issn 2193-4673 • Vol. 16 • Issue 1/2020 roots international magazine of endodontics 1/20 case report Retreatment of a tooth with a double curvature trends & applications Testing a novel endodontic sealer meetings ROOTS SUMMIT: New dates
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editorial | Dr David E. Jaramillo Guest editor Scientiﬁc director of ROOTS SUMMIT Dear readers, It is difficult to believe that nearly two years have passed since the last extremely successful ROOTS SUMMIT in Berlin. It is also difficult to believe that it will be one more year until we will meet due to the current issues surround- ing the COVID-19 pandemic. The safety and security of all was our primary consideration when the decision was taken to postpone the live ROOTS SUMMIT until 20 to 23 May 2021. As that is far too long to get together and share the numerous scientific and clinical information that has been generated, we will be having an online ROOTS SUMMIT which will take place on 22 and 23 May 2020. It is an honour to be the scientific director of the event again. As with all ROOTS SUMMITs, we have an out- standing line-up and combination of clinicians and re- searchers ready to share their results in both areas. We are certain that attendees and viewers will be pleased with and surprised at the advanced surgical techniques and research that will be shared at both events. research—more than worthy of inclusion in any peer- reviewed journal. The first paper is about the impor- tance of knowledge of the root canal anatomy to avoid iatrogenic failures in a two-rooted maxillary premolar. A world-renowned expert on this topic and vertical root fractures, Dr Aviad Tamse, professor emeritus at Tel Aviv University, was gracious enough to submit this paper, and you will not want to miss it. We hope that you will enjoy this issue of roots. We also hope that you will join us in Prague for our unique online meeting, where all participants see the same presenta- tion and where the camaraderie of our global member- ship will create yet another outstanding endodontic and social experience. I look forward to seeing you at the online ROOTS SUMMIT this May, and in person in Prague in May 2021. I am also pleased to announce that roots magazine is launching a new section containing the latest clinical Dr David E. Jaramillo Guest editor Scientific director of ROOTS SUMMIT roots 1 2020 03
| content editorial Dear readers Dr David E. Jaramillo study Buccal root of the bifurcated maxillary premolar— a danger zone during root canal therapy Drs David E. Jaramillo & Aviad Tamse page 06 research Innovative endodontics using SWEEPS technology Drs Giovanni Olivi & Matteo Olivi case report Treatment of the result of chronic activation of substance P Prof. Philippe Sleiman, Dr Pamela Kassabian, Dr Valerie Batrouni & Dr Alexey Volokitin page 26 Root canal therapy with a modular NiTi system: A case report Dr Vishal P. Gandhi Retreatment of a tooth with a double curvature Dr Gaizka Loroño trends & applications Testing a novel endodontic sealer Drs Paolo Generali & Francesca Cerutti manufacturer news page 46 practice management Successful communication in your daily practice Part X: How to improve your own punctuality Dr Anna Maria Yiannikos “As dental coaches, we are servants in a noble profession” An interview with Kirk Behrendt feature Cover image courtesy of Henry Schein www.henryschein.com “Diets rich in plant foods are increasingly associated with longevity and healthy ageing” “We aim to prepare dentists for care of the ageing population” issn 2193-4673 • Vol. 16 • Issue 1/2020 roots 1/201/20 meetings AAE announces its 2020 award winners ROOTS SUMMIT: New dates AAE considerations for dental care during COVID-19 crisis about the publisher submission guidelines international imprint case report with a double curvature trends & applications Testing a novel endodontic sealer meetings ROOTS SUMMIT: New dates 04 roots 1 2020 03 06 10 16 20 24 26 30 32 34 36 40 42 44 46 48 50
HyFlex™ CM & EDM STAYS ON TRACK Æ Safer use Æ Preparation following the anatomy Æ Regeneration for reuse www.coltene.com 8 9 0 4 0 0
| study Buccal root of the bifurcated maxillary premolar—a danger zone during root canal therapy Dr David E. Jaramillo, USA & Dr Aviad Tamse, Israel Fig. 1 Fig. 2 Fig. 3 The purpose of this study is to describe the depression in the buccal root of the bifurcated maxillary premolar as a danger zone during and after endodontic treatment and to recommend clinical modalities to prevent root fractures and perforations in this root. There are a known number of reasons for complica- tions during and after root canal preparation.1 Curved roots such as the mesial root of the mandibular molar are a challenge to prepare and clean, and this was es- pecially the case during the era of stainless-steel instru- ments.2, 3 The curvature in the middle part of the mesial root is still considered a danger zone where either strip perforations (Fig. 1) or perforations from a post can still occur (Fig. 2). Almost half of maxillary premolars are two-rooted. These roots present a variety of morphological and an- atomical appearances, such as roots spreading apart and a variety of locations of bifurcation from the coro- noapical direction (Figs. 4a–d). Curved and divergent roots and root canals are difficult to treat endodontically. One major reason for the operator’s frustration is the fact that, in bifurcated maxillary premolars, it is extremely difficult to determine the aetiology when a poor outcome is diagnosed. Fig. 4a Fig. 4b Fig. 4c Fig. 4d 06 roots 1 2020
study | Maxillary premolars are among the teeth most suscep- tible to vertical root fractures in endodontic treatment.4, 5 This is a common complication of endodontic treatment and most often leads to the extraction of the tooth or root (Fig. 3).4, 5 Although the American Association of Endodontists stated that the combination of a deep probing defect and a sinus tract in the endodontically tooth is pathognomonic for a vertical root fracture,6 only some vertical root fracture cases manifest these signs and symptoms at the same time. This occurs for a va- riety of reasons. The signs, symptoms and radiographic features often mimic those of a poor endodontic out- come or periodontal disease, and it may be difficult to correlate the clinical findings to the radiographic manifes- tations. In a systematic review on this topic, it was con- cluded that there is a conflict between the clinical impor- tance of timely and accurate diagnosis of vertical root fractures in the endodontically treated tooth and a lack of evidence-based data supporting the usefulness of com- mon clinical and radiographic evaluation methods.7 The findings mentioned are especially true in bifurcated maxillary premolars. The major reason is the unfavour- able position of the bifurcated premolar in the jaw. The buccopalatal roots are positioned buccopalatally in the maxilla, and if an endodontic complication occurs in one of the roots, whether a vertical root fracture, perforation or even just a poor outcome of an endo- dontic treatment, it can be extremely difficult at times to establish the reason on a routine periapical radio- graph. This unfavourable position of the roots at times causes a periodontal problem around the tooth. A mesiodistal bifurcation is very difficult for the patient to clean, and if a periodontal pocket occurs, the periodontal disease will advance very rapidly (Fig. 5). Fig. 5 The bifurcated maxillary premolar has a complex anat- omy and morphology as described in the endodontic textbooks and atlases. In the buccal root of the maxillary premolar, there is a unique anatomical feature: a depres- sion (called also a concavity or furcation groove) in the bifurcation (palatal) aspect of the root, located mostly in the middle (Figs. 6a & b). The morphometric character- istics of this depression have previously been described and found to occur in between 78 and 100 per cent of cases.8–12 Booker and Loughlin claimed that the original thickness in this area is extremely thin.13 Gher and Vernino speculated that the depression represents a tendency of the buccal root to form two separate buccal roots during tooth development.12 In a study of 35 bifurcated maxillary premolars, this depression in the buccal root was found in 97 per cent of the cases.8 Most of the root canals had a kidney shape, and the mean width of the distance from the deepest areas of the invagination to the canal wall was 0.81 mm. Li et al. found the same results using computed tomo- graphy.11 Therefore, it is thus understandable that it is Fig. 6a Fig. 6b Fig. 7 roots 1 2020 07
| study risky (in terms of fracture or perforation) to remove too much dentine in this area, whether with hand instrumen- tation or in preparing circular flaring to fit a post (Fig. 7). A recent study by Chai and Tamse again demonstrated the necessity of trying to maintain the original shape and size of the buccal root canal during endodontic treatment in order to avoid vertical root fractures in endodontically treated teeth.14 This study looked at the issue of vertical root fracture from the stress and force aspect. The results showed that, although vertical root fracture can occur in the palatal root as well, it was mostly limited to the buccal root. Using a finite element analysis technique, it was shown that, when force from lateral condensation was applied to this root, the stress concentrated at the deepest point of the depression and from this initiation point, the fracture propagated either in a straight line to the canal wall or as two or more curved fractures to the canal walls (Figs. 8a–d). According to Mamede-Neto et al., no file system is able to achieve perfectly centred root canal preparation, so care should be taken especially when using a reciprocating system.15 This system presents the most mesiodistal and buccolingual transportations compared with a rotary instrumentation system. In his histological evaluation, Walton compared instru- ments and techniques and found that none were able to achieve complete debridement of pulp tissue from inside the root canal system.16 This is in agreement with Gutiérrez and Garciá, who were the first authors to report the lack of effectiveness of any instrumentation technique in obtaining root canals completely free of pulp tissue.17 Owing to the impossibility of obtaining complete pulpal debridement, root canal enlargement is the main pur- pose of the general dentist and endodontist. Kerekes and Tronstad published a morphometric eval- uation on the different root canal sizes of anterior teeth, premolars and molars.18–20 They found large diameters in all thirds of the root canals of maxillary first and second premolars. These findings may suggest to the operator to enlarge the width of the root canal in order to obtain cleaner and better pulpal debridement of the root canal system. As a result of the excessive reduction of dentine in the most critical areas, strip perforation may occur. All these findings lead us in the direction of a better knowledge and understanding of root canal shapes and sizes in the various canal locations, in order to prevent over-instrumentation that could lead to weakness of the root and possible root fracture. The problem of effective cleaning of the root canal sys- tem is especially true in those root canals which are not round in cross section, that is, oval root canals in those roots which are also susceptible to fracture, such as the maxillary premolars, the mandibular premolars and the mandibular incisors.21 In a series of studies, it was Fig. 8a Fig. 8b Fig. 8c Fig. 8d 08 roots 1 2020
