Tạp chí nội nha EPUS tháng 3&4/2013 Vol6 No 2 Tạp Chí Endodontic Practice US Tháng 3 và tháng 4/2013Vol.6 No.2
clinical articles • management advice • practice profiles • technology reviews Learn more at Sirona3D.com March/April 2013 – Vol No PROMOTING EXCELLENCE IN ENDODONTICS New instruments for root canal negotiation and preparation Drs Peet van der Vyver and Casper Jonker Top ten tips # Magnification and illumination Drs Jozef Mincík and Marián Tulenko CBCT within endodontics: an introduction Dr Navid Saberi Corporate profile Coltene: Growth helps fund innovation Practice profile Dr John R Hughes PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR! ORTHOPHOS® XG 3D Long-term treatment of root fractures • Visualize canal anatomy prior to treatment • MARS for better diagnosis around metal • Easy patient positioning Dr Tony Druttman 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 John Whitworth BchD, PhD, FDS RCS PUBLISHER Lisa Moler Email: lmoler@endopracticeus.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 PRODUCTION MANAGER/CLIENT RELATIONS Email: kmurphy@medmarkaz.com Kim Murphy NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595 NATIONAL SALES REPRESENTATIVE Sharon Conti Email: sharon@medmarkaz.com Tel: (724) 496-6820 E-MEDIA MANAGER/GRAPHIC DESIGN Greg McGuire Email: greg@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORDINATOR Lauren Peyton Email: lauren@medmarkaz.com 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 Individual subscription year (6 issues) years (18 issues) Should endodontics remain a specialty? Of course we endodontists would all reply with a resounding “Yes!” but it’s not quite that easy — in fact, we were almost decertified back in the late 1980s! As you probably know, every 10 years, the American Dental Association (ADA) requires that each dental specialty submits the reasons why the specialty is necessary Fortunately, we were recertified a couple of years ago due, in part, to the generous efforts of our AAE Foundation, which has funded research to expand the envelope of endodontic knowledge On a more personal level, what are we endodontists doing (or should be doing) to reaffirm the need for our specialty? Our AAE appoints a committee to prepare a document that will be sent to the ADA highlighting the distinguishing practice guidelines that justify our specialty existence; these guidelines have to reflect what all endodontists are capable of performing In fact, the AAE has position papers on the breadth and depth of what general dentists and the public should expect from a practicing endodontist With this introduction, I have a few questions for my endodontic colleagues: Are we all using CBCT (cone beam) when periapical radiographic images are insufficient to make an accurate diagnosis? We don’t necessarily need to buy a CBCT (they are costly) because there are so many dental X-ray centers so nearby By employing CBCT, when appropriate, we can make more sophisticated and accurate diagnoses After all, who but we endodontists are better trained to diagnose vertical root fractures? How about the more elusive (occult) incomplete vertical root fractures? But the subtext of this question about CBCT leads to another question: we endodontists have sufficient training acquired either through a rigorous post-graduate endodontic program or through continuing education programs to interpret CBCT findings? In 2013, there is a reasonable expectation by general dentists and the patients we serve that endodontists should know when to employ and how to interpret CBCT When it comes to a complex diagnosis (e.g., atypical facial pain) that presents ostensibly as “toothache,” our advanced training in history gathering and testing enables us to recognize this uncommon entity We endodontists must reaffirm through our clinical diagnostic acumen that recognizing complex diagnostic entities is another area that distinguishes our specialty from general dentistry Accurate diagnosis is part of the foundation of our specialty, and this in turn, leads to accurate and appropriate treatment planning All of us have seen countless cases that were misdiagnosed which, of course, led to inappropriate treatment or even worse, mistreatment If an injured patient files a complaint against an endodontist alleging negligent treatment, it is quite likely Plaintiff’s counsel will inquire if the endodontist used CBCT leading to the diagnosis and treatment plan — and if not, why not? Of course, not every case we treat requires CBCT; however, if we fail to employ CBCT when it is indicated for diagnosis or treatment planning, we may expose ourselves to claims of negligent care Pulp regeneration is not merely science fiction, it’s a science fact based on many fine studies published in our peer-reviewed endodontic journals Are we endodontists prepared to employ pulp regeneration when an appropriate case presents in our office? After all, our ability to stimulate pulp regeneration is another distinguishing feature that sets us apart from the general dentists’ skill-set When symptoms subside, patients may become dilatory about returning to their general dentist for a final restoration, or the