team, and I am very proud of them The leader of our staff team is our Practice Manager, Michele Whitley Michele and other staff members have taken an active role in continuing education by presenting courses at the AAE Annual Session and at other CE venues Holly LeBlanc, another staff member, has served as a consultant to EndoVision Dr Andrew Bradley Dr Andrea Chung Shah Partners: Dr Yuri Shamritsky, Dr Fixa Singh, and Dr Peter Morgan Dr Paul Talkov we complete the emergency treatment At a subsequent appointment, the patient returns with gratitude for having had his/ her very significant problem resolved painlessly Patients benefit greatly from the skill of their endodontist, and the model of how we move patients between offices in response to patient need is a model that should be more frequently found in health care Professionally, what are you most proud of? I am very proud of our practice While I know that group practice is not for everyone, it has been a very favorable format for my partners and me Because we have a group of doctors, we have the opportunity to share ideas and to collaborate on cases Because we are bigger, we have more staff, and they also bring new ideas and capabilities to the table The biggest gains in our business management have come about as a result of empowering our staff Dr Morgan and two of his key team members, Cheryl Bennet-Delong and Jennifer Hamlett This involvement in the larger world of endodontics outside our practice walls empowers our staff to bring back to our practice innovative ideas they develop in collaboration with colleagues at these educational sessions As AAE Annual Session chair some years ago, I stressed Endodontic practice PRACTICE PROFILE now includes six offices Dr Yuri Shamritsky began his dental career with a Doctor of Dental Science from the University of Moscow In the U.S., he continued his dental education at Boston University Goldman School of Dental Medicine where he received a DMD and a Certificate of Advanced Graduate Studies He served for over 10 years as Associate Clinical Professor and Director of the Microendodontic Surgical Program Yuri has inspired many students by his dedication to precise microsurgical techniques, and he has applied his skills to resolve many problems for his patients in our practice Dr Singh received her Doctorate of Dental Surgery from New York University College of Dentistry She holds a Certificate in Endodontics, a 3-year specialty fellowship from The Harvard School of Dental Medicine, and Masters of Medical Sciences from Harvard Medical School, including years of research at The Forsyth Institute Her specialized training includes Oral Implantology and Oro-Facial Musculoskeletal Pain/TMD Disorders from the New York University College of Dentistry Dr Singh is also board certified in Endodontics in Canada, where she is a member of the Royal College of Dental Surgeons We are also fortunate to have the following doctors in our practice: Dr Paul Talkov, who completed his dental school at Tufts University and endo residency at Boston University Goldman School of Dental Medicine Dr Andrea Shah, who completed her dental school at Harvard University and endo residency at Tufts University While a resident, she was recipient of a Research Grant from the AAE Foundation Dr Andrew Bradley, who completed his dental school at Tufts University and endo residency at Boston University Goldman School of Dental Medicine We are very proud to have Dr Schilder and Dr Joe William’s former practice, Brookline Endodontics, as a part of our current practice Many of the doctors in our practice had the benefit of Dr Schilder’s teaching during their training Continuing his treatment philosophy in the office where he practiced has been very professionally rewarding for us PRACTICE PROFILE Michele Whitley, practice manager and Dr Peter Morgan, managing partner Dr Morgan and his team taking a break at the EndoVision booth, from presenting at the AAE Annual Session in San Antonio the need to incorporate more staff educational courses in our programs to fulfill this objective What is practice? unique about your I believe our practice is unique It was started in Lynn, Massachusetts in 1962 by Dr Harold Levin At that time he was the only endodontist between Boston and Montreal, Canada That has changed of course, and now there is competition for almost every endodontist no matter where they practice What makes us unique is our multi-office format Because of this, while we face competition, we stay busy in many locations The key to business success is having a full appointment book This is our way of helping that to be true What systems you use? I have been fortunate to practice in the time of the evolution of technology in endodontics We all appreciate the teaching and patient education advantage of digital X-ray However, to really appreciate it, you have to have worked for years with film As I tell my patients, in the past I would look at the little X-ray films and tell the patients that they needed a root canal Now I enter the room and the image is already on the big monitor, and the patient often says to me, “I guess I need a root canal.” We started with Schick digital X-ray in 1998 We made a big commitment to equip all of our locations at that time It was immediately very helpful clinically and provided a “WOW factor” for patients as they had never seen such a thing before Endodontic practice Our relationship with Schick continues today and has led us to an equally rewarding relationship with Sirona We followed the integration of digital X-ray with conversion to EndoVision and an Electronic Health Record (EHR) EHR is certainly the current standard for records, and we find it to be essential for a multi-location practice Because we have multiple doctors, we have loyalties to both Global and Zeiss operating microscopes, and surprisingly we have all become comfortable with both More recently, we have opened our eyes even wider with the incorporation of the Sirona XG3D CT scan machine This technology has provided exceptional value to our patients by giving us more information than ever before from which to make treatment decisions The XG3D by Sirona provides a remarkably clear cm X cm focused field which is truly the current “WOW!” in 3D imaging The availability of this technology has enhanced our relationship with referring dentists because they repeatedly see the value of the informed treatment decisions we can make in retreatment, surgical, resorption, and unusual anatomy cases My partner, Dr Shamritsky and I recently had the opportunity to attend a Sirona/Sicat opinion leaders conference in Bonn, Germany I was very impressed with the application of the XG3D CT technology to the creation of surgical guides This has the potential for application in endodontics as well as in implant placement and the creation of precision prostheses Another recent addition to our practice is a marketing tool, the Endofone App This is essentially an electronic business card that uses smart phone technology to inform our patients about our practice Accessed via a QR code, patients can instantly learn about us and get all of the essential information about us on their smart phone without having to go to the web site These technologies help us, but I believe it is more