study | Fig. 9a Fig. 9b Fig. 9c demonstrated that long oval canals are impossible to instrument and clean completely, leaving many areas of the canal walls uncleaned and with debris.22–24 Extra care should be taken in instrumentation and cleaning in order not to perforate such canals16 and in order to ensure proper obturation.23, 24 Weller et al. compared ultrasonic instrumentation and hand instrumentation with ultrasonic irrigation.25 Their findings were that there was no difference in the de- bridement efficiency between hand and ultrasonic in- strumentation compared with ultrasonic irrigation alone. But when they added ultrasonic irrigation to both (hand and ultrasonic) instrumentation groups, they obtained better results. In summary, the ultrasonic instrumentation technique does not improve root canal debridement. This is only improved when there is a combination of any in- strumentation technique and ultrasonic irrigation. Langeland et al. found hand, sonic and ultrasonic in- strumentation to be ineffective in the complete debride- ment of the curved roots of mandibular molars.26 Van der Vyver et al. found, independent of the nickel-titanium alloy phase or heat treatment, that all rotary and reciprocating systems produce root canal transportation in all three root canal thirds.27 The introduction of newer technology such as the Gentle Wave system (Sonendo) allows minimal instrumen- tation of the root canal system with excellent debride- ment parameters (Fig. 9a) by producing multi- sonication in a de-gased liquid and closed system. The closed system allows the propagation of multi-sonication waves that reach all areas of the complex root canal anatomy.28 Minimally invasive instrumentation of the root canal sys- tem will increase the possibility of less reduction of tooth structure, thus decreasing the possibility of weakening of the root canal walls. Reducing the risk of file separa- tion, canal perforation and fractures is a further benefit of minimally invasive instrumentation, which results in sig- nificantly less presence of debris (Fig. 9b) compared with conventional methods (Fig. 9c). Editorial note: A list of references is available from the publisher. about Dr David E. Jaramillo, DDS, is Pro- fessor in the Department of Endodon- tics at The University of Texas Health Science Center School of Dentistry at Houston. Former clinical assistant pro- fessor of endodontics at the University of Southern California (USC) in Los An- geles (2004–2006). He was an associ- ate professor at Loma Linda University School of Dentistry in California (2004–2014). Actively partici- pated in research at the Center for Biofilms under the direct su- pervision of Dr William Costerton at USC School of Dentistry and the Department of Electrical Engineering/ Electrophysics at USC Viterbi School of Engineering. Dr Jaramillo is scientific director for ROOTS SUMMIT meetings. Former president of Houston Academy of Endodontists, Chair IFEA Grant Research Committee and new member of the International College of Dentists USA Section. He has 2 patents in the US. Dr Aviad Tamse received his DMD degree from the Hebrew University and Hadassah Faculty of Dental Medicine in 1969, and from 1971 to 1973, he attended the Harvard School of Dental Medicine, Boston, Massachusetts, where he re- ceived his endodontic training. Dr Tamse was twice President of the Israel Endodon- tic Society, Chair of the Endodontic Board Examiners Committee of the Israel Dental Association Scientific Committee, and Chair of the Accreditation Committee of Graduate Dental Programs of the Israel Dental Association. Dr Tamse served as chair of the department of Endodontology Tel-Aviv University School of Dental Medicine from 2000–2008, and in 1982 was a co-founder of the European Society of Endodontology. Currently Dr Tamse is Professor Emeritus at the Department of Endodontology, School of Dental Medicine, and Tel-Aviv University. contact Dr David E. Jaramillo Scientific director ROOTS SUMMIT firstname.lastname@example.org roots 1 2020 09
| research Innovative endodontics using SWEEPS technology Drs Giovanni Olivi & Matteo Olivi, Italy The ultimate goal of endodontic treatment is the eradication of microorganisms responsible for endodon- tic disease.1, 2 Enlarging and shaping the root canals to a size sufﬁcient for delivery of irrigants into the endodontic space allows for pulp tissue dissolution and antibacterial activity in the full space.3 A stable and hermetic sealing of the endodontic space permits long-lasting success of the therapy. Present-day endodontic research is more focused on instrumentation than on irrigation to improve the success rate of root canal therapy. The newest high- performance nickel-titanium alloys reduced the stiffness and increased the elasticity of endodontic instruments, permitting simpliﬁed and faster root canal preparation with reduced diameter and taper and greater preserva- tion of the dental structure. However, Peters et al.,4 more recently conﬁrmed by other researchers,5, 6 demonstrated the incomplete action of the tested instrument systems, which left 35 % or more of the canal’s surface area un- changed. Furthermore, the reduced operating time aris- ing from using new mechanical rotary systems reduces the contact time of decontaminating agents (chemical and mechanical cleansing) with the root canal surfaces, and from this perspective, improving the ﬂuid dynamics of irrigants in the endodontic space appears to play an important role.7 Irrigation techniques The ﬂuid dynamics of the irrigants in the conﬁned canal space is one of the main problems in endodontics and very few innovations have been introduced in this regard. Many techniques are currently used to deliver and acti- vate the irrigants in the endodontic space. A constant ﬂow of irrigants helps to dissolve inﬂamed and necrotic tissue, to disinfect the canal walls by removing bacteria and bioﬁlm, and to ﬂush out debris and the smear layer from the root canal, and hence is essential for the suc- cess of endodontic therapy. The complex macro- and micro-anatomy of the root canal system limits the ac- cess, ﬂow and turbulence of irrigants in the endodon- tic space and ﬁnally the deep penetration of antibacte- rial agents into the dentinal walls, thus limiting their 3D cleaning and disinfecting ability.8, 9 Ricucci and Sique- ira reported that chemomechanical preparation partially removed vital and necrotic tissue from the entrance of lateral canals and apical ramiﬁcations, leaving adjacent tissue inﬂamed and infected, and associated with peri- radicular disease.10 Sodium hypochlorite (NaOCl) is the most commonly used endodontic irrigant because of its antimicrobial and tissue-dissolving activity. Many factors inﬂuence its effectiveness. Optimisation of surface ten- sion, concentration, temperature, agitation and ﬂow can improve tissue-dissolving effectiveness by as much as 50-fold.11 When the NaOCl was modiﬁed with the adjunct of a surface active agent, it showed lower contact angle on dentine, resulting in more effective tissue dissolution compared with conventional NaOCl solutions.11 Also, ag- itation and higher temperatures considerably enhanced the efﬁcacy of NaOCl. However, the effect of agitation on efﬁcacy was greater than that of temperature, and contin- uous agitation resulted in the fastest tissue dissolution.11 Comparing the efﬁcacy of different agitation systems on the activity of NaOCl, De Gregorio et al. found limited penetration of the irrigant into lateral canals using an apical negative pressure irrigation system—it was how- ever the most effective in reaching the working length— in comparison with the other tested systems (sonic irri- gation; passive ultrasonic irrigation; F-ﬁle; and positive pressure irrigation).12 In contrast, passive ultrasonic irri- gation demonstrated signiﬁcantly greater penetration of irrigant into lateral canals.12 The efﬁcacy of NaOCl de- pends on the quantity and reactivity of its free-chlorine form. Macedo et al. veriﬁed that Er:YAG laser activa- tion of the irrigant produced a greater reaction rate of NaOCl, producing more active chlorine ions in three times less time than with passive ultrasonic irrigation.13 In the last ten years, the use of laser in promoting the activity of intra-canal irrigants (laser-activated irrigation) has been investigated and successfully introduced in endodontics. Laser in endodontics Lasers are used with different techniques in endodon- tics (Table 1, Fig. 1). They can be used to directly irradi- ate the canal walls or to irradiate and activate ﬂuids intro- duced into the canal (photosensitisers or irrigants), thus performing their clinical action on the endodontic system indirectly. 10 roots 1 2020