general dentist may delay restoring the endodontically-treated tooth Thus, I would submit that we endodontists should also place final restorations in our access openings because we know, through many papers published in endodontic journals, that there are countless failures due to coronal leakage around provisional restorations Every day we are in practice, we must demonstrate our sophisticated Standard of Endodontic Excellence to justify endodontics as a specialty! $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 Stephen Cohen, MA, DDS, FICD, FACD Diplomate, American Board of Endodontics www.cohenendodontics.com Endodontic practice INTRODUCTION March/April 2013 - Volume Number TABLE OF CONTENTS Practice profile Dr John R Hughes: Privileged to serve Dr John Hughes discusses restorative dentistry, the importance of sharing with colleagues, and his fulfilling humanitarian efforts Clinical Electronic root canal measurements using Endo-Eze Quill, Root ZX mini, Root ZX II, and SybronEndo Mini apex locators — an in vitro comparison with actual canal length Drs Carlos A Spironelli Ramos, Renato de Toledo Leonardo, Richard D Tuttle, and Bruno Shindi Hirata, study the location of the suitable apical file position 12 Long-term treatment of root fractures Drs Jozef Mincík and Marián Tulenko discuss the long-term treatment of root fractures with Rebilda Post System 16 Corporate profile 10 Coltene®: Growth helps fund innovation The COLTENE ENDO group offers a complete product lineup, ranging from diagnostics, isolation, drying and filling products, to post and core build-up materials Endodontic practice Endodontics in focus Tip number – Magnification and illumination Dr Tony Druttman looks at the importance of magnification and illumination in the practice of endodontics 20 Volume Number simple, adaptable endodontic solutions Adaptable delivery for your irrigation protocol NaviTips® deliver any irrigant Your endo procedures, your protocols, your techniques They’re personal They’re tested And they work So why would you change them? You wouldn’t But you would make them easier NaviTips are designed to deliver any manufacturer’s irrigant directly where and when you need it And they adapt to your technique Use NaviTip to deliver these and many other irrigants: ChlorCid · EDTA 18% · File-Eze · Consepsis Don’t change your technique Make it easier with NaviTip Scan to watch a short video showing NaviTip’s side port delivery in action 800.552.5512 ultradent.com NaviTips are available with side port delivery for safe delivery of sodium hypochlorite NaviTip delivers any irrigant just short of the apex—right where you need it ©2012 Ultradent Products, Inc All Rights Reserved NaviTip ® TABLE OF CONTENTS Cone beam computed tomography 24 Research Effect of repeated sterilization and simulated clinical use on the heating capacity of System B™ Continuing education CBCT within endodontics: an introduction Dr Navid Saberi presents a guide to cone beam computed tomography .24 New instruments for root canal negotiation and preparation Drs Peet van der Vyver and Casper Jonker introduce X-plorer canal navigation nickel-titanuim files for glide path preparation followed by Typhoon Infinite Flex nickel-titanium files for root canal preparation 32 Case study Preoperative risk assessment and endodontic treatment planning: examination of a complex clinical endodontic case Dr Rich Mounce looks at some common challenges in endodontic therapy 38 Endodontic practice Product profile The TF Adaptive System The TF Adaptive System by Axis | SybronEndo is a new NiTi file system designed to work with the Elements motor which features Adaptive Motion Technology 42 PIPS™ Laser Endo PIPS™ Laser Endo harnesses the power of the Lightwalker Dual Wavelength Laser: improving clinical results and patient treatment acceptance 44 Vista SOLUTIONS Tested and proven for superior outcomes 46 Vari™-Tip Engineered Endodontics™ is revolutionizing the ultrasonic tip market with the Vari™-Tip, the first customizable, cost efficient, all-metal ultrasonic tip 48 Heat Source pluggers Drs Steven W Black, Brian E Bergeron, Mark D Roberts, Jacob P Bitoun, Zezhang T Wen, Van T Himel, and Joseph L Hagan, MSPH, explore possible degradation and pathogens related to routine heat activation .50 Anatomy matters Root canal system anatomy only matters when it matters Dr John West explains the importance of educating referring dentists about endodontic diagnosis and technique .56 Diary 59 AAE Preview 60 Materials & equipment .63 Ruddle on the radar Thrill of the fill Avoiding apical and lateral blocks .64 Volume Number PRACTICE PROFILE Dr John R Hughes Privileged to serve Alexi, an orphan, and I in an orphanage in Tijuana, Mexico What can you tell us about your background? Is your practice endodontics? I was born in the back bedroom of the church parsonage of the First Baptist Church, Gene Autry, Oklahoma My father was a minister, my mother was a full-time mom, and both were the children of dirt farmers in Oklahoma and Texas We were poor as church mice, but I did not know it! I was the second of four, a total nerd, and moved to different locations every to years I took 18 to 21 hours