important than ever for all endodontists to focus on true clinical skills There is a saying, “It is a poor carpenter who blames his tools.” Herb Schilder and many of the great early endodontists did not use a microscope or digital X-ray Yet they were instrumental in establishing many of the treatment methods we still use today They showed cases then that would rival any case done today with enhanced vision and rotary instrumentation I believe the future of endodontics will depend on endodontists defining the value of consistent predictably successful cases for their patients If endodontics is defined by equipment and technology, it will allow anyone with that equipment and technology to claim the high ground What has been your biggest challenge? I think the most successful practices are those that know how to change to meet the challenge of the changing market for our services The model used by my partner, Dr Levin, when he started the practice, may not be the model for success today The single practitioner then had more patients than the doctor could manage They were often begging the endo department chairs to send them their next graduate Today’s single practitioners had better find an area in need of an endodontist, or they will not have a busy schedule In addition, starting a practice today requires Volume Number PRACTICE DEVELOPMENT Apply current tax laws to improve patient care Bob Creamer explains Section 179 and Bonus Depreciation T hriving dental practices understand that patients are the lifeblood of the dental practice Indeed, without patients, a dental practice does not exist Success is therefore determined by the quality of patient care provided and the overall patient experience In the last decade, we have seen many important and amazing advancements in dental equipment that have assisted dentists in the delivery of ultimate patient care One of the newest, but well-proven advancements is with 3D CBCT technologies Investing in equipment and technology upgrades can provide a number of benefits for your practice – a competitive advantage, expanded services, improved efficiency, and overall patient comfort These advantages can certainly make a difference to your bottom line, especially when you incorporate significant tax incentives for investing in your practice and yourself In recent years, we have enjoyed a series of tax laws enabling dentists to take accelerated tax deductions when purchasing equipment and technology A couple of tax code provisions that have been very beneficial to dentists are known as Section 179 and Bonus Depreciation Both provisions allow for accelerated deductions even when purchases are financed These laws are so advantageous that I am often asked, “Should I purchase some new equipment this year to help reduce taxes?” I trust their true objective in upgrading their practice is not to simply create a tax deduction, but rather to provide better services and improved care Patients recognize and appreciate the dentist who makes patient care the focal point of the practice During the recent Bob Creamer, CPA, is president of the accounting firm Creamer & Associates, PC, specializing in financial and retirement planning, dental transitions, practice enhancement, wealth creation, tax savings and related services He is also a founding member of the Academy of Dental CPAs Bob can be reached at 800-248-1120 or Bob@bestcpas.com 46 Endodontic practice struggles in our country’s economy, I witnessed that dentists who invested in their practices to improve the quality of care they provided, attracted a loyal patient following and a market share that continued to increase even while others struggled It is with these practices that patients were willing to spend their precious dental dollars However, investing in the practice provides a reward for dentists far beyond income and tax deductions – the peace of mind of knowing that they are delivering the highest level of patient care possible Section 179 and Bonus Depreciation Section 179 of the IRS Tax Code was introduced as a way to stimulate the economy by allowing business owners to deduct the full cost of a qualified asset in the year it is acquired, rather than spreading deductions over the normal depreciable life or many years During its early years, Section 179 allowed a maximum accelerated tax deduction of $10,000 to $24,000 This amount has varied as needed to spur Volume Number economic growth, and was increased to a very generous $500,000 maximum deduction in 2010 and 2011 That amount dropped to a $139,000 deduction for 2012, but was retroactively raised after the first of this year back to $500,000 for tax calculation purposes for 2012 Additionally, the maximum deduction for Section 179 for 2013 was originally set at $25,000 However, during Congressional wrangling early in the year to address the ominous “fiscal cliff” predictions, Congress adjusted the law to again allow a maximum Section 179 deduction in the amount of $500,000, with a spending cap of $2,000,000 before phase-outs begin Looking ahead, the law as currently written (as of the writing of this article) has deduction limits scheduled to drop all the way down to $25,000 for 2014, unless Congress acts to change the law and keep the deduction limit elevated Therefore, there may be a drastic reduction in deduction limits for those who wait until next year to make their purchases Section 179 provides tax incentives for purchasing both new and used equipment and technology The complementary Bonus Depreciation provides incentives for new purchases only For new equipment and technology purchases in 2013, a dentist can take a 50% Bonus Depreciation deduction on all purchases without purchase limitation While Section 179 has a $2,000,000 cap with a dollar phase-out for every dollar spent over the cap, Bonus Depreciation has no spending cap Unlike Section 179, which is scheduled to simply be reduced, Bonus Depreciation is currently scheduled to end on January 1, 2014 Today’s tax laws allowing accelerated deductions have led many dentists to rightfully consider them as a key aspect of their yearly tax and financial planning As the tax rates continue to increase, there is greater incentive to invest in yourself and your practice In addition to tax laws that make practice investments attractive and accessible, historically low interest rates on equipment loans have made it easier to incorporate practice upgrades that may have seemed out of reach just a few years ago While today’s accelerated tax deductions can be highly advantageous from a business perspective, they are not permanent as I have already illustrated When considering the forthcoming expiration or reduced deduction laws, and the recent significant tax rates increases for those making $250,000 or more, it certainly makes sense to invest in equipment and technology where needed When you couple this with low interest rates, which may soon be on the rise, there seems to be a window of opportunity for dentists to make their purchases during 2013 I strongly advise my doctors to invest in their practices and purchase equipment and technology, provided it’s for the right reasons After all, it is not tax rates, accelerated tax deductions, or even low interest rates that determine whether or not you need to invest in your