research | Wavelength Laser technique Target chromophore Laser–tissue interaction Laser effects Near infrared Conventional direct irradiation Bacteria pigment Diffusion Photothermal Medium infrared Conventional direct irradiation Water content of dentine Bacteria Absorption Photothermal Visible near infrared PAD indirect irradiation Photosensitisers Absorption Photochemical Medium infrared LAI indirect irradiation Water content of irrigants Absorption Photothermal cavitation Medium infrared SWEEPS indirect irradiation Water content of irrigants Absorption Photothermal Photoacoustic cavitation Shock wave PAD = photoactivated disinfection; LAI = laser-activated irrigation; SWEEPS = shock wave enhanced emission photoacoustic streaming. Table 1: Classiﬁcation of laser techniques used in endodontics (modiﬁed from Olivi14). Conventional laser endodontics The term “conventional laser endodontics” was coined by Olivi in 2013 to describe the conventional use of laser ﬁbre inserted inside the canal, up to the working length (–1 mm), to directly irradiate the dentinal walls.14 The laser ﬁbre inserted inside the canal is activated during the with- drawing movement. Laser irradiation interacts with the canal surface according to the various modalities typical of the wavelength used. The primary effect produced is a photothermal one, followed by a secondary bactericidal effect, but undesired morphological modiﬁcation of den- tinal walls is also generated. The main problems associ- ated with conventional laser endodontics are the irregular ﬂuence supplied along the canal and the inability of laser ﬁbres to passively negotiate the canal without interfer- ence with the dentinal walls. Contact of laser ﬁbre with dentinal walls can create thermal damage varying from ablation to melting, and bubbles of recrystallisation of the hydroxyapatite and microcracks.15 Photoactivated disinfection Photoactivated disinfection involves the use of a photo- sensitiser that is introduced into the root canal and selectively activated by an afﬁne wavelength. The visi- ble wavelengths (from 635 nm to 675 nm) activate tolou- dine and methylene blue, while the near-infrared (810 nm) wavelength activates indocyanine green. The laser irra- diation produces a photochemical effect that activates the photosensitiser solution with release of reactive rad- icals and singlet oxygen. There is no direct laser interac- tion with the dentinal surface, eliminating any undesired collateral effect. Owing to the low oxygen concentration inside the dentinal tubules and the prevalence of anaer- obic/aerobic facultative bacteria in the root canal system, the use of photoactivated disinfection is considered only an adjunct procedure to the conventional one.16 Laser-activated irrigation Laser-activated irrigation (LAI) involves the irradiation of commonly used irrigant solutions in the canal by a laser. The minimum common denominator of different LAI techniques is the wavelength that can be used: the wave- lengths of erbium lasers (Er,Cr:YSGG [2,780 nm] and Er:YAG [2,940 nm]) are the only ones absorbed by water, the main component of common irrigant solutions (17 % EDTA and 5 % NaOCl). The greater the absorption coefﬁcient of the molecule for a wavelength, the lower the Fig. 1: Graphic representation of various laser techniques used in endodon- tics: CLE = conventional laser endodontics; aPAD = antibacterial photoac- tivated disinfection; LAI = laser-activated irrigation; PIPS = photon-induced photoacoustic streaming; SWEEPS = shock wave enhanced emission photo- acoustic streaming. roots 1 2020 11
| research a [cm-1] ) 1 - i m c ( t n e c i f f e o c n o i t p r o s b A 105 104 103 102 10 1 10-1 10-2 10-3 10-4 2 3 Wavelength µm Fig. 2: Different water absorption coefﬁcients in the medium electromag- netic spectrum for 2,780 nm and 2,940 nm. The absorption of Er:YAG laser radiation at 2,940 nm by water is three times greater than that of Er,Cr:YSGG laser radiation at 2,780 nm. energy required to obtain its absorption (Fig. 2). Specif- ically, the absorption of Er:YAG laser radiation by water is three times greater than that of Er,Cr:YSGG laser ra- diation and requires less energy to obtain the same ef- fect.17 To thoroughly understand the mechanism of LAI, the various devices and settings used, and consequently the proposed protocols in recent years, it is important to consider all the parameters that determine the differ- ence between one laser system and another. Indeed, regardless of the positive results achieved in various LAI investigations, the use of the different protocols can con- H2O fuse readers. Besides the wavelength spec- iﬁcity (2,940 nm and 2,780 nm) for the tar- get (water), it is important to consider the laser setting used, including energy, pulse repetition rate, ﬂuency, pulse duration and peak power. Also important is to choose the correct laser ﬁbre or tip and position inside the tooth, including tip end design 2,78 2,94 µm and diameter. Laser setting The laser energy is absorbed by the water of the solu- tions, and the water rapidly increases in temperature until it reaches boiling point (100 °C), forming typical bubbles of explosion (photothermal/photoacoustic primary phe- nomenon) and thus generating immediate cavitation in the canal (secondary phenomenon; Figs. 3a–e).18–21 The higher the energy applied, the bigger the bubble size and the more efﬁcient the cavitation produced. However, the application of high energy with the tip inserted in- side a canal can have obvious contra-indications owing to rapid vaporisation of liquid from the canal, dry irradia- tion and consequent undesirable thermal effects on the dentinal walls. A fundamental concept, which explains the efﬁciency of one system over another, is the peak power emitted by the laser pulse as a function of the energy applied in the time, according to the formula: peak power = energy/pulse duration. The goal is to reach a high peak power (400 W) with very low energy applied at subablative levels (20 mJ), to avoid any thermal or ab- lative effects. This is possible when the pulse duration is very short (50 microseconds), to produce an efﬁcient photoacoustic effect. The higher the peak power of each Fig. 3a Fig. 3b Fig. 3c Fig. 3d Fig. 3e Fig. 4a Fig. 4b Figs. 3a–e: Premolar model showing an Er:YAG laser (LightWalker) equipped with a SWEEPS conical-end tip of 400 µ ﬁring a single 25-microsecond pulse at 20 mJ in water: bubble explosion (a & b), bubble implosion and primary cavitation (blue arrows) (c–e), red arrows show secondary cavitation in the apical third (c). Figs. 4a & b: Premolar model showing an Er:YAG laser (LightWalker) equipped with a SWEEPS conical-end tip of 400 µ: single 50-microsecond pulse at 20 mJ in water: bubble explosion at the tip end (a), single 25-microsecond pulse at 20 mJ in water: bigger bubble explosion at the tip end (b). 12 roots 1 2020
pulse, the greater the pressure wave generated by the primary bubble explosion (Figs. 4a & b). The pulse dura- tion and the peak power of a laser depend on the tech- nology utilised by the various laser devices. Also, the efﬁciency of the irrigant streaming depends on the tip used and its position in the endodontic space. Laser tip A high peak power, closely related to the pulse duration, of the various erbium lasers used explains the different energy settings used and the different positions of the tip, as reported in the various techniques. During LAI, the tip may be used in motion, up and down, in the ca- nal and withdrawn slowly towards the pulp chamber or may be used in stationary position or with small move- ments in the apical third or middle third of the canal.22, 23 In contrast, when using PIPS (photon-induced photo- acoustic streaming), the laser pulse (of 20 mJ emitted at 50-microsecond pulses [super-short pulse], with the Er:YAG laser LightWalker, Fotona) generates a high peak power (400 W) and creates primary phenomena of explosion and secondary cavitation even at a relevant distance from the area of activation (access cavity), at an average speed of about ten times higher than that mea- sured for passive ultrasonic irrigation.24 Accordingly, the PIPS technique requires the speciﬁc and easy position- ing of the laser tip, not inserted into the canal, but held stationary in the pulp chamber, where the irrigant solu- tion is supplied by a syringe.17 Today, the PIPS technology has been updated, improved and presented as SWEEPS (shock wave enhanced emission photoacoustic stream- ing) technology (Fig. 5).25 SWEEPS technology SWEEPS represents the technological evolution of PIPS. The laser is the same Er:YAG laser (2,940 nm), now produced in two models (LightWalker and SkyPulse, Fotona). The endo-mode permits emission of energy in two modalities: single pulse and dual pulse. The single super-short pulse modality (50 microseconds; the same as for PIPS) is today accompanied by the ultra-short sin- gle pulse modality (25 microseconds, USP) that allows better modulation of the emitted energy, maintaining the same peak power (i.e. 400 W peak power using only 10 mJ) or a more powerful peak power (800 W) using the same energy (20 mJ) as PIPS. In addition, the emission of the dual-pulse modality is now available, ﬁring a sec- ond laser pulse after the ﬁrst in rapid succession. The emission interval between one pulse and another var- ies randomly from 250 to 600 microseconds (SWEEPS- Auto; Figs. 6a–d). More sophisticated is the emission of the second pulse in resonance with the ﬁrst (X-SWEEPS); this can happen when the delay of the second pulse permits exact ﬁring when the ﬁrst bubble is still in the implosion phase, thus implementing the primary cavita- research | 2x EDTA 30s water 30s 3x NaOCI 30s Fig. 5: SWEEPS ﬁnal irrigation protocol: at the end of therapy, a ﬁnal irrigation protocol entails two cycles of 17 % EDTA activated by SWEEPS for 30 seconds each, followed by rinsing with distilled water activated by SWEEPS for 30 seconds, then three cycles of 5 % NaOCl activated by SWEEPS for 30 seconds each and a resting time of at least 30 seconds. tion produced. This technology makes it possible to op- timise the pressure waves produced depending on the internal volume of the tooth to be treated (molar, premo- lar, incisor).25 Also the possibility of modulating the peak power of the single pulse and consequently of the intra- canal irrigant pressure wave allows better manage- ment of the irrigation in the case of particularly wide canals and resorbed apices of large dimensions. Advantages of LAI (SWEEPS) Laser activation and agitation of irrigants introduced a new standard among the several irrigation methods. Fig. 6a Fig. 6b Fig. 6c Fig. 6d Figs. 6a–d: Molar model showing an Er:YAG laser (LightWalker) equipped with a SWEEPS conical-end tip of 400 µ. Dual-pulse modality at 20 mJ in water: blue arrows show the ﬁrst bubble (a), the second bubble (b) and the induced shock waves (d); red arrows show the secondary cavitation in the middle and apical thirds of the canal (b, c & d). roots 1 2020 13