per semester at Oklahoma Baptist University where I majored in chemistry and math with a physics minor I applied to one dental school at the end of my junior year and graduated from The University of Missouri at Kansas City years later I married my wife, Thompson, a designer for Hallmark Cards, a month later Still married to the same wonderful woman after 46 years! I was a restorative dentist in Kansas City for 15 years and dealt with my mid-life crisis by going to Boston University to study endodontics under Dr Herb Schilder Two years later, at the end of the residency, we decided we didn’t want to be cold any more We came to Tucson, Arizona, where I started Southern Arizona Endodontics (SAE) 30 years ago, a practice with 12 endodontists (one retired), four locations and 55 of the best employees in southern Arizona SAE is an endodontics-only specialty practice I think most endodontists’ drift toward implants represent a lack of busyness rather than a love of implants We would rather be great at endo than good at endo and implants Endodontic practice limited to Why did you decide to focus on endodontics? My initial interest in endodontics was driven by a hope for more control of the result of my efforts There is no tougher professional task in my mind than being a good restorative dentist Great longterm success depends on the lab and patient attention to detail The greatest effort of the dentist is compromised by too many things outside of his control Endodontics is certainly one of dentistry’s most predictable procedures and one that is most dependent on operator excellence How long have you been practicing, and what systems you use? I started restorative dentistry in 1966 and endodontics in 1983 Endodontics has seen many changes in that span The growth of new products and procedures has been almost exponential In our office, we have all of the bells and whistles There is probably nothing one of us has not tried There is a wide variety of the types of rotary instruments we use We all end up using vertical compaction of warm gutta percha for stuffing the root system While we have a lot of great systems at our disposal, most that are advertised to make the process easier also lend themselves to misuse Faster and easier rarely translate to more predictable and better outcomes Regardless of the systems you use, they require knowledge of the root canal system you are invading, an understanding of the complexity of that system, and the determination to seal it well Ninety-nine percent of today’s graduates are wellinformed and well-trained endodontists The systems they are most deficient in are the systems associated with the attraction and nurturing of referral sources That is an area that spells success or failure for many offices Failure to thrive with today’s high debt loads is not uncommon What training undertaken? have you I was fortunate to train under the firm control of Dr Herb Schilder I was fortunate to also study with a group of 33 exceptional residents; 11 in my class, 11 in the class before me, and 11 in the class behind The majority of my training came from the residents around me We Volume Number Who has inspired you? It would be impossible to be around Dr Herb Schilder without being inspired His commitment to the mastery of endodontics was and is a frequent reflection The rest of the dental list is rather long, but includes Drs Pankey, West, Ruddle, Pannkuk, Melnick, Stropko, Yu, and Sam Marescalco, the best restorative dentist I ever knew My wife, Thompson, is also a source of great inspiration to me Though visually impaired, her outlook on life, her commitment to the joy of others, and her love of her grandchildren bring a smile to my mind Professionally, what are you most proud of? For many years, we have maintained a relationship with over 350 different dentists who refer to our group We track our referrals very closely If we see a decline, we are quick to see where we are failing them We are in the relationship business The lengths we travel to maintain that connection and the service we perform for their patients consistently is the result of systems we have had in place for many years We good endo, but most offices good endo We really excel before and after treatment, from our followup to our commitment to see all patients who are in pain that same day What would you have become if you had not become a dentist? We are in the widget business If we are not making widgets, our income stream is threatened I would have been fascinated with the challenges of management/ leadership of a company or service that allowed delegation of responsibilities without affecting the outcome I think an attorney with an MBA would allow for a great latitude of opportunities What is the future of endodontics and dentistry? These may look like young fillies, but they are workhorses I have worked with for a combined total of over 65 years! I am excited about the challenges that lay before us When I look at where dentistry has come during my watch, I would hesitate to guess where it is going Just 15 years ago, implants were considered risky business Now, in the right hands, they are predictable I don’t see them