practice, it’s the need to continually take extraordinary care of your patients So if you need to invest to deliver the care you desire, why wouldn’t you take advantage of Section 179 and Bonus Depreciation to help you accomplish your professional goals? It only makes great sense! EP Volume Number Endodontic practice 47 PRACTICE DEVELOPMENT Patients recognize and appreciate the dentist who makes patient care the focal point of the practice During the recent struggles in our country’s economy, I witnessed that dentists who invested in their practices to improve the quality of care they provided, attracted a loyal patient following and a market share that continued to increase even while others struggled It is with these practices that patients were willing to spend their precious dental dollars However, investing in the practice provides a reward for dentists far beyond income and tax deductions – the peace of mind of knowing that they are delivering the highest level of patient care possible PRACTICE MANAGEMENT Growing the money tree William H Black, Jr discusses the financial advantages of having a good plan in place Y our practice is established You have a good reputation and a good management team in place Gone are the days of building the practice and putting all profit back toward growth That’s the good part! But success creates other questions and concerns When clients first come to us they typically have the same refrain: “I am paying salaries, sick pay, vacation pay, major medical, matching Social Security and Medicare, paying into unemployment and Workman’s Comp I have to pay a lot of money in income taxes…How I keep more of what I make? No one has any solutions for me!” What I’ve found clients really mean is they want an idea that is not “outside the box,” that won’t increase their audit profile, an idea that won’t get them in trouble with Internal Revenue The simple answer is to consider a custom-designed qualified plan! In other words, consider a form of a pension plan (known as “qualified” because the contribution qualifies for an income tax deduction) Think about it this way: there is not a company on the New York Stock Exchange, a union, or government agency that doesn’t have a pension plan So using the rules that are on the books to create a custom-designed plan for the closely held professional practice may be the answer • Plan assets grow tax deferred • Plan assets are protected from judgment creditor claims1 • Plan assets are eligible for tax-free rollover to one’s IRA account • Qualified plans receive up-front approval from Internal Revenue in the form of a Favorable Determination Letter Let me clear up a few myths straightaway These plans are not about retirement; they are about the tax benefits and asset accumulation features, i.e., your money tree Who’s worried about retirement? It’s the employees putting $25 a week into their 401(k) plan More power to those employees, but we, as business owners, are past that Look at a plan as a way to pay yourself on a tax-favored basis! Here is how to look at the merits Assume a 39% federal income tax rate and assume a 6% state income tax rate So, for brevity, we will assume an overall tax rate of 45% Since there is no requirement to have a plan, what does it look like without one? For every $10,000 in taxable income, what does it look like with a plan or without one? (We use $10,000 in this analysis because it is scalable Want to know what $50,000 would do? Multiply by $75,000? Multiply by 7.5, etc.) Here is where it gets interesting On one hand you have $10,000 working for Consider the benefits: • Contributions are income tax deductible William H Black, Jr has been in the pension administration business for 34 years The firm Pension Services, Inc administers both defined contribution and defined benefit plans, employs an ERISA attorney, an Enrolled Actuary, and complete clerical staff Mr Black is qualified to give continuing education to CPAs in 47 different states He has spoken nationally and internationally on retirement plans, has been quoted in USA Today, written articles for several industry journals and has appeared on many financial radio shows discussing the topic of retirement and financial matters He may be contacted at bill@pensionsite.org 48 Endodontic practice you; on the other, you have $5,500 The tax benefits alone give you 81% more (10,000 ÷ 5,500) right out of the gate Now, consider the plan’s assets grow tax deferred while the non-plan grows taxably Add it all together, and you can see the benefits growing with every passing year! Many believe, initially, that the plan will cause all employees to come in, with contributions for all, and any employee is entitled to take his/her contribution out immediately While plans like that exist, they are not well designed or well thought out ERISA, the Employee Retirement Income Security Act of 1974, gives us 39 years of instruction on how to design a plan In other words, these plans are black and white, really no gray area Now the question becomes how to design a plan to benefit the rainmaker? That is the easy part! Many different options exist, hence the need for customization Many “cookie cutter” plans are out there, a one-size-fitsall approach These are commonly referred to as “bundled” plans While those plan designs have their place, they cannot be all things to all people What to do? Start with a checklist of basic questions What is the annual budget for the contribution? How is the business set up, as a Corporation either Without a Plan With a Plan Taxable Income $10,000 $10,000 Tax at 45% $4,500 $0 After-tax Balance $5,500 $10,000 Comments on graph: • No tax on the “with a plan” column as the contribution is income tax deductible • After-tax balance is as of the present day In the future, monies coming out of an IRA or qualified plan are subject to ordinary income taxes • The chart does not take into account asset protection benefits • This is scalable Considering a $50,000 contribution? The values are five times as much, etc Volume Number us they typically have the same refrain: “I am paying salaries, sick pay, vacation pay, major medical, matching Social Security and Medicare, paying into unemployment and Workman’s Comp I have to pay a lot of money in income taxes…How I keep more of what I make? S or C, as an LLC, LLP, PA, Partnership, or Sole Proprietor? How many employees? Are there existing plans in place now? How is the ownership structured, all in the hands of one person, or two or more? With the above, and an employee census, i.e., employee names, dates of birth and dates of hire, job titles and annual salaries, a projection can be created that will show, in black and white, what the benefits and detriments are Look at it in conjunction with your CPA and make a business decision on what is right for your situation EP This discussion is not intended as tax advice The determination of how the tax laws affect a taxpayer is dependent on the taxpayer’s particular situation A taxpayer may be affected by exceptions to the general rules and by other laws not discussed here Taxpayers are encouraged to seek help from a competent tax professional for advice about the proper application of the laws to their situation References Patterson v Schumate (http:// financial-dictionary.thefreedictionary.com/ Patterson+v.