| research Er:YAG laser activation offers various advan- tages over the other methods and has been validated by several peer-reviewed papers: – It provides superior chemical activation of NaOCl.13 – It produces superior chemical disso- lution of pulp remnants by NaOCl.26 – It provides superior physical disrup- tive action on bioﬁlm.27 – It provides a superior smear layer cleaning ability to that of EDTA.28–30 – It produces a superior bactericidal effect.31–33 In addition, the easy positioning of the tip in the access cavity offers new clinical possibilities in endodontics (Fig. 7). LAI in the access cavity can start just after the opening of the access cavity, allowing progressive re- duction of the bacterial load, even before scouting and preparation of the canals. Moreover, using NaOCl, it dis- solves the pulp tissue, reducing the possibility of irre- versible dislodging of pulp remnants laterally and apically in the endodontic space during instrumentation. In ad- dition, it allows irrigation of narrow and/or long canals with the same simplicity as irrigation of wider canals. Furthermore, it produces, in narrow canals, a more effective and faster ﬂow of ﬂuids in the apical direction, but with reduced pressure (hydrodynamic paradox or Venturi effect). Also, it provides irrigation throughout the entire endodontic space, one or more canals, at the same time. Clinically, it greatly helps in calciﬁed canals, in case of a separated instrument, as well as in endodontic retreatment (Figs. 8 & 9). Conclusion The Er:YAG laser, at low energy and with ultra-short pulse duration, has been found to perform very well for activa- tion of intra-canal endodontic irrigants. Owing to the lack of uniformity of parameters used in the various studies (including wavelength, pulse duration, energy, frequency Fig. 7: SWEEPS tips: conical end and 9–14 mm ﬂat. and tip design and diameter) confusion still remains in LAI procedures regard- ing how to achieve the best results. However, there is now an overwhelm- ing published evidence of the beneﬁts of Er:YAG laser-supported root canal irrigation. Of course, in-depth study of advantages and possible complications of the LAI technique is advisable before in vivo clinical application. Editorial note: A list of references is available from the publisher. about Dr Giovanni Olivi is an Italy-based dentist and internationally published author. He graduated cum laude in Medicine and Surgery (MD) and in Dentistry (DDS) in Rome. He obtained the postgraduate diploma in “Laser Dentistry” from the University of Flor- ence and the Master status from the Academy of Laser Dentistry. In 2007, Dr Olivi was awarded the “Leon Goldman Award” for clinical excellence by the Academy of Laser Dentistry. Dr Matteo Olivi graduated in Dental Medicine at University Victor Babes¸ , Timisoara, Romania. He obtained the Master EMDOLA in Laser Dentistry from La Sapienza University of Rome. He is a member of the Italian Society of Endodontics (SIE). Dr Olivi is a co- author of several peer-reviewed articles and books on laser dentistry. Fig. 8 Fig. 9 Figs. 8 & 9: Tooth #47 with deep decay on the distal proximal wall. One-visit therapy was performed with SS White and ProTaper Next X2 rotary instru- ments. The SWEEPS irrigation technique allowed good decontamination and cleaning prior to the ﬁnal sealing (EndoSequence BC Sealer, Brasseler). contact Dr Giovanni Olivi InLaser Dental Practice Piazza Francesco Cucchi 3 00152 Rome, Italy Phone: +39 06 5809315 email@example.com 14 roots 1 2020
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| case report Treatment of the result of chronic activation of substance P Prof. Philippe Sleiman, Dr Pamela Kassabian, Dr Valerie Batrouni, Lebanon & Dr Alexey Volokitin, Ukraine Introduction Pulp stones are primarily a physiological manifestation and may increase in number and/or size owing to local or sys- temic pathology. The aetiological factors involved in their formation are still not fully apparent; their formation may be Fig. 1 Fig. 2 Fig. 3 16 roots 1 2020 associated with some local irritants that are long-stand- ing, such as caries, dental restorations and systemic dis- turbance.1 Calcific atheromas and the calcification of dental pulp have a similar pathogenesis, so routine dental radio- graphs may be useful. If the patient is found to have multiple pulp stones, further evaluation for associated diseases, ca- rotid artery calcification and renal calcification is required.2 Calcification can occur in the dental pulp as discrete calcified stones or as a diffuse form. These pulp stones may exist freely within the pulp tissue or be embedded in the dentine.3 Depending on their microscopic structures, pulp stones were histologically classified by Kronfeld into a true or false form.4 Radiographic examinations are not likely to detect pulp stones of less than 200 µm in diameter. Radiographically, pulp stones appear as radiopaque structures in the pulp cavity. The prevalence of pulp stones is higher in females than in males and occurs most commonly in molars than in other tooth types.1, 5 Implicated factors The formation of these calcifications is not well under- stood, and many aetiological factors have been proposed: – Ageing: With age, the frequency of pulpal calcification increases because of a higher concentration of alkaline phosphatase, which could trigger calcification.1 – Excessive occlusal force: Such force causes changes to the pulp (hyperaemia, pulpitis, pulp ne- crosis, etc.). Tooth trauma causes damage to the neurovascular supply of the pulp and leads to vari- ous responses of the pulp, including tertiary dentine formation, pulp revascularisation, pulp canal calcifi- cation, chronic pulp inflammation, internal root re- sorption, pulp necrosis and infection of the root ca- nal system.6 – Long-standing irritants, such as caries, deep fillings, chronic inflammation, abrasion and orthodontic tooth movement. Additionally, a high prevalence of pulp stones has been reported in individuals with cardiovascular disease, kid- ney stones, gallstones and salivary gland stones. Also,
case report | pulp stones have been observed in females more than in males because they experience sleep bruxism more frequently.1, 5 First molars have a maximum number of calcifications compared with any other teeth because they are the first teeth to erupt and have a greater sur- face area and occlusal forces, perhaps leading to early degenerative changes.1, 5 Classification of pulp stones Pulpal calcifications have been classified by Kronfeld as: (1) true denticles (composed of orthodentine); (2) false denticles (composed of concentric layers of calcified ma- terial not resembling dentine); and (3) diffuse calcification (small calcified deposits scattered throughout the pulp tissue). However, most pulpal calcifications are conglom- erates of different tissues—orthodentine, and regular and irregular calcified material—so applying this classification becomes nearly impossible.4 In a calcified pulp, a slight increase in collagen content is present, but there is no evidence of an inflammatory response or the presence of microorganisms.7 In occlusal trauma and masticatory function, the den- tal pulps respond with a neurogenic inflammatory pro- cess in which substance P plays an important role in the direct and indirect mechanisms of angiogenesis by activating the neurokinin-1 receptors of cells such as fibroblasts, and endothelial and inflammatory cells, lead- ing to the formation of new blood vessels, which are needed as a defence mechanism, by stimulating the for- mation of mineralised tissue.8 These neuropeptides, sub- stance P, neurokinin A and calcitonin gene-related pep- tide, once released by the sensory fibres, have effects on the blood circulation, inflammatory process, immune re- sponses and connective tissue cells, and therefore they have an important role in inflammation and pulp pain.9 Further research is needed on the association between these neuropeptides and the pulp state for understand- ing more about pulp inflammation and dental pain. Types of calcifications Fig. 4 Fig. 5 There are two main morphological forms of pulpal calci- fications: discrete pulp stones and diffuse calcification. The discrete form appears radiographically as a round or ovoid opacity, and it is more common in the pulp cham- ber than in the root canal. The diffuse form is a gen- eralised calcification in a large area of the pulp cham- ber and canals. It is called calcific degeneration, and it is amorphous and unorganised.3 Fig. 6 Clinical signs The clinical signs are (1) a yellowish discoloration or re- duced transparency of the crown or even grey discolor- ation, although not all teeth with pulp obliteration undergo Fig. 7 Fig. 8 roots 1 2020 17
| case report Fig. 9 Fig. 10 a colour change;7 (2) a progressive decrease in the re- sponse to thermal and electrical pulp testing compared with adjacent teeth;4 and (3) generally asymptomatic.4 Radiographic findings Pulp stones are calcified masses present in any portion of the pulp. Coronal pulp stones are more common than radicular ones. Radiographically, they appear as dense radiopaque masses.5 To identify pulpal calcifications, previous studies have performed research on the prev- alence of pulp stones using panoramic, periapical and bitewing radiographs, as well as cone beam computed tomography (CBCT).1 Fig. 11 Complete or partial radiographic obliteration of the pulp cavity does not necessarily mean the absence of the pulp canal. In the majority of these cases, a pulp cavity with pulp tissue is present.7 Treatment Teeth with a negative response to sensitivity and tender- ness to percussion should be treated in cases of pulpal calcification, and any sign of a periapical infection is an indication for root canal therapy. In 2010, the American Association of Endodontists (AAE) advised clinicians to treat teeth with obliteration of the pulp in a careful way through clinical observation and periodic radiographic examination in view of the difficulties envisaged during this treatment. CBCT presents the tooth in all spatial planes, allowing exploration of the anatomy of the root canal, and can help in the assessment of pulp canal calcification. It is a non-invasive, reliable imaging modality with low radia- tion doses and has the advantage of reducing process- ing time. In 2015, the AAE and the American Academy of Oral and Maxillofacial Radiology updated their guidelines on the use of CBCT imaging in endodontics.10 When initiating the treatment, the use of a dental micro- scope is recommended, and during creation of the ac- cess cavity, straight-line access to the pulp is better than traditional access using different ultrasonic tips. Clinical Case 1 A fistula between the two maxillary molars was seen by the hygienist during a routine cleaning session of the patient. When the patient was transferred to my room, I inserted a gutta-percha cone into the fistula and took a radiograph (Fig. 1). Upon studying the radiograph (we will not discuss the molar in this article), I saw that the canine had a prob- lem. Legally, we are responsible for all the information re- vealed by the radiograph or on the area shown by the ra- diograph, which is why we always need to interpret very carefully the entirety of the radiograph and not focus only on what is considered the main problem. A CBCT scan was taken in order to understand better what was going on (Fig. 2). Looking at one sagittal cross section (Fig. 3), we can see clearly that the canine indeed had an apical infection and that there was a calcification in the middle of the root canal. The calcification was located at almost 16.3 mm, and the thickness of the calcification was almost 2.0 mm (Fig. 4). But this was not all the information that we could gain from the scan: at almost 16.5 mm and a bit beyond, by 0.2 mm, the canal was completely obliterated (Fig. 5). In Figure 6, it can be seen that the canal reopened after 2 mm but from the palatal angulation. This is crucial information, as when we opened the canal, we would need to choose a palatal angulation in order to access the orig- 18 roots 1 2020