replacing endodontics, but it has allowed us an alternative to treating marginal teeth We will continue to be faced with access to care issues Products and solutions will continue to evolve I think success will always follow quality of care, especially in dentistry What are your top tips for maintaining a successful practice? Dr Hughes and his colleagues at Southern Arizona Endodontics What is the most satisfying aspect of your practice? What you think is unique about your practice? I would say the growth of those I work with We have had dental assistants who have decided to go back to school and on to dental school Two of our staff leaders have been with SAE for over 20 years, and many have excelled with us for 10 years or more The strength of our culture is the result of the commitment our workforce has to treat patients and each other with kindness, courtesy, and respect I have never seen a staff more aligned in the pursuit of excellence both in and out of the tooth The quality of care we extend to our patients from the time of their contact with us to follow up after they leave our office We work hard to treat every one as if he/she is a guest in our home; a special person we are privileged to serve Volume Number and maintaining our office culture became a priority We are fortunate to have a firstrate administrator to manage our systems, culture, and priorities Michael Austin allows us to stay in the operatory with the confidence that outside the operatory, everything is under control What has been your biggest challenge? Early on, the biggest challenge was to control our growth to allow us to maintain quality of care in a caring environment Once our systems were in place, developing You never get a second chance to make a good first impression Always have your best telephone personality answering the phone There is no position in your practice for a person with a bad attitude A person with average skills and a great attitude always trumps a very skilled person with poor attitude We hire attitude and train skills You must be very intolerant of poor culture We work very closely with patients who are our guests at a challenging time in their life They not need to be exposed to staff that is not harmonious and supportive of each other Kindness, courtesy, and respect rules the day Your office requires management and leadership Managers focus on systems and structure, leaders on development Managers push; leaders pull Management involves efficiency; leadership involves effectiveness Peter Drucker once commented that “with the emergence Endodontic practice PRACTICE PROFILE saw more, learned more, and experienced more by the shear numbers of endodontic procedures we were exposed to Some of the best endodontists I have known came out of those 33 people I also was involved with a mastermind group of 10 or 12 endodontists from all over the United States for many years that met every months to compare successes, frustrations, and challenges That really shortened the learning curve for all of us and exposed us to a lot of the movers and shakers in the profession In addition, I have been a student of business systems and applications Part of our success has been our attention to detail outside of the root system Henry Wadsworth Longfellow wrote: The heights of great men, reached and kept Were not obtained by sudden flight, But they, while their companions slept, Were toiling upwards in the night Success or mastery is not a 9-to5 endeavor Success favors those who entertain the thoughts and wisdom of others We all drink from wells others have dug PRACTICE PROFILE A pro bono work in progress, we built in 1/2 days Getting ready to raise a home for another family Last project’s work crew of the knowledge worker, the challenge is not to manage people; the task is to lead them.” That involves allowing staff to contribute to the decision-making process They work harder to implement ideas when they are included in the process A staff that is in alignment with decisions they help develop, “buy in” to the success of the office 5) Emergency practice: See all people in pain 6) Make the experience so compelling, exceeding the expectations of the patient and the referring office SAE combines the last two We strive to be able to say, “Send them right over!” We know that frequently the patient isn’t hurting, the dentist is! We don’t judge whether he made a good decision in sending them; we are happy to triage the patient Rarely does the patient require immediate treatment If you are swamped, you medicate them You can say, “My, my, my, I bet that hurts We are going to get you on some antibiotics that will make you feel better in a day or two In the meantime, we will give you something for the pain to get you some rest If we tried to something today, I am afraid we would not be friends afterward! We will first get the swelling down and get you comfortable.” Or you can incise and drain or open the tooth None of that takes a long time Then, schedule them in the next week They will be happy that you saw them There are three great things about emergency patients; 1) They are thrilled to be seen, 2) they are referred, not because of the