+Shumate) Volume Number Endodontic practice 49 PRACTICE MANAGEMENT When clients first come to ENDOSPECTIVE One clinician’s means of obtaining patency and preparing the glide path Dr Rich Mounce discusses a method for obtaining patency and preparing the glide path with hand files U sing hand files correctly to negotiate canals and prepare a glide path is often the difference between an excellent clinical result and one less so Intelligent hand file use allows the clinician to fully appreciate canal anatomy and guide subsequent treatment For example, learning canal curvature, length, and calcification through proper hand file exploration, the clinician can decide to subsequently use a crown down or a step-back approach, reciprocated nickel-titanium methods, or a hybrid of these Intimate canal knowledge via tactile feedback gained from hand files is also the first and most important step in reducing iatrogenic misadventure This column was written to discuss one method (among many valid clinical approaches) for obtaining patency and preparing the glide path with hand files to provide the benefits above Obtaining patency is dependent on correct orifice management Optimal tactile and visual control of the orifice requires straightline access and includes removal of the cervical dentinal triangle and eliminating restrictive coronal third dentin This action provides unrestricted hand file access to the point of first canal curvature — the hand file reaches the first canal curvature without deflecting off canal walls Benefits of straightline access and early restrictive dentin removal in the coronal third include less canal blockage and transportation, greater tactile control, and easier apical negotiation Once straightline access is prepared, and the cervical dentinal triangle removed, pre-curved stainless steel hand files (in this approach utilizing Mani® K files and D Finders) are inserted to begin negotiation Given the resistance to apical hand file Rich Mounce, DDS, is in full-time endodontic practice in Rapid City, South Dakota He has lectured and written globally in the specialty He owns MounceEndo, LLC, marketing the rotary nickel-titanium MounceFile in Controlled Memory© and Standard NiTi He can be reached at RichardMounce@MounceEndo.com, MounceEndo.com Twitter: @MounceEndo 50 Endodontic practice advancement, the clinician can determine if the canal is easily negotiable, how much pressure is needed to advance, what hand file size, length and type are needed, and what canal curvature is present based on the shape of the stainless steel hand file that emerges upon removal In essence, the tactile feedback received during initial hand file insertion tells the clinician what steps are required to negotiate the canal For example, to use a longer or shorter hand file, a larger or smaller one, a stiffer or more flexible file, etc In my hands, the first hand file used to negotiate most canal is either a pre-curved stainless steel Mani D Finder Nos 8, 10, 12, 15, or a Mani hand K file Nos 6, 8, 10, 12, or 15 The hand file type, tip size, and length are dependent on the degree of curvature, calcification, and length of the canal The smaller and more complex the Using hand files correctly to negotiate canals and prepare a glide path is often the difference between an excellent clinical result and one less so curvature, the smaller the hand file used in initial negotiation The less complex the canal, the larger the first file used Mani D Finders are designed for negotiation of calcified canals They allow more vertical pressure to be placed upon them than K files without deformation If the clinician has estimated a preoperative working length from the initial radiograph, once this length is reached, the electronic (true) working length should be determined Often, a tactile “pop” of the hand file can be felt as the minor constriction of the apical foramen is reached Optimally, irrigation should follow every hand file insertion, and all hand file work takes place in the presence of irrigation and lubrication Clinically, once the electronic working length is determined, if the first file that reaches the MC is tightly bound, the canal can be enlarged manually, or the file reciprocated with the W&H WA 62A reciprocating hand piece attachment The W&H WA 62A attachment fits on an endodontic motor with an E type coupling Reciprocation of hand K files and NT Mani Flare Files is safe, effective, and easily accomplished Reciprocation reduces hand fatigue and is efficient relative to hand filing Clinically, if the first file is tightly bound at the MC, once reciprocated adequately, it should spin freely at the MC The next larger file is then reciprocated, etc Sequentially, once the canal is enlarged to a minimum size No 15 Mani hand K file, 05 tapered nickel-titanium (NT) Mani Flare Nos.15 and 20 files can be used as needed to complete the glide path Mani NT Flare files can be safely reciprocated Such a glide path provides an optimal platform for subsequent rotary nickel-titanium canal enlargement After preparing the glide path, while many methods are available for bulk canal shaping, one deserves a special mention in the context of canal negotiation, glide path creation, and canal preparation, the versatile 08/25 MounceFile (MF) CM instrument It acts as both an orifice opener and canal shaper The MF 08/25 CM can reach the apex of many canals without the use of additional rotary instruments In essence, this instrument often connects orifice enlargement and canal shaping (after the glide path is prepared) without involving complex sequences of additional instruments, in part because of the benefits of CM technology CM technology allows the file to remain curved as it rotates through the canal, instead of exhibiting shape memory as other nickel-titanium instruments — an action that both reduces fracture risk and transportation, and improves cutting ability In the near future, a new reciprocating NT system will be introduced, the MounceFile “RStar” instruments, which can be used alone or in combination with MounceFile CM instruments to enlarge canals once the glide path has been prepared I welcome your feedback EP Volume Number THE NEW STANDARD I N E N D O D O N T I C I N S T R U M E N TAT I O N ™ Standard NiTi $25* Controlled Memory NiTi $35* NiTi Flare Files Combining outstanding flexibility and strength, the Mani NiTi Flare hand files are available in a 05 taper, in sizes 15-40 in 21 and 25 mm lengths Pricing from $18.95* *Pack of instruments, limited time offer, minimum purchase quantities apply, please call for this pricing and details Aseptico We are a fully authorized Aseptico dealer and carry the entire line of Aseptico motors and handpieces at significant savings Stropko Irrigators The Stropko irrigator can be used in every dental procedure to assure a gentle and effective stream of water and/or air for superior and efficient cleaning and drying of any surface or working area The Stropko easily adapts to old or new air/water dental syringes Priced at $75 EFFICIENT, SAFE, ECONOMICAL MounceFiles are proudly manufactured in America MounceEndo, LLC | Rapid City, SD, USA 57701 | 605.791.7000 | info@MounceEndo.com | www.MounceEndo.com ANATOMY MATTERS “Could it all simply be a coincidence?” Part