case report | Fig. 12 inal part of the canal and to avoid any perforation in this area. Ultrasonic tips were used in order to open the canal and remove the internal calcification, allowing for the root canal therapy to be performed in a single session (Fig. 7). Clinical Case 2 A patient was referred to the office with signs of irreversible pulpitis of a mandibular molar. From the preoperative ra- diograph, we could see a deep filling, a very calcified pulp chamber and calcification extending to the roots (Fig. 8). After opening the access cavity under the microscope, we could see the amount of calcification (Fig. 9). Using the diamond ultrasonic tip, we were able to cut the calcifica- tion very carefully and create a second access cavity in- side the first one, where, with the help of ultrasonic tips and a clinical microscope, we were able to go as deep as we could inside the canals. Figure 10 shows complete ac- Fig. 13 cess to both distal canals and a bit of calcification left in- side the isthmus between the canals. The treatment was achieved in a single session (Fig. 11). Figures 12 and 13 show the structure of the pulp stones under a scanning electron microscope and the pulp stone blocking the dis- tal root beyond the middle part of the root (courtesy of Dr Alexey Volokitin). Editorial note: A list of references is available from the publisher. about Prof. Philippe Sleiman received his DDS in 1990, his DUA in 1995, and his PhD in 2006 at the Lebanese University School of Dentistry. He also received his CESE in Endodontics at Saint-Joseph University in 1999. He lectures interna- tionally and is currently Assistant Pro- fessor at the Endodontic Department of the Lebanese University Dental School. Prof. Sleiman teaches at the Lebanese University and University of North Carolina (USA). He achieved fellowship with the Inter- national College of Dentists and the American Association of Endodontists, and maintains private practices in Beirut, Leba- non, Dubai, UAE, and Oman. Prof. Sleiman is an international speaker in endodontics, collaborates in several undergoing re- search endodontic studies, and has a private practice limited to endodontics. roots 1 2020 19
| case report Root canal therapy with a modular NiTi system: A case report Dr Vishal P. Gandhi, India Fig. 1 Fig. 2 Fig. 1: Pre-op radiographic image of tooth #46. Fig. 2: Mesioangular radiograph with five root canals visible. Once in a while, some cases bring something extra to the operating table: unusual anatomical structures, such as a kind of additional main root canal, can add an incalculable variable to an already challenging 3D structure in the root canal system. The radiographic image in the following case revealed a rare specimen that almost resembled an octopus and required a spe- cial treatment with a modular, flexible nickel-titanium (NiTi) system. Case report: More canals in the pipeline a delayed reaction. In the preoperative radiograph, the diagnosis and the amazing anatomy of the tooth became apparent. Although human anatomy differs a great deal from case to case, the typical molar usually has no more than four main canals in its root canal system. However, the mesial root canal pattern of the molar in question showed some substantial side structures. The radio- graph almost resembled an image of an octopus with many arms attached to the body (Fig. 1). Acute pulpitis was diagnosed, and the patient consequently agreed to a non-surgical root canal therapy. A 42-year-old female patient presented to our dental clinic reporting problems affecting the mandibular right first molar. A standard cold test of tooth #46 showed Fig. 3a Fig. 3b Fig. 3c Figs. 3a–c: CM-treated NiTi files: new (a); save for reuse (b); and unwound (c). 20 roots 1 2020 According to our standard approach, the endodontic treatment naturally started with the isolation of tooth #46. We thus applied the mandatory dental dam to create a clean operating field, before gaining access. The first step then was to remove all caries from the affected tooth. Entering the pulp chamber gave us an idea of the true dimensions of the problem: the mesial canals were totally necrosed. Besides that, it was interesting to discover the unusual root pattern we suspected based on the radiographic images. The mesioangular radiograph showed how important it is to capture radiographs from different angles: it clarified the separate mesiolingual root and helped us to prepare the access properly (Fig. 2). In an unusual, winding root canal system, in general, the greatest challenge would be thorough canal preparation. We opted for flexible NiTi files that would allow for safe and efficient cleaning of the main canals.
case report | Fig. 4a Fig. 4b Fig. 4c Fig. 4d Fig. 4a: HyFlex CM 25/.08 orifice opener. Figs. 4b–d: HyFlex CM sequence: 20/.04 (b); 25/.04 (c); and 30/.04 (d). Very early on, international dental specialist COLTENE was one of the first suppliers of fracture-resistant NiTi files with the so-called controlled memory (CM) effect. CM-treated NiTi files are prebendable, but unlike conventional NiTi files, they do not bounce back. Owing to the special production process, certain physical qualities of the alloy are strength- ened, making the files both flexible and very fracture- resistant. The practice team can even see with naked eye whether the files can be reused without any problems: CM-treated NiTi files automatically resume their original shape when heated during sterilisation. Coming out of the autoclave, they should look like new with their characteristic winded shape. If they appear to be unwound and sporting an unregular form, they have reached the end of their life cycles and should be discarded immediately (Figs. 3a–c). Best-fit NiTi files for every canal Modular NiTi file systems like the HyFlex allow experts as well as beginners to compose their own set of instru- ments. Depending on their favourite working method and the given anatomical structures, they can choose from a wide range of special and universal files. In the case described in this article, we were able to use an almost identical sequence of HyFlex CM files to prepare all five main canals. To begin with, all the canals were scouted with a size 10 hand file, until a manual glide path was established. Then the actual preparation took place. For pre-flaring, a HyFlex CM 25/.08 orifice opener ( COLTENE) was used (Fig. 4a). Next, the HyFlex CM 15/.04 was inserted into the canal. With a gentle peck- ing motion, we proceeded up to working length. We then switched to the corresponding size 20 file with the same taper of .04 to approach the apex. The fine-tuning in the three mesial canals was achieved with the help of a HyFlex CM 25/.04. In the distolingual and distobuc- cal canals, the final instruments in the sequence were a HyFlex CM 25/.04 and the 30/.04 (Figs. 4b–d). The files moved smoothly through the centre of the canal and Fig. 5: GuttaFlow bioseal automix syringe, 5 ml. roots 1 2020 21
| case report documentation will confirm whether we were able to create a durable seal. At international meetings, my international colleagues and I often observe that the different shapes of root canals never cease to amaze the endodontic expert. No matter how many lateral canals, isthmuses and side structures you have seen in your career, there is always that one case that brings a special challenge to the treat- ment. On the one hand, such anatomical structures need flexible instruments. On the other hand, such root canals need a reliable obturation material that fills even remote areas and flows into parts of the 3D root canal system that cannot be reached otherwise. In India, many patients wait until the dentinal decay is already far advanced and a major part of the root canal system is necrosed. Sound, revision-safe root canal therapy helps to encourage people to seek treatment at an earlier point, when many conditions can even be resolved or managed far better. Conclusion Varying anatomical structures require flexible instruments that adapt to the individual situation in the root canal and move reliably in the centre of the canal. A modular NiTi system like HyFlex CM or EDM files allows endodontic specialists to choose from a range of special files, from glide path files and orifice openers up to finishing files of different sizes and tapers. A bioactive obturation material moreover flows into all kinds of lateral canals and pro- motes healing. Editorial note: A list of references is available from the publisher. This article is part of a three-part series titled So Many Roots to Travel and developed by COLTENE. In the series, endodontic specialists around the world discuss their most spectacular cases and show how they met the treatment challenge using modern NiTi instruments. contact Dr Vishal P. Gandhi is a specialist in micro-endodontics. He works in a pri- vate clinic in Ahmedabad in India. JAL Dental Clinic & Microscopic RCT hub Sector 3/466 Chankyapuri, Ghatlodia Ahmedabad – 380061 India Vishalgandhi1234@gmail.com Fig. 6 Fig. 6: Post-op radiographic image with visible obturation. did not become blocked at any point. The high flexibility helped us to gain a good feel of the exact curvature of the canal, as we used the tactile approach to scout the path one third by one third. It goes without saying that thorough rinsing following a strict cleaning protocol between instrument changes was crucial for a reliable overall result as well. For the chemical irrigation between the mechanical preparation, 5.25 % sodium hypochlorite and 17 % EDTA were used. This procedure also helps to reach side structures that cannot be cleared of debris and bacteria by file prepara- tion alone. In this case, there was a substantial coronal isthmus between two mesial canals, whereas in other patients, lateral canals are far more delicate and particu- larly difficult to reach. Different anatomical challenges The last step was to create a proper seal to prevent microorganisms from re-entering the root canal system and to protect the root from future recontamination. For an efficient and durable obturation, we chose GuttaFlow bioseal (COLTENE; Fig. 5) for the hydraulic condensation technique. The three-in-one obturation material com- bines fluid gutta-percha with a suitable sealer at room temperature and bioceramics in an automix syringe. This composition results in an easy-to-handle material with excellent flow properties and a working time of ten to fifteen minutes. The gutta-percha is warmed and can be pushed down with a plugger if it has not already begun flowing into all (possibly hidden) the canals itself. After polymerisation, the bioactive material forms hydroxyapatite crystals on the surface, significantly improving adhe- sion and actively encouraging the regeneration of bone and dentine. Almost like a traditional Indian healer, you thus do your magic and wait for the result to show in the final radiograph. The postoperative radiograph depicts the mighty octopus with its clearly recognisable arms, all reliably filled with gutta-percha (Fig. 6). The long-term 22 roots 1 2020
REGISTER FOR FREE! DT Study Club – e-learning platform Join the largest educational network in dentistry! www.DTStudyClub.com Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for one continuing education credit.