degree of difficulty, but because of the referring dentist’s lack of time, and 3) the dentist feels like he is a stud, and he can say, “they will see you today.” Once they are in our office, it is our chance It is our job to pamper them from the moment they step in our office to the time they leave You can say it is not necessary, I know it is not necessary! You it because you are building a practice that is exceptional People not know good endo, but they know how they were treated, and how they felt when they left When they think of your office, it should put a smile on their face! Third, don’t get too full of yourself When was the last time you were impressed by someone who introduced himself/ herself as “doctor?” Your patient knows that you are a doctor…your assistant can introduce you as doctor…but you, use your name “Hello, I am John Hughes.” That is much more powerful, whether in the office or in social settings They will find out soon enough that you are a doctor Charles DeGaulle, former general and president of France, once said, “Graveyards are full of indispensable people.” Keep your eye on possibilities! You must be a rainmaker Referrals don’t just come; they must be earned What advice would you give to budding endodontists? First, join or start a mastermind group It should be comprised of endodontists outside of your geographic area Our group met twice a year for many years We each brought copies of all of the current printed material in our office (such as referral pads, letterheads, post-op correspondence) and distributed them with the agreement that we could mimic anything in our office Sharing and discussing challenges and solutions greatly reduces the learning curve We spent Friday on tooth stuff and Saturday on management, leadership, and interface with referring offices Second, know what your gift is, what your strengths and weaknesses are Those affect how you can best thrive There are really just five or six ways you can practice Each has pluses and minuses; some attract specific personality types, or fill specific needs and wishes of the dentist Most practices are a combination of one or two of the following 1) Government services: Veterans Administration, Indian Health Service, armed services, etc These involve somewhat of an 8-to-5 group involvement with retirement after a fixed number of years 2) Education/Research, with an intermural practice: Schools need endodontists 3) Develop products and/or systems, lecture, become an “authority.” 4) Underserved area: These are becoming hard to find Endodontic practice What are your hobbies, and what you in your spare time? I really enjoy pro bono construction in Mexico When I retire, I hope to build a home every month or so I now build every March with a group of students from Westmont College during their spring break It greatly changes the lives of the givers and the receivers EP TOP FAVORITES My wife, Thompson My two sons, Justin and Cole, and my daughter Wendy My four grandchildren, Hailey, Tanner, Tenley, and Britney My partner of 25 years, Dean Hauseman DEXIS®: There are several good digital radiograph systems available I think DEXIS is the cream of the crop Dentrix: We have over 75 work stations, 67 users, over four locations This software system gives us real time access to any chart in any location It also works seamlessly with DEXIS A great pairing Tulsa Dental: We are, I assume, one of Tulsa’s largest accounts and biggest fans! They seem to always be there when the “next big thing” is introduced They have a large variety of rotary instruments that fit our group perfectly! Roydent™ Dental Products: We have used Roydent’s files and reamers forever Smart Practice®: The best, most economical, suppliers of gloves Very service oriented Volume Number u m h t s I s e s d n n a o i t ls a a ig n r r a I C e l al d r e e e t La n N e t T a r er t e tt n e e B P Ultrasonic Irrigator • Distributes and ultrasonically activates sodium hypochlorite to increase debridement of lateral canals and isthmuses • Ratcheting syringe permits controlled delivery of 0.2 ml of solution with each audible click Benefits of Continuous Ultrasonic Irrigation: • Removes significantly more debris from narrow isthmuses better than conventional needle irrigation* • Significantly increases the penetration of irrigation solutions into lateral canals** *Adcock et al, J.Endod 2011; 37 (4) **Castelo-Baz et al, J Endod 2012; 38 (5) See us at AAE booth # 711 235 Ascot Parkway | Cuyahoga Falls, OH 44223 Tel USA & Canada 800.221.3046 | 330.916.8800 | coltene.com PATENT PENDING ... *Adcock et al, J.Endod 20 11; 37 (4) **Castelo-Baz et al, J Endod 20 12; 38 (5) See us at AAE booth # 711 23 5 Ascot Parkway | Cuyahoga Falls, OH 4 422 3 Tel USA & Canada 800 .22 1.3046 | 330.916.8800... leave You can say it is not necessary, I know it is not necessary! You it because you are building a practice that is exceptional People not know good endo, but they know how they were treated,... an in vitro study J Endod 20 06; 32( 2):1 42- 144 Welk AR, Baumgartner JC, Marshall JG An in vivo comparison of two frequency-based electronic apex locators J Endod 20 03 ;29 (8):497–500 Ponce EH, Vilar