Endo Tribune Middle East & Africa Edition No. 5, 2021
N L Y A L S O N F E S SI O O R T A L P N E D PUBLISHED IN DUBAI www.dental-tribune.me September-October 2021 | No. 5, Vol. 11 FKG Dentaire expands its endodontic motor range with new Rooter X3000 A cordless endodontic motor, which can reach high speeds. By FKG Dentaire SA FKG Dentaire presents the Rooter X3000, redefining endodontic stand- ards. This novel cordless endodin- tic motor combines technology, functionality, and adaptability in a 20 cm unit. It stands out for the fast- est speed on the market (3,000 rpm), ten programmable memories, and preset programs for different types of FKG files. Its ergonomic design, light weight, and 360° rotatable extra-slim contra-angle head ensure perfect handling and visibility. Every new FKG product responds to the most exacting needs of endo- dontists with leading-edge technol- ogy and uncompromising quality. The Rooter X3000 advances endo- dontics with a new cordless, brush- less endo-motor with integrated apex locator. Adaptability as technical keyword Benchmark speed coupled with guaranteed stability and precision are only the tip of the iceberg of Rooter X3000’s features. Adaptabil- ity reflects its core, starting with the four FKG presets: XP-endo Treat- ment, XP-endo Retreatment, RACE EVO, and R-Motion. This saves time for endodontists, who can rely on ÿPage A2 AD A S e r i a t n e D G K F © • H I G H S P E E D U P T O 3 0 0 0 R P M • F K G P R E S E T P R O G R A M S • F R E E D O M O F S E T T I N G S L E F T T O T H E U S E R • A D J U S T A B L E R E C I P R O C A T I N G A N G L E S • E X T R A S L I M C O N T R A - A N G L E H E A D • B U I L T - I N A P E X L O C A T O R • B R U S H L E S S E N D O M O T O R • W I R E L E S S C H A R G I N G • L O N G L I F E B A T T E R Y • A P I C A L F U N C T I O N S www.fkg.ch
A2 ◊Page A1 manufacturer’s predefined recom- mendations for each file type. The endodontic motor also provides ten user-programmable memories for all modes (EAL, CW, CCW, REC, or ATR), more than 60 speeds, and—of course—a high-precision built-in apex locator and a range of automat- ic apical functions. ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 5/2021 Agility as practical credo As with any device, practice validates innovation. With its ergonomic handpiece weighing only 157 g, perfect balance, and fully rotatable ultra-slim contra-angle head, the Rooter X3000 ensures a comfortable grip, agile handling, and excellent visibility of the operating field. FKG has designed and developed all de- tails to provide maximum freedom of use to the practitioner, optimizing both speed and efficiency. Features include complete adaptability of the device and its display for both left- and right-handed users, a broad range of user-controlled settings, extensive file brand compatibility, wireless charging stand, and volume control. For further information, contact the FKG Dentaire team: FKG Dentaire SA Crêt-du-Locle 4 CH-2304 La Chaux-de-Fonds Switzerland Tel. +41 32 924 22 44 Email: firstname.lastname@example.org Web: www.fkg.ch FB: www.facebook.com/FKGDentaire Principle-driven endodontics: Proven case results By Drs Brett E. Gilbert & Richard Mounce, USA This article was written to demon- strate that the application of proven literature and/or evidence-based endodontic principles leads to excel- lent clinical results, irrespective of the materials used. We will describe the key points to achieving excellent results in initial non-surgical endo- dontic treatment in the key areas of diagnosis, shaping, irrigation, obtu- ration and restoration. Assessing “proven” and “literature-/ evidence-based” techniques and ma- terials is easier said than done. We cannot prove by high-level studies that warm obturation is better than cold lateral condensation, nor can we prove that activated irrigation is superior to passive cold irrigation, among a host of other such clinical questions. However, lower levels of evidence in studies certainly lead us to adopt new techniques but not with the confidence that the efficacy can be proved without doubt to be an improvement over older techniques. Fig.1: Sodium hypochlorite accident post-op, extra-oral. Fig.2: Sodium hypochlorite accident approximately ﬁve months post-op, intra-oral (dif- ferent case from that shown in Figure 1). Fig.3: Calcium hydroxide extruded into the mandibular canal through a perforation. An example is a study by Gutarts et al., which showed that 1 minute of ul- trasonic activation of irrigating solu- tion resulted in significantly cleaner canals histologically in the mesial root of mandibular molars.1 This is a low level of evidence (in vivo/ex vivo, low N), but certainly compelling and a valid justification to adopt the tech- nique.1 We will incorporate many of these references, but we want to em- phasise that Level 1 studies are not in place to validate these techniques to the highest possible evidence levels. The above notwithstanding, regard- less of philosophies and corporate relationships, it is the overwhelming preference of endodontists globally to use warm obturation techniques and activated irrigation (concepts discussed in greater detail later in this article). Specialist preferences also are hedged by the eyeball test, the visual evidence that is observed in treatment in comparison with pri- or techniques. Hence, this article will focus on key technique objectives that universally are agreed upon. As a starting place, before ever pick- ing up a syringe, the two single great- est prerequisites for creating excel- lent endodontic results are time and comprehensive treatment