Dr John West considers the mysteries of endodontic success or failure Introduction It is fascinating to me that after seven “Anatomy Matters” articles in Endodontic Practice US about the incidence and examples of underfilled endodontic portals of exit in endodontic failure that no one has written a challenge to my case reports After all, these have not been randomized controlled studies that I have submitted They are case reports of my patients of record They could have been called anecdotal, bias, tunnel vision, or even self-serving Indeed, there is a contrarian and adamant thinking in the endodontic literature that sterilization of the root canal system is currently technically impossible, and therefore, there are certain patients who simply will not heal It has been further suggested over the years, and even currently, that some patients’ root canal treatments are considered “mysterious failures.” I will tell you that I would be the first to say that it is impossible to achieve endodontic success every time But how close can we get, and to what degree we influence our getting there? We cannot control all the variables; the least of which are the host and host resistance to bacteria The other control and the biggest variable of all is the clinician How thorough are we? Do we control our practice size? In other words, we only START the number of endodontic treatments that we can FINISH well? Or we attempt to FINISH everything that we START If our practice style is the latter, then the entire Anatomy Matters conversation and examples are of little interest or significance These are columns that have been designed to ask a different question: Not “What is good enough?” but rather “What is possible?” After being a clinician and an endodontic educator for over 35 years, I have been humbled a few times…quite a few times However, my humbling has not been failure of the biology but failure of my capacity to treat the biology Or maybe it has been a failure from time to time to be willing to treat the biology…to slow down even more…to schedule another session where there are no adjacent patients, and we have a fresh start If there were several Figures 1A-1F: Staightforward case Nothing special, just predictable healing Figure 1A: Pretreatment mandibular right molar with apparent LEO Figure 1B: Clinical of buccal sinus tract Gingival crevice probes within normal limits Figure 1C: Radiographic image of gutta-percha cone tracing sinus tract Figure 1D: Perpendicular pack image demonstrating four canals and multiple POEs filled Figure 1E: Oblique image of Figure 1D Figure 1F: Clinical image of healed sinus tract at 6-month posttreatment Patient scheduled for cuspal coverage John West, DDS, MSD, the founder and director of the Center for Endodontics, continues to be recognized as one of the premier educators in clinical and interdisciplinary endodontics Dr West received his DDS from the University of Washington in 1971 where he is an affiliate associate professor He then received his MSD in endodontics at Boston University Henry M Goldman School of Dental Medicine in 1975 where he is a clinical instructor and has been awarded the Distinguished Alumni Award Dr West has presented more than 400 days of continuing education in North America, South America, and Europe while maintaining a private practice in Tacoma, Washington He co-authored “Obturation of the Radicular Space” with Dr John Ingle in Ingle’s 1994 and 2002 editions of Endodontics and was senior author of “Cleaning and Shaping the Root Canal System” in Cohen and Burns 1994 and 1998 Pathways of the Pulp He has authored “Endodontic Predictability” in Dr Michael Cohen’s 2008 Quintessence text Interdisciplinary Treatment Planning: Principles, Design, Implementation, as well as Dr Michael Cohen’s soon to be published Quintessence text Interdisciplinary Treatment Planning Volume II: Comprehensive Case Studies Dr West’s memberships include: 2009 president and fellow of the American Academy of Esthetic Dentistry, and 2010 president of the Academy of Microscope Enhanced Dentistry, the Northwest Network for Dental Excellence, and the International College of Dentists He is a 2010 consultant for the ADA’s prestigious ADA Board of Trustees where he serves as a consultant to the ADA Council on Dental Practice Dr West further serves on the Henry M Goldman School of Dental Medicine’s Boston University Alumni Board He is a Thought Leader for Kodak Digital Dental Systems, and serves on the editorial advisory boards for: The Journal of Esthetic and Restorative Dentistry, Practical Procedures and Aesthetic Dentistry, and The Journal of Microscope Enhanced Dentistry Visit www.centerforendodontics.com, or email: johnwest@centerforendodontics.com, phone 1-800-900-7668 (ROOT), fax 253-473-6328 52 Endodontic practice canals, maybe I could finish the ones I can, and by later “dividing and conquering,” I could focus on a single canal for as long as it took Someday within the next 15 years, approximately, research suggests that we will be able to grow a biomimetic and/or biological tooth that is structural, functional, and esthetically successful At some point, we probably all have a time where we give up What Anatomy Matters is all about is to stretch that point to a level that perhaps we did not think possible Then we have created a new standard for ourselves I made up a quote some time ago that goes like this: “If it’s been done before, it’s probably possible.” If we have done it before, then we know it is possible Following are four examples of patients where, once again, it cannot be proven that the anatomy matters or that it mattered in order to heal Without a control, it may simply be an observation You be the judge Patient No 1: “Straightforward case Nothing special Just predictable healing.” (Figures 1A-1F) This patient presented with a buccal sinus tract, a nonvital pulp, and a gingival crevice that probed within normal limits The diagnosis was lesion of endodontic origin Volume Number Patient No 2: “Good enough, or what’s possible?” (Figures 2A-2D) This patient is referred with slight palpation tenderness buccal to mesiobuccal root of maxillary right first molar What would you do? Try this scenario: what if the crown were the third attempt at matching this patient’s high smile-line esthetics, what if the post were bonded, and what if the patient were a top Microsoft executive and wants the most efficient, noninvasive, most predictable treatment? What if the referring dentist told you that there is minimal ferrule, and that is why the post was chosen to help hold the foundation, and the dentist was concerned that a nonsurgical retreatment would cause micromovement in the crown that could later cause microleakage? Also, what if the dentist did not want you to risk reducing any of the marginal ferrule in a new access? Most of us would think twice about nonsurgical retreatment, especially if the endodontics were 20 years old Maybe the palatal and distobuccal have demonstrated that they will be successful for another 20 years, and all you have to is surgically bevel, prep, and seal the MB underfilled system But what about the unfilled second MB canal that is suggested by the MBD radiographic rule Volume Number Figures 2A-D: Good enough or what’s possible? Figure 2A: Pretreatment image of maxillary right first molar MB area is palpation tender with no swelling Figure 2B: Posttreatment image demonstrating two MB canals sealed, correction of internal palatal transportation, and several DB portals of exit discovered on packing Figure 2C: Oblique posttreatment image of Figure 2B Figure 2D: Three-month nonsurgical retreatment posttreatment Patient is asymptomatic, and lamina dura and periodontal ligament are beginning radiographic repair Next 6-month post care visit scheduled to validate complete healing MAX-I-PROBE ® ENDODONTIC/PERIODONTAL IRRIGATION PROBES The irrigating probe confirmed THE BEST in the Journal of Endodontics “ the Max-i-Probe removed significantly more bacteria the unique side vent of these safety-ended needles produces upward turbulence that enhances complete cleaning of root canals.