| case report Retreatment of a tooth with a double curvature Dr Gaizka Loroño, Spain Fig. 1a Fig. 1b Fig. 1c Figs. 1a–c: Intra-oral radiograph of the periapical area showing the apical lesion (a). CBCT image showing a curvature in the mesiodistal direction (b). CBCT image showing a curvature in the buccopalatal direction (c). Retreatments are a challenge for the majority of clinicians. While there may be various reasons for the primary failure, it always relates to inadequate cleaning of the endodont. It may also be due to a very complex canal system or failure to reach the working length, as in the case described here. A 51-year-old female patient was referred for treatment. The patient presented a non-contributory general med- ical history. The specific medical history of tooth #15 was sensitivity to percussion in the tooth and sensitiv- ity to palpation in the apical region of the same tooth. The intra-oral radiograph demonstrated an apical lesion in the periapical area. The suspected cause of this was pathologically altered pulp due to a previous treatment with infra-obturation (Fig. 1a). The cone beam computed tomography (CBCT) image confirmed the suspected apical lesion, and the analysis of the CBCT image identified a double curvature in the mesiodistal (Fig. 1b) and buccopalatal directions (Fig. 1c). The estab- lished diagnosis was symptomatic apical periodontitis in a previously treated tooth. Fig. 2a Fig. 2b Figs. 2a & b: Radiograph of the periapical area (a) and intra-oral view (b) with the VDW.ROTATE 20/.05 in the root canal. 24 roots 1 2020
case report | Fig. 3 Fig. 4a Fig. 4b Fig. 4c Fig. 3: EDDY irrigation tip in the root canal. Figs. 4a–c: Final obturation with gutta-percha and a synthetic resin-based sealer. Occlusal view (a). Intra-oral distal radiograph of the periapical area (b). Intra-oral orthoradial radiograph of the periapical area (c). After the administration of a local anaesthetic in the form of 3.6 ml of 2 % lidocaine with the addition of epi- nephrine (1:80,000), rubber dam isolation and access preparation were completed. Irrigation was carried out during all the preparation with a total of 12 ml of 5.25 % sodium hypochlorite (NaOCl). A size 2 Gates–Glidden bur and a VDW.ROTATE 25/.05 retreatment file (VDW) were used for the coronal gutta-percha removal. As the obturation was much too short, the unintentional creation of a ledge was suspected, and special care was taken at this point to avoid a further worsening of the situation. After removing the obturation material, the ledge was detected and overcome using pre-curved ISO size 8 K-type files (VDW). Next, the working length was deter- mined with the RAYPEX 5 apex locator (VDW). A glide path was obtained using ISO size 10 and 15 K-type files and then prepared using VDW.ROTATE 15/.04 and 20/.05 (Figs. 2a & b). The files were not used in the recommended sequence and single-length technique, but in combination with a crown-down technique. The crown-down technique makes it possible to widen the coronal section of the root canal to ease the passage of the file into com- plex areas and to reduce wall contact and therefore stress for the instruments. For that reason, as soon as VDW.ROTATE 15/.04 had bypassed the curvature, VDW. ROTATE 20/.05 was used to shape the section coronal to the curvature, in order to widen the canal and facilitate the arrival of VDW.ROTATE 15/.04 to working length. After VDW.ROTATE 20/.05 had also reached working length, it was decided to stop the preparation. This decision was made because apical gauging de- tected an ISO size 20 tugback and it was not necessary to widen the canal further. Final irrigation was carried out with 3 ml of 5.25 % NaOCl, 1 ml of 17 % EDTA and a further 3 ml of 5.25 % NaOCl. The irrigants were activated with an EDDY irrigation tip (VDW) with a frequency of 6 kHz for 30 seconds “The crown-down technique makes it possible to widen the coronal section of the root canal...” each (Fig. 3). After drying of the canal, downpacking and backfilling were carried out with a BeeFill 2in1 (VDW), using AH Plus (Dentsply Sirona) as a sealer (Figs. 4a–c). The tooth was then sealed with a tempo- rary material and the patient referred back for perma- nent restoration. contact Dr Gaizka Loroño Endodoncia Exclusiva Hurtado de Amezaga 20 48008 Bilbao Biscay Spain www.loronoendodoncia.com roots 1 2020 25
| trends & applications Testing a novel endodontic sealer Drs Paolo Generali & Francesca Cerutti, Italy Many different sealers are available on the market, but all of them ideally aim to have the following features: tissue tolerance, no shrinkage with setting, slow setting time, ad- hesiveness, radiopacity, bacteriostatic properties, absence of staining, solubility in solvents, insolubility to oral and tissue fluids, and easy handling.9 The different endodontic sealers are categorised based on their main components: zinc oxide eugenol (ZOE), calcium hydroxide, glass ionomer, resin-based, polydimethylsiloxane- based and bioceramic-based sealers. Resin-based sealers became popular because of their adhesive properties and have been reported to be used with the single gutta-percha cone technique for canal obturation;10 even bioceramic sealers can be used with this last technique.11 The most commonly used sealers in root canal therapy are ZOE-based sealers, modified for endodontic purposes based on Grossman’s or Rickert’s formula. The powder of these sealers contains zinc oxide, which combines with a liquid, generally eugenol. Zinc oxide is an environmen- tally friendly material with antibacterial properties and favourable characteristics in terms of biocompatibility, and it has been used widely in medical applications. Unlike resin-based sealers, which are subject to shrinkage, the setting reaction of ZOE-based sealers is chelation between eugenol and the zinc ion of the zinc oxide; this reaction might also occur between the zinc oxide phase of gutta- percha and the calcium ions of dentine. This might ex- plain the decreased setting shrinkage associated with ZOE-based sealers.10 Michaud et al. have shown that volu- metric expansion of gutta-percha (almost 135.35 per cent) occurred in contact with eugenol during a 30-day period, and a pilot study done earlier showed a remarkable in- crease in the gutta-percha dimensions when placed in eugenol that continued even after 4.5 years.12 Fig. 1 The aim of endodontic treatment is to eliminate micro- organisms and their by-products from the root canal sys- tem while avoiding recontamination.1–3 The outcome of endodontic treatment is strictly linked to several steps: root canal debridement, disinfection protocols and her- metic obturation of the canal space.4 Root canal obtura- tion in a 3D space with a stable, nontoxic material and the creation of a tight seal are fundamental for the success of the treatment, since the root filling seals communica- tion between the periodontium and the endodontium and, along with shaping and disinfection, allows further bacte- riological defence.5, 6 Sealers should be used to fill the morphological root canal system irregularities in order to avoid gap formation be- tween the dentinal walls and core materials; moreover, sealers should facilitate the placement of the filling core with a lubricant action, penetrate into dentinal tubules to pre- vent microleakage and entomb any remaining bacteria.2, 7, 8 Fig. 2a Fig. 2b 26 roots 1 2020
trends & applications | Fig. 3 Fig. 4 Theoretically, sealer penetration into dentinal tubules could improve sealing of a root filling by increasing the surface con- tact area between the root filling materials and dentinal walls. Furthermore, retention of root filling material might be im- proved by mechanical locking. However, contrary to common belief, a positive correlation between sealer penetration into dentinal tubules and sealability has never been established.13 Penetration refers to the amount of sealer entering the dentinal tubules, and adaptation qualitatively describes the way in which the sealer conforms to the dentinal wall. Penetration and adaptation depend on many factors, in- cluding the patency and density of the dentinal tubules.14 Russell et al. investigated the penetration and adaptation of common types of root canal sealers (AH Plus, Pulp Canal Sealer, MTA-FILLAPEX and EndoREZ) in cross sections of tooth roots exhibiting the butterfly effect to determine whether this differs between coronal and middle root sections.15 Penetration and adaptation quality varied be- tween obturation material groups, but this did not reach significance. AH Plus was reported as the best-performing material of the tested cements, and Pulp Canal Sealer and EndoREZ as the worst-performing. The superior adaptation and penetration of a sealer may be attributed to its pseudoplastic behaviour inside root canals; this has been described as a decrease in viscosity and an increase in flow parallel to an increase in shear rate during filling procedures. When using gutta-percha with sealer as a core material for filling the canal space, the amount of sealer should be kept to the minimum, whereas the amount of gutta-percha placed into the canal must be maximised.16 To reach the ideal consistency of the sealer, it is import- ant to calibrate the powder–liquid or paste–paste ratio of the mixed cement, because even small alterations to this ratio may cause a change in thickness and flow of the material, affecting its penetration and adaptation to the dentine. ZOE cements have some drawbacks, such as the capa- bility of staining the tooth and a setting time dependent on the heat or humidity of the environment. Many attempts have been made to improve ZOE powder–liquid sealers, adding various substances or substituting eugenol in the liquid component. This has given rise to a number of zinc oxide non-eugenol-based sealers. In 2019, a new sealer containing tea-tree essential oil ( EssenSeal, Produits Dentaires) was launched on the market (Fig. 1). Tea-tree oil is obtained from the native Australian Melaleuca alternifolia tree, or tea-tree, indigenous to northern New South Wales and southern Queensland.17 Tea-tree oil is a complex mixture of essential oils, com- prising approximately 100 components, most of which are monoterpenes and sesquiterpenes and their related alcohols.18 Tea-tree oil has been shown to possess a num- ber of therapeutic properties, including anti-inflammatory activity;18 antimicrobial activity against a wide spectrum of microorganisms, for example Staphylococcus aureus;19 a range of oral bacteria;20 certain viruses, including herpes simplex and influenza viruses;20 and many fungi, including some azole-resistant yeasts.21 Tea-tree oil has also demon- strated potential biofilm-inhibiting activity.22 In an animal Fig. 5 Fig. 6 roots 1 2020 27