planning. It is essential that the clinician have enough time to carry out the treat- ment in a relaxed but productive environment, in essence, practising with high efficiency. It is axiomatic that the clinician only starts cases that he or she believes he or she can finish well and never treats a patient solely for money. All procedures must be carefully pre-planned. Such treatment plan- ning includes performing high-level imaging and a thorough clinical ex- amination to determine a definitive diagnosis. Preoperative treatment planning includes informed consent, assurance of restorability, profound pain control (local anaesthesia), visu- alisation and magnification (surgical microscope), instrumentation (stain- less-steel and nickel-titanium [NiTi]), irrigation and disinfection protocols, obturation and coronal seal strate- gies prior to endodontic access. A lack of treatment planning strategies is the harbinger of endodontic mis- adventure (Figs. 1–3). While a discussion of each principle- driven step required in a first-time endodontic procedure would fill a textbook, there are a number of key features of well-treated cases that are showcased in this article. Please see the caption that accompanies each case and describes its application of the principles discussed. As a starting place, assuming a thor- ough examination and indication i r e l s o R o g r e S r D © Fig.4: Cleared tooth showing the true complexity of the anatomy within this molar tooth. for treatment in addition to de- tailed informed consent, the most difficult gateway to comfortable patient treatment is anaesthesia for the “hot” mandibular molar. Flu- ency with the Gow-Gates injection as well as intraosseous anaesthesia (X-Tip, Dentsply Maillefer) will in large measure eliminate shortcom- ings in anaesthesia when standard block injections do not profoundly anaesthetise an anxious patient with a severely inflamed pulp. is Managing complex anatomy much simpler if the clinician has a preoperative road map. The CBCT scan provides the road map and the surgical microscope the lens (liter- ally) through which to visualise the result. Aside from a relaxed patient who is profoundly numb, being able to visualise anatomy by taking a pre- operative (and possibly intra-opera- tive) CBCT scan and using a surgical microscope during treatment has no substitute. These methods are the current gold standard in that 3D im- aging shows the clinician the true re- ality of a clinical situation as opposed to the suggestion gained from a 2D radiograph. Proper interpretation of imaging prior to and/or during en- dodontic treatment goes a long way towards taking the guesswork out of identifying canal location and other anatomical complexities as the pro- cedure unfolds. In a 2014 study by Ee et al., it was determined that, with a preoperative CBCT scan, compared with 2D radiographs alone, the treat- ment plan was modified 62% of the time.2 That the information gained from 3D imaging changed the plan of treatment more than six times out of ten is a significant game- changer (Fig. 4).2 While there are many preoperative clinical features to be considered prior to starting treatment, the key pre-operative decision points are the patient’s medical and dental history and anxiety level, the position of the tooth, space limitations to reaching the tooth and the canal anatomy. It is incumbent on the clinician to assess ÿPage A3
Dental Tribune Middle East & Africa Edition | 5/2021 ENDO TRIBUNE ◊Page A2 Fig.5a Fig.5b l z r o b A m a S r D © Fig.6a Fig.6b A3 n a h C x e l A r D © Figs.5a & b: Case treated with Chlor-XTRA and SmearOFF with EndoUltra activation. Note the excellent cone ﬁ t and apical control of obturation. Figs.6a & b: Case treated with Bassi Logic controlled memory NiTi ﬁ les. Note the visualisation of the third root on this mandibular molar and conservative canal preparation shape. Fig.7a Fig.7b Fig.7c Fig.7d Fig.7e Fig.7f Fig.7g Figs.7a–g: Cased treated with PIPs (photon-induced photoacoustic streaming). Note the oriﬁ ce barrier placed in composite to protect the endodontic treatment from coronal leakage. Fig.8a Fig.8b Figs. 8a & b: Case treated with a bioceramic master cone, sealer and putty. Note the excellent apical control in this blunderbuss apex. t r o h S o c i R r D © every aspect of the case prior to ini- tiating treatment and to give the pa- tient a detailed assessment of what treatment is being recommended. Access should be large enough to enable visual and tactile control, but not so large as to structurally weaken the tooth. Only as much dentine as required to enable ad- equate cleaning and shaping should be removed, effort being expended to always debride the tissue from the pulp horns and other hidden anatomy within the coronal portion of the tooth. Neelakantan et al. deter- mined that orifi ce-directed dentine conservation access design (ninja access) signifi cantly compromised debridement of the pulp chamber.3 Therefore, common sense is the best guideline when access design is considered, assuring that the pulp chamber and all pulp horns are de- brided.3 Tooth anatomy for the most part indicates how much time will be required using hand fi les for canal negotiation, especially with calci- fi ed canals. Calcifi cation requires fl uency with ultrasonic instrumen- tation to know which tips and units are required to enable the clinician to remove restrictive dentine. For example, in a C-shaped mandibular second molar, using a bur in the fur- cation predisposes the canal to a fu- ture fracture. Alternatively, using the appropriate ultrasonic tip pre-serves tooth structure and