“ — Journal of Endodontics, Vol.33, No 6, June 2007 FREE SAMPLE AT WWW.RINNCORP.COM ‘Closed-end’ generic probe Others claim a closed tip, but a microscope may reveal a much different story Max-i-Probe The RINN Max-i-Probe tip is welded closed to protect your patient from fluids expressing past the apex Endodontic practice 53 ANATOMY MATTERS and nonsurgical endodontics treatment planned The sinus tract closed days after access and cleaning After packing, I count four canals and eight POEs filled Please be aware that I am exceedingly liberal about the number of foramina that I count and consider visibly sealed, but I have a fair amount of experience reading endodontic images relative to interpreting actual ToothAtlas.com teeth during studies identifying optimal cleaning solutions and protocol The sinus tract and LEO continue healing at 6-month posttreatment I am thinking right now that most of the clinicians reading this article would agree the shapes are appropriate in design and size for the root that surrounds them But what is intriguing to me is how important does each of you think the perpendicular pack film looks? Honestly, I suspect I could have cemented four single cones without any compaction and gotten the same clinical and radiographic result But what might have happened a decade from now? I am not so sure At some point, we have done enough We just never know where that point is, and so my premise of Anatomy Matters stands: all you can, and then plan on doing it even better in your future.2-8 ANATOMY MATTERS and verified with a CBCT image? What if the crown was loose, or caries and new crown were planned? What if you knew the post was cemented with zinc phosphate cement? Most of you would treatment plan a nonsurgical retreatment The biologic, structural, and esthetic options must always be weighed and have to be patient appropriate Then the option with the most treatment value should be offered to the patient, and let him/her make an informed decision along with your coaching Of course, you should always privately and publically tell the patient WWIDIIWM (What would I if it were me?) Herein is always the proper answer And so, while the crown was not loose in this particular patient, I did review the pluses and minuses of nonsurgical versus surgical I also allowed the patient the options of treating the MB system alone or removing the post if I could and retreating the entire root canal system The patient chose to have me retreat the entire tooth, and I was content with that choice, though I could have supported him choosing just the MB system or surgery I think the patient made the best option with the greatest value Who knows what anatomy will have been significant? And who knows how long this patient will live? Sometimes we forget time as a major consideration It has been suggested by scientists, doctors, and futurists that the first person to live to be 150 years old is alive today Meanwhile, a mesiopalatal canal was discovered, we corrected the internally transported MB, DB, and palatal canals, and restored the access Time will tell, but I am betting on this one Patient No 3: “Which POE don’t you want?” (Figures 3A-3F) This patient was referred for surgical retreatment of maxillary right second molar The tooth has been endodontically attempted months previously and had been percussion sensitive since then The dentist reported that she could not “negotiate” any deeper What would you do? Sometimes you can make a dentist “look better” by doing treatment that appears to be an extension or an additional treatment But what is needed here, of course and for a variety of reasons, is simple and thorough nonsurgical retreatment 54 Endodontic practice Figures 3A-3F: Which POE don’t you want? Figure 3A: Pretreatment image of maxillary right second molar Endodontics was attempted months earlier, and the tooth has been percussion sensitive ever since The dentist said he could not “negotiate” any deeper and referred the patient for surgical retreatment Figure 3B: Downpack image Figure 3D: Perpendicular posttreatment image Figure 3C: Oblique downpack image Figure 3E: Oblique posttreatment image A predictable result is what makes the dentist look good, and a case like this is an excellent opportunity for you to invite a conversation about many aspects of endodontics that will help the dentist in the future Now, if I were to ask you which POE you didn’t want, what would you say? Go ahead, count them You should come up with around 10, give or take Actually, if you are like me, you want them all How could anyone possibly say that this one or that one probably won’t matter? And that is precisely my whole point of writing, documenting, archiving, and chronicling this series of Anatomy Matters Figure 3F: Clinical of MB adjacent MP joining orifice Patient No 4: “Does POE location matter?” (Figures 4A-4F) The patient presents with a clinically duplicable pulpitis: paroxysmal pain to heat that is immediately relieved with ice The pain started the day before, and the day after was unbearable Local anesthetic eliminated the pain, and endodontics was started with complete relief that evening Endodontics was scheduled and completed A furcal canal was staring me right in the eye (I mean microscope), and I had a decision to simply place sealed in the chamber and pack it or “follow” the furcal canal to its terminus, clean, and make a short preparation, cone fit, and pack just Volume Number like any other canal, though much shorter Was this necessary? I (we) will never know Hopefully, I will not have to, nor will you, in your future Challenge/invitation Figure 4A: Pretreatment image of pulpitic mandibular right second molar Figure 4B: Modified periapical image “following” furcal canal to radiographic and then adjusted to physiologic terminus Figure 4D: Perpendicular posttreatment image Four canals and eight POEs sealed Figure 4C: Furcal conefit after downpack image Figure 4E: Oblique posttreatment image I make an invitation to anyone to submit contrarian documentation about Anatomy Doesn’t Matter I believe it will be just as difficult to prove anatomy doesn’t matter as to prove that it does matter What matters to me, however, is not so much that Anatomy Matters at all…at least biologically What matters to me is that in order to discover, clean, fit cones, obturate, eliminate the root canal system’s LEO to source, and finish the coronal seal, I must all the right things the right way The details and