| trends & applications Fig. 7 Fig. 8 study, tea-tree oil promoted healing of the extraction sockets and prevented alveolitis.23 Editorial note: A list of references is available from the publisher. According to Siqueira, the microbial flora present in failed canals has unique characteristics, consisting of extremely resistant bacterial strains and even yeasts, and these pathogens can survive in an inhospitable environment, of- ten organising in biofilms.24 Incorporating plant extracts or purified compounds derived from plants has become an emerging area of great interest in the medical and scientific community. Antibiotic resistance has directed researchers toward alternative therapies, including traditional plant-based medicines. Many such plants are those traditionally used by indigenous communities to treat infectious diseases.25 This is the case of tea-tree oil, which has been used thera- peutically for a long time, being one of the plants used in tra- ditional medicine by the Bundjalung Aboriginal Australians of northern New South Wales.26 Its use in an endodontic sealer for endodontic retreatment could be an example of the new trend towards the use of natural products derived from plants in association with conventional means in order to overcome problems due to microbiological resistance. EssenSeal is a highly flowable powder–liquid cement with a low paste thickness and should be mixed according to the manufacturer’s instructions: one drop of liquid to one spoon (provided) of powder. The clinical impressions of this sealer are positive: mixing and manipulation of the cement are easily done (Figs. 2a, 2b & 3), and the final product has a smooth consistency that allows easy placement of the gutta-percha cone into the root canal. The good flowabil- ity of the sealer and its capability of adapting to the canal preparation are appreciable and promote 3D sealing of the root canal system. In addition, this sealer diffuses a pleas- ant scent during manipulation and its white colour should prevent discoloration issues. A procedure performed on a freshly extracted tooth showed good penetration of the root canal anatomy and sufficient radiopacity (Fig. 4). A clinical case shows the good penetration of the sealer into the root canals and the absence of voids (Figs. 5–8). The white colour, the pleasant scent and the good handling make this product suitable for everyday endodontic treat- ment. In addition, the interesting properties of tea-tree oil against resistant microorganisms and biofilms particularly recommend its use in retreatment procedures. about Dr Francesca Cerutti graduated from the University of Brescia in Italy in 2007. In 2013, she obtained her PhD in materials for engineering from the same university, and in 2016, she completed a master’s degree in aesthetic medicine. She collaborates with Prof. Dino Re at the University of Milan in Italy, where she conducts clinical research and, since 2018, has been a visiting professor. She has published several articles in peer-reviewed journals and has co-authored books on restorative dentistry and endodontics. Dr Cerutti has spoken at national and international congresses on post-endodontic restoration and aesthetic reconstruction of teeth. She is a reviewer for international journals such as the Journal of Adhesive Dentistry, the European Journal of Paediatric Dentistry and Biomaterials. Dr Cerutti is a member of the Italian Society of Endodontics and served as editorial coordinator of the Giornale Italiano di Endodonzia from 2008 to 2011. She is a silver member of Style Italiano Endodontics. Dr Paolo Generali obtained his MD cum laude from the University of Pavia in Italy in 1983 and DDS from the Uni- versity of Parma in Italy in 1987. He was a visiting professor in restorative dentistry at the University of Modena and Reggio Emilia in Italy from 2004 to 2009 and again from 2017 to 2018. He also lectured in the postgradu- ate courses of restorative dentistry, and clinical and surgical endodontics at the same university. He taught the master’s course in prosthetic dentistry at the University of Bologna in Italy from 2009 to 2013 and the master’s course in endodon- tics and restorative dentistry at the University of Siena in Italy from 2016 to 2018. Dr Generali is an active member of the Italian Society of Endodontics and a gold member of Style Italiano Endodontics. 28 roots 1 2020
| manufacturer news Retractors for endodontic microsurgery Penn endo retractor set by Dr Syngcuk Kim These specially designed retractors for endodontic microsurgery have many special features not found in regular retractors (Fig. 1). The tips of all the retractors have a miniature 90° angled wedge of steel with serrations on the tips of the blades to provide an excellent grip on the bone without slipping. Regular retrac- tors do not have this feature, making them very prone to slipping, causing damage to soft tissue (Fig. 2). Fig. 1 The retractor set includes two ergonomic handles (Fig. 3) and seven retractor blades. The first blade is 12 mm wide, is angled at 15° and has a V-groove (Fig. 4). It is designed to follow the maxillary curva- ture, being convex and concave where the bone is not flat. The remaining six blades range from 12 to 15 mm in width, are angled at 15° or straight, and notched to the right or left (Fig. 5). During surgery, it is difficult to keep the jaw horizontal. As the jaw drops a bit during surgery, one needs a retractor to compensate for the minor tilt. These retractors are especially important for mandibular posterior surgery. These retractors are very effective when one uses a bone groov- ing technique, especially in the mandibular posterior area. A small, thin groove is made preferably using a piezo-surgery saw. The retractor tip is then engaged in the groove, keeping the retrac- tor stable during the surgery. Kohdent Roland Kohler Medizintechnik www.kohler-medizintechnik.de Fig. 3 Fig. 2 Fig. 5 30 Fig. 4
manufacturer news | Excellent overview of treatment materials VDW.FLO Endo Organizer Fig. 1 Fig. 1: The 16 trays are designed for common packaging sizes. Fig. 2: The VDW.FLO Endo Organizer. Fig. 3: Blank and preprinted stickers facilitate the indi- vidual’s own organisation scheme. Endo Organizer can be adapted to individual workfl ows with the aid of the corresponding labelling set of blank and preprinted stickers. The VDW.FLO Endo Organizer is made of easy-to-clean, robust plastic and features a non-slip silicone underside to facili- tate compliance with hygiene measures in practice. Integrated solutions for endodontics For over 150 years VDW has represented experience in the devel- opment and manufacture of products for endodontics. VDW devel- ops innovative ideas and produces optimised solutions to improve the clinical success of endodontic treatments. Today, VDW pro- vides a holistic range of solutions covering the entire endodontic treatment spectrum, from obturation to post-endodontic care. The company also offers numerous application-related advanced training programmes in endodontics. VDW www.vdw-dental.com Fig. 3 31 Fig. 2 VDW, one of the world’s leading manufacturers of endodontic solu- tions, began 2020 with the launch of its VDW.FLO Endo Organizer. This multifunctional plastic insert for drawers and equipment trolleys was specially developed to bring order to the materials used for endodontic treatment. The organiser fi ts the standard drawer and table sizes, and its compartments are precisely matched to the packaging of the relevant materials. At the beginning of February, VDW launched the VDW.FLO Endo Organizer on the global market. The multifunctional insert for drawers and equipment trolleys organises loose instruments and irrigation, obturation and post-endodontic materials in order to create a clear overview of the inventory. Used on a table, the organiser keeps all necessary materials tidy and readily at hand during treatment. Its 16 small, medium and large compartments are specially designed for common packaging sizes. The VDW.FLO
practice management | 5 essential steps Isn’t that easy? In order to cope with situations like the one that I have just described more effortlessly and effectively, follow these ﬁve steps: 1. Say that you’re sorry Immediately express your apologies to the patient who has been kept waiting and state how deeply sorry you are. If necessary and possible, interrupt the still ongoing previous appointment in order to do that. Here’s what you can say: “I promise that, next time, you will get the ﬁrst appointment of the day, so that there cannot be any delays whatsoever.” “The best dentist is the one that respects his or her patients by being punctual.” 2. Avoid excuses Don’t try to wriggle out of the situation by giving drawn- out explanations for why there are delays. It’s unprofes- sional and the patient probably won’t care anyway; he or she just wants to be treated. Patients come to you to have their problems ﬁxed and not the other way around. Implement the above-mentioned steps as a protocol in your daily practice and you will soon notice that you are in control again of time-related issues in the day-to-day work of your practice. Now knowing the exact steps to avoid and resolve unwanted situations created by poor time management, you will gain greater peace of mind in the long run. Moreover, I’m certain that you won’t end up losing patients (and possibly their families too) when following these steps. Just try them out and let me know what you think! I am sure that you are already looking forward to the next issue of the roots magazine, in which I will present the 11th part of this unique series of communication con- cepts and touch on further useful and interesting topics. Are you curious about what’s next? We will discuss how to attract patients from abroad and extend your patient base on an international scale. Wouldn’t you agree that the topic of medical tourism is extremely interesting? In addition to discussing the subject, I will provide seven crucial methods to achieve your goals. Until then, remember that you are not only the dentist at your clinic, but also its manager and leader. For questions and further information and guidance, don’t hesitate to reach out by sending me an e-mail at firstname.lastname@example.org or via our website, www.dbamastership.com. I am looking forward to our next step towards business growth and educa- tional development! 3. Give in order to receive Replace bad news with good news. For instance, tell the patient who has been kept waiting that he or she will receive a free laser-assisted treatment session to make up for the inconvenience caused. However, be prepared for possible negative reactions towards your offer. If that happens, show understanding and compassion. about 4. Make use of your assistant Instruct your assistant to always remind you of an up- coming appointment ﬁve minutes ahead. Your assistant can become your personal alarm. If there are any delays, also instruct him or her to let your next patient know for how long he or she will probably have to wait. By doing so, possible annoyance and irritation from the patient’s side can be avoided. Dr Anna Maria Yiannikos (DDS, LSO, M.Sc., MBA) is one of the ﬁrst two women worldwide to have obtained a master’s degree in laser dentistry. She has owned a dental clinic for 23 years now and is the leader of the innovative Dental Busi- ness Administration Mastership Course at RWTH Aachen University in Germany. contact 5. Make a change Start your daily programme earlier than usual each day. In addition, schedule some extra time for every appoint- ment, even if you don’t end up needing it. For instance, if you schedule 20 minutes per appointment, now plan for 30 minutes instead. I’m aware that, in the beginning, you probably won’t like it, but by doing so, you are already allowing for possible delays. Dr Anna Maria Yiannikos Adjunct Faculty Member of AALZ at RWTH Aachen University Campus, Germany DDS, LSO, M.Sc., MBA email@example.com www.dbamastership.com roots 1 2020 33