fundamentals are not trifle They are, instead, a measure of my thoroughness, my commitment, my declaration to the patient, staff, and referring doctors Mandating that Anatomy Matters means that I take a stand to all these things and more Anatomy is a way of being, a way of practicing, and a way of thinking It is a belief system; something we make up But that made-up belief that for this patient that Anatomy Matters is truly a philosophy that allows us to experience those endodontic miracles, joy, and satisfaction That Anatomy Matters is essential to your today’s signature, your today’s signature becomes tomorrow’s reputation, and your tomorrow’s reputation, becomes your legacy; the footprint you leave to all of us when your work is finished EP Figure 4F: Slightly oblique posttreatment image in order to better discern furcal canal minimal shaping References West J, Chivian N, Arens DE, Sigurdsson A Endodontics and esthetic dentistry In: Goldstein RE, Lee EA, Stappert CFJ, Chu S, eds Esthetics in Dentistry 2nd ed Shelton, CT: People’s Medical Publishing House—USA; 2014 In press West J Anatomy matters Endodontic Practice US 2012;5(2):14-16 Volume Number West J Anatomy matters — part Endodontic Practice US 2012;5(4):26-27 West J Anatomy matters part Furcal endodontic seal heals furcal lesion of endodontic origin Endodontic Practice US 2012;5(6):22-24 West J Anatomy matters Long-term case report Endodontic Practice US 2013;6(1):50-51 West J Anatomy matters Root canal system anatomy only matters when it matters Endodontic Practice US 2013;6(2):56-58 West J Anatomy matters Do lateral canals really matter? Part Endodontic Practice US 2013;6(3):5253 West J Anatomy matters “What’s it all about?” Part Endodontic Practice US 2013;6(4):52-54 Endodontic practice 55 ANATOMY MATTERS Figures 4A-4F: Does POE location matter? INDUSTRY NEWS J Morita USA hires senior vice president of sales and marketing J Morita USA announced recently that Travis Harrison has been hired as senior vice president of sales and marketing In this role, he will assume responsibility for sales management, marketing programs, and strategic partnerships for the company’s capital equipment, small equipment, and consumable product lines Mr Harrison comes to Morita with more than years of sales and marketing experience in imaging technologies Henry Schein CFO, Steven Paladino recognized for outstanding achievement, exemplary performance, leadership, and integrity Long Island Business News awarded its 2013 CFO Lifetime Achievement Award to Steven Paladino, Executive Vice President and Chief Financial Officer of Henry Schein, Inc., the world’s largest provider of health care products and services to office-based dental, animal health, and medical professionals DENTSPLY Tulsa Dental Specialties’ substantial donation used to outfit state-of-the-art facility with latest endodontic technology DENTSPLY Tulsa Dental Specialties, a manufacturer and marketer of innovative products for endodontics (ProTaper NEXT®, WaveOne®, GuttaCore®, ProUltra®) recently made a significant donation to help establish the University of Tennessee’s new Advanced Specialty Education Program in Endodontics The university used the funds to purchase endodontic equipment featuring the latest technology that is housed in a newly renovated, state-of-the-art teaching facility located on the university’s Health Science Center campus in Memphis, Tennessee The new clinic is named after the company in honor of its contribution Previously, University of Tennessee dental students had to leave the state to receive endodontic training The addition of the Advanced Specialty Education Program in Endodontics was a long-time goal of the university’s College of Dentistry and a demonstration of its commitment to giving patients in the community more options when a higher level of endodontic care is necessary With the new clinic, students can learn in a total digital operatory with custom endodontic carts, digital radiography, practice management software, and microscopes connected to highdefinition plasma screens For more information about the Advanced Specialty Education Program in Endodontics, visit http://www.uthsc.edu/dentistry/Grad/Endo/ MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Hu-Friedy’s new group of instruments designed for performance Hu-Friedy, a global leader in the manufacturing of dental instruments and products, has launched the Black Line Surgical Instrument Collection, featuring a performance-engineered coating to enrich contrast and reduce light reflection during procedures in order to consistently deliver optimized clinical outcomes The 51 meticulously handcrafted Hu-Friedy Black Line instruments include periosteals, periodontal knives, periotomes, luxating elevators, surgical curettes, bone chisels, and sinus lift instruments The instruments were engineered to deliver efficiency throughout the entire perio and surgical procedure The collection features a performance engineered coating for a harder, smoother surface For more information call 1-800-HU-FRIEDY or visit www.hufriedy.com 56 Endodontic practice Clinician’s Choice introduces a full line of products designed for both general dentists and endodontic specialists New products to the CLINICIAN’S CHOICE endo line are TUNNEL VISION™ - a water soluble 19% EDTA solution for effective lubricating, chelating, and debridement of root canal preparations, as well as TRUE CAL™ 35% Calcium Hydroxide Paste With a high 12.5pH, TRUE CAL is ideal for use as an intermediate interappointment canal treatment, as well as for a superior antimicrobial agent for apexification procedures Both products are syringe delivered directly to the apex via an EndoFlex Tip for the ultimate in efficiency and precise placement CLINICIAN’S CHOICE can be counted on for every day endodontic essentials, such as access burs, cordless obturation and backfill units, rotary instrumentation systems, ultrasonic units and tips, gutta percha, paper points, esthetic fiber posts, and core material The company’s flagship endodontic product, TYPHOON™ Infinite Flex NiTi Files, was one of the first files on the market to offer controlled memory NiTi™ technology For more information, contact CLINICIAN’S CHOICE at 1-800265-3444 or visit www.clinicianschoice.com Volume Number The Ideal 3D Imaging Systems • Ideal for canal assessment and canal anatomy review • Versatile volume sizes (small ø4 x cm, medium ø8 x cm, large ø8 x 11 cm or ø8 x 14 cm with vertical blending) for a single impaction to full dentition, and beyond • Secondary canal, hairline fracture and calcification detection • Patented SCARA technology for unlimited viewing positions of treatment site • Sharp image acquisition integrates seamlessly into Romexis open architecture software for easy image analysis and treatment planning • Space saving - small footprint and compact design • Mac OS compatible and DICOM compliant PLANMECA® For a free in-office consultation, please call 1-855-245-2908 or email www.planmecausa.com It’s amazing what a great image can for your practice The CS 9000 3D is ready to work hard for your practice This technologically-advanced system will give you high-resolution 3D images that can assist you in making accurate endodontic assessments and diagnoses It will also show your patients how dedicated you are to their oral health • Designed with the endodontist in mind • Do your best work when you capture scans with a focused field-of-view with a high resolution of 76 μm • Make accurate assessments and diagnoses with our full-featured CS 3D Imaging Software • Experience seamless integration with all Carestream Dental software, as well as top endodontic practice management software programs To learn more about what a great image can for your endodontic practice, visit carestreamdental.com/EP3D or call 800.944.6365 today © Carestream Health, Inc 2013 9752 EN 90 AD 1013 clinical articles • management advice • practice profiles • technology reviews EdgeFile™ Flexible Fire-Wire™ NiTi Files EdgeCore™ Pink Gutta Percha Carrier Obturators $19.95 /pack File Compatibility Reference EDGEFILE x3™ FOR Waveone ® USERS FOR Protaper ® USERS EdgeFill™ plastic carrier thermal obturators As an endodontist, every file brand with Yellow N1 17/06 purple the hopes of finding 25/06 Red n2 17/04 white d the one that creates the 40/06 black co m p leting files c1 20/06 Yellow best shape, is efficient, c2 25/06 Red and flexible, yet has a C3 30/06 Blue decreased affinity for C4 40/06 Black separation I can easily 20/04 20/06 30/04 30/06 Yellow Yellow FOR Vortex® Profile® K3® TF® & Sequence® USERS 17/04, 17/06 white 20/04, 20/06 Yellow Blue black 40/06 black with their file system Red The price point is a very 30/04, 30/06 Blue welcomed bonus 35/04, 35/06 Green 40/04, 40/06 Black 45/04, 45/06 white EdgeEndo.com Dr Charles J Goodis, DDS Endodontist, Albuquerque, NM | Founder & Owner, EdgeEndo® – DR Abbas Raissi, DDS Endodontist,California 1-855-985-3636 October 2013 – Vol No 40/04 has established this 25/04, 25/06 Blue Tired of Big Endo Shaking You Down? say that EdgeEndo® EDGEFILE x7™ EDGEFILE x5™ FOR GT ® and GTX ® USERS – Dr Robert Lesniak, DDS Endodontist, Pennsylvania I have used almost N eg oti ating files 20/06 They’re a winner I love ‘em! And, I’ll save $25,000 this year $19.95 /pack $24.95 /pack EDGEFILE x1™ Endodontic Practice US EDGE ENDO® Offers a Full Line of Cutting Edge Endodontic Supplies at Half the Cost October 2013 – Vol No Cost saving is crucial for today’s dental practices Stop overpaying for supplies In today’s economy you need ways to save money EdgeEndo® believes premium technology shouldn’t have to come with a premium price tag We sell direct to dental professionals without the unnecessary costs other endodontic companies charge ® All the Quality Half the Cost Every ten years or so there is revolution in Endodontics, and this is it With their supernatural elastic modulus and extremely efficient instrument design they have completely changed the way I clean and shape From a Board Certified Endodontist– you must try these files – Brett A Rosenberg, DDS Endodontist, Florida All the Quality Half the Cost EDGEFILE x1 ™ for waveone ®users $19.95 / pack EDGEFILE x3 ™ for protaper ® users $19.95/ pack EDGEFILE X5 ™ for GT ® and GT ®x users $19.95 / pack EDGEFILE x7 ™ for vortex ®, profile ®, k3 ®,tf ® & sequence ® $19.95 / pack EdgeFile™ $19.95 /pack Order your FREE assortment pack of files with Flexible Fire-Wire™ NiTi A file that is stronger and lasts longer A broken file is one of the worst things that can happen during a procedure Our revolutionary heat treated Fire-Wire™ Niti yields performance enhancing durability (PED) that provides not only incredible flexibility, but far out performs even the most expensive files on the market in cyclic fatigue testing; a key indicator of file strength and durability ave r age ti m e to fai l u r e in seconds * Strong and Flexible Files are Critical Average in Nm (Neuton meters) The revolutionary EdgeFile™ uses our own flexible FireWire NiTi The EdgeFiles™ are also comparable to your current system which is forged with our proprietary heat treating process Our files Go to our file chart to see which EdgeFile™ you should use to are two to eight times more resistant to cyclical fatigue compared to replace your current file system You will find EdgeEndo® products are designed to fit effortlessly with the system you already use other NiTi files This can help to substantially reduce the incidence of making the transition to using our products completely seamless file separation We have an experienced staff who can guide you in your product The benefit of the file being manufactured, using FireWire, with our comparison and selection Our mission is to deliver endodontic heat treating process also gives the EdgeFile™ Series, “ products and solutions at a substantially lower cost, which in Canal Contouring Technology.” turn benefits practitioners and This enhances the material’s ™ Flexibility EdgeFile patients everywhere properties, making the files ISO 3630.1 Stiffness test Innovation is the heart of not only extremely flexible but 0100 0086 ® We are dedicated to EdgeEndo reduces the shape memory and 0081 0075 0080 0073 the pursuit of bringing leading-edge straightening effect, seen in other endodontic products to your practice NiTi files We feel by the file not 0052 0053 0053 0060 0047 This thought and modern business trying to straighten out in the 0040 model is revolutionizing endodontic canal, it gives the file the ability practices across the U.S We believe to follow the anatomy of the 0020 premium technology shouldn’t have canal very closely, reducing the 0000 Pro Sybron to come with a premium price tag risk of ledging, transportation, Pro SequGT Series Edge Vortex Sybron File Blue® ence® K3XF® X® Taper® K-3® File® We sell direct to dental professionals, and perforation EdgeFile’s “Canal Contouring Technology” enhances the material’s without unnecessary costs, which In addition, the file has a very properties, making the files extremely flexible and reduces the shape memory and straightening effect seen in other NiTi files characterize other endodontic flexible shaft which allows the file companies and are reflected in to get around high curves and inflated prices Our commitment is to bring you all the quality, reduces the need for excessive straight line access, needed in at half the cost other files This allows you to preserve more tooth structure EdgeFile™ 655.6 sec 299.9 sec 255.3 sec Vortex Blue® Sybron K3XF® Sybron K-3® GT Series X® Watch the video at edgeendo.com/videos 192.1 sec 119.4 sec ProTaper® 89.4 sec Sequence® 80.9 sec Dr Charles Goodis, DDS Owner and founder of EdgeEndo®, Dr Charles Goodis introduces his line of cutting edge and *Cyclic fatigue rates conducted by internal testing See EdgeEndo.com/testing for details technologically advanced endodontic supplies Get Your FREE Sample Visit edgeendo.com or call 1-855-985-3636 ... Scottsdale, AZ 85 260 Fax: (480) 62 9-4002 Tel: (480) 62 1-8955 Toll-free: ( 866 ) 579-94 96 Web: www.endopracticeus.com SUBSCRIPTION RATES year (6 issues) years (18 issues) $99 $239 © FMC, Ltd 2013 All rights... cone-beam CT Dentomaxillofac Radiol 20 06; 35 (6) : 410- 4 16 Patel S New dimensions in endodontic imaging: Part Cone beam computed tomography Int Endod J 2009;42 (6) : 463 -475 Cohenca N, Simon JH, Mathur... technique Int Endod J 1997;30 (6) : 361 - 368 Hemmings KW, King PA, Setchell DJ Resistance to torsional forces of various post and core designs J Prosthet Dent 1991 ;66 (3):325-329 Ray HA, Trope M Periapical