| feature Morbidity and mortality due to cardiovascular disease are low in Mediterranean countries. Epidemiological data indicates that the Mediterranean diet and polyphenol intake are cardioprotective factors. Remarkably, melatonin is a powerful antioxidant and anti- inflammatory agent promoting bone metabolism in the oral cavity. Therefore, a certain degree of synergy between melatonin and polyphenols has been hypo- thesised. However, the melatonin and polyphenols we get from our diet are far from effective in the oral cavity, because they should be administered as topical formu- lations to reach pharmacologically active concentrations in saliva and oral tissue and also bypass the Phase I and Phase II metabolic transformation by our digestive system. Low oral bioavailability represents the major drawback of dietary phytochemicals. Nonetheless, morbidity and mortality due to cardio- vascular disease are low in Mediterranean countries, and epidemiological data indicates that adherence to a Mediterranean diet and polyphenol intake are cardio- protective factors. As vaso-dilating, anti-thrombotic and antioxidant agents, polyphenols can mitigate endothelial dysfunction, reduce low-density lipoprotein oxidation and prevent atherosclerosis. Regular low to moderate red 38 roots 1 2020 “Dietary patterns involving plenty of fruit, vegetables and legumes have been associated with reduced risk and incidence of chronic degenerative diseases.” wine consumption at main meals has shown to be cardioprotective. Are there examples of organic plant compounds that have already become commonplace in the treatment of disease? A plethora of dietary supplements based on botanicals and nutraceuticals have been developed. However, these products are not drugs and care should be taken not to try to cure major diseases with dietary supplements. With regard to oral health, aloe vera gel and Melaleuca alternifolia (tea-tree) essential oil have proven to be effective as antimicrobial and wound-healing agents. Antibiotic resistance is becoming an increasingly common problem. Do you think a transition towards more organically sourced polyphenols in oral care products could offer a solution here? This is a very relevant topic. Antibiotic resistance is one of the biggest threats to global health, as is anti-cancer drug resistance. In this scenario, polyphenols could be promising natural antibiotics. Indeed, plant extracts rich in polyphenols can be active on different bacterial and fungal targets, thus reducing the risk of selecting resis- tant microbial populations. In addition, polyphenols can reverse chemoresistance by targeting some microbial resistance mechanisms. In this regard, polyphenols could be used as adjuvants in combination with con- ventional antibiotics with the goal of slowing down the occurrence of resistance. Lastly, has your research changed the way you eat and live? Yes, of course, even though I was already “ Mediterranean” before becoming a researcher. I am Italian and come from a southern region where traditional Mediterranean dishes are part of everyday life. The Mediterranean diet is one piece of the puzzle, but the Mediterranean lifestyle also includes sociocultural aspects relevant in terms of well-being, such as low- to moderate-intensity physical activity and of course conviviality.
the Nakao Foundation right after my 70th birthday and fi- nal retirement from the board of directors of GC Corp. Which problems are associated with an ageing population? What can we, or the Nakao Foundation, do to be prepared? While an ageing population is a long-term and global development, it is important to note that the impact and quality of this ageing can vary greatly. A healthy person will age differently than a sick person in terms of physical strength, quality of life, and cost of and possibility of requiring medical care. That is why the Nakao Foundation is seeking to promote oral disease prevention and healthy ageing through identification, prevention, disease man- agement and education. How can the experience and knowledge gained at GC aid the Nakao Foundation? What is the synergy between the two? The mission of GC is to develop and supply the products and information that practitioners need. Therefore, we be- lieve that we are in a great position: being able to respond appropriately to requests and developments from our foundation’s research support programme and being able to promote the mission of the Nakao Foundation through GC. “We want to support academic research, not for profit but because we believe this will make a significant and sustainable impact on people’s oral health.” The foundation is about to launch its ﬁrst activities. What can we expect? Yes, we are now at kick-off stage and just closed two board meetings, one with the foundation’s board and another with the management board, in which six world- renowned experts finalised a detailed procedure as well as the criteria for applying for funding. We will be starting the application process soon and encourage researchers to visit our website (www.foundation-nakao.com) on regular basis. The call for applications will also be for- warded to all International Association for Dental Research members. We want to support academic research, not for profit but because we believe this will make a signifi- cant and sustainable impact on people’s oral health. Thank you very much. feature | AD EssenSeal® THE POWER OF TEA TREE Join MyPd and get access to unique materials, case studies, clinical articles and webinars. Visit pd-dental.com for more information Produits D entaires SA . Vevey . S witzerland
meetings | was recently honoured with the International Association of Dental Research (IADR) Pulp Biology and Regener- ation Distinguished Scientist and the Journal of Dental Research Cover of the Year award. He has contributed the development of many endodontic programmes and served as an advisor and mentor to students. He is also a member of the AAE’s Editorial Board Committee. Ralph F. Sommer Award of the AAE, Louis I. Grossman Award of the AAE, Philanthropic award of the AAE Foun- dation, the Edgar D. Coolidge Award of the AAE, Louis I. Grossman Award of the French Association of Endodontists, LLUAHSC Vanguard Award for the Mission of Healing, Distinguished Dental School Research Award, Loma Linda University (LLU) Distinguished Investigator Award. Stephen P. Niemczyk, DMD, will be presented with the Calvin D. Torneck Part-time Educator Award. This award recognises a part-time educator in a predoctoral or advanced specialty programme in endodontics whose valuable contributions have demonstrated dedication to endodontics and instilled in his/her students the desire to pursue excellence in their careers. Niemczyk is an assistant programme director at Albert Einstein Medical Center with the Department of Dental Medicine and Post Graduate Endodontics. He was also director of endodontic microsurgery and clinical pro- fessor at Harvard University School of Dental Medicine. He has presented on hundreds of topics, contributed to or authored six books and 13 reports. He is the recipient of many awards, including consecutively receiving the Earl Banks Hoyt Award for Academic Teaching Excellence. Anil Kishen, BDS, MDS, PhD, is being honoured with the Louis I. Grossman Award. This award recognises an author for cumulative publication of significant research studies that have made an extraordinary contribution to endodontology. Kishen is a professor at the University of Toronto Faculty of Dentistry. He has published more than 135 journal publications, 20 book chapters, three books and co- invented eight patents/invention disclosures. He has received several awards including Enterprise Challenge Innovator (Singapore), American Association of Endo- dontists Foundation-Dentsply-Research Excellence and W.W. Wood Award for Excellence in Dental Education from The Association of Canadian Faculties of Dentistry. He is a prolific researcher whose work is focused on nano- biomaterials and phototherapeutics to fight oral health infections and improve patient outcomes. He specifically studies topics in endodontic infections and analyses interactions between host tissue and harmful bacteria. Mahmoud Torabinejad, DMD, MSD, PhD, receives the Ralph Sommer Award. This award is given to the prin- cipal author(s) of a publication of specific significance to the science and art of endodontology. Torabinejad was an adjunct professor at Loma Linda University, University of Pacific in San Francisco, University of California in San Francisco. He has presented on over 100 topics, authored 271 articles and has won the following awards: Iranian Gold Medal of Education, Alejandro M. Aguirre, MBA, DDS, is being celebrated with the Spirit of Service Lifetime Award. This award acknowl- edges a member who has demonstrated the true spirit of leadership either recently or over the years. “These particular individuals that the association is honoring are among the best within the endodontic fi eld...” Aguirre is an endodontist with Endodontic Associates Limited in the Minneapolis/St. Paul Metropolitan area of Minnesota. He has his master’s in business administra- tion and is a member or past member of local, state and national boards of different dental and volunteer organisa- tions. Aside from being a skilled endodontist, his back- ground also includes entrepreneurship, finance, business analytics, association management and leadership devel- opment, parliamentary procedure, diversity and inclusion, and consulting in all aspects of leadership especially on developing emerging leaders from traditionally under- represented groups. His community service work includes Minnesota Mission of Mercy, where he was the first chair of the committee and raised over $300,000 in cash do- nations and involved in passing a new state law to allow out-of-state dentists who want to come to Minnesota to treat patients to obtain a temporary license. Lynda L. Davenport RDA, FAADOM, will receive Honorary Membership, which is granted by the Board of Directors in acknowledgement of their significant contributions that have furthered the advancement of endodontics. Davenport is the practice manager for Endodontic Associates in Nashville. She has owned and managed a contracting business and was the president of a manufacturing com- pany. She was a professional track organiser for AAE events, served on the AAE’s Annual Meeting Planning Committee and was Chair of the Special Committee on Professional Staff Development. She currently serves at The Heimerdinger Foundation—Board of Directors and as chair of the Ambassador Committee, which is a non-profit to support patients undergoing cancer treatment with foods identified to fight the side effects of cancer treatment. roots 1 2020 43
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Online class taught by Dr. Arnaldo Castellucci: A MODERN APPROACH TO MICROSURGICAL ENDODONTICS duration: 1 hour | language: english/russian | Q&A | 99 € OBSERVE DISCUSS YOUR CASE ON DEMAND ALL DEVICES GUARANTEED Online classes taught by the world’s best doctors directly from their practice: www.MasterClass.Dental Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 1 continuing education credits. This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune Int. GmbH.
EXPAND YOUR MIND ADAPTIVE. EASY. SAFE. EFFICIENT. www.fkg.ch/xpendo
is coming to PRAGUE 20–23 May 2021 Prague, Czech Republic www.ROOTS-SUMMIT.com Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 18.5 continuing education credits. This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune International GmbH.