enables a precise removal of tooth structure. There are literally dozens of instru- mentation systems available glob- ally at this time. One of us (BG) uses the Twisted File (KavoKerr) and the other Bassi Logic (Bassi Endo). This notwithstanding, the goals of canal shaping are identical regardless of the system used. Regardless of the instrumentation system used, pa- tency is always sought during canal scouting and instrumentation. Clini- cians can debate the relative merits of reciprocation versus rotary mo- tion, optimal austenite fi nish tem- peratures (austenite transformation temperatures that control whether a fi le undergoes martensitic trans- formation), controlled memory fi les ground by computer numerical control machines versus twisting NiTi in R phase, along with a multi- tude of different similar clinical is- sues. Regardless of these nuances, it is the adherence to basic principles of canal preparation that fi les create a pathway from the coronal to the apical aspect to allow irrigant to fl ow into all of the canal ramifi cations, cleaning the root canal system and optimising clinical success. philosophies differ, the minimum fi - nal prepared taper should be .04 and the minimum fi nal prepared apical diameter size 30 (depending on the initial size of the foramen). Given the advent of controlled memory NiTi, there is little indication for larger tapers, especially in fi ne 3D apical curvatures. The goals of canal preparation in- clude keeping the canal centred in its original position within the root structure and keeping the api- cal foramen at its original position and size. One of the hallmarks of all the cases illustrated is that the api- cal foramen has been respected. Specifi cally, it has not been moved, transported, zipped or altered in any way. Reaching the apical constric- tion without transporting the canal and eliminating all debris from the canal and providing a tapering fun- nel from orifi ce to apex is a key canal preparation objective. The fi nal prepared canal shape should be large enough to irrigate and obturate, but not so large as to structurally weaken the tooth. For practical purposes, while treatment As mentioned, patency is essential because its obtainment means that the clinician can always reach the apex during every phase of treat- ment, and its loss means that tissue, toxins and bacteria can remain de- spite irrigation procedures, especial- ly in the apical third. Apical debris is the harbinger of iatrogenic events, including canal transportation, zip- ping, irrigant extrusion and a lack of optimal canal cleaning. Conceptually, root canal system cleansing can be divided into a macro-phase and a micro-phase. Debridement with fi les is the macro- cleaning. Removal of bacteria and biofi lm from the canal walls and dentinal tubules with antimicrobial solutions is the micro-cleaning. i l m l E a u a P r D © During preparation, it is axiomatic that debris should be removed as quickly as it is produced regardless of whether it is in the chamber or ca- nals. Inserting a NiTi fi le into a dry ca- nal full of debris in an effort to make apical progress is the harbinger of blocked canals and separated fi les. This action packs the fi ne 3D anat- omy (apical deltas, fi ns, cul-de-sacs, isthmuses, etc.) of canals with debris that can become much more diffi - cult to remove later in the treatment process. Alternatively, irrigating after the insertion of every fi le and recapitulation with hand fi les is ideal to prevent the subsequent build-up of debris, improve circulation of ir- rigant apically and optimise irrigant refreshment. Today’s rotary fi les are designed to funnel debris out of the canal in a coronal direction, further facilitating the debris removal. Irrigation regimens differ widely, but the goal of removal of all organic and inorganic material, bacteria, bio- fi lm and toxins from the root canal space is universal. After the canal is prepared, irrigation should be copi- ous. The average volume of sodium hypochlorite (NaOCl) delivered dur- ing treatment at the specialty level is approximately 20–50cm3 per case or more for a molar tooth. The volume of liquid EDTA ranges from 5cm3 to 10 cm3 per case or more for a molar tooth. The utilisation of surfactants and enhanced solutions is common at the specialty level. For example, Chlor-XTRA (Vista), ChlorCid Surf (Ultradent) and Hypo- Pure Pro (Kerr Endodontics) are pharmaceutical- grade NaOCl solutions that possess surfactants which reduce solution surface tension and optimise canal wall wetting. Palazzi et al. showed that NaOCl with the addition of sur- factant had better penetration into dentinal tubules than did NaOCl ÿPage A4
A4 ◊Page A3 ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 5/2021 Fig.9a Fig.9b Fig.9c Fig.9d Fig.9e Fig.9f t r e b l i G t t e r B r D © Figs.9a–f: Case assisted with CBCT to determine the anatomy preoperatively. Note the multiple cross sections moving apically and the correlation to the 2D view. Note also the conservative taper in relation to the root width. Fig.10a Fig.10b Fig.10c Figs.10a–c: Note the expert management of the apical constriction and the acute curvature of the mesiobuccal root. Fig.11 a c n e h o C r o t s e N r D © Fig.11: Note the degree of penetration of sealer and gutta-percha be- tween the primary canals. Obturation of this space demonstrates both the macro- and micro-cleaning referred to in the article. Fig.12a Fig.12b Figs.12a & b: Note the attention to detail required to locate all of the canals in this exceptional case done under the surgical microscope. a c n e h o C r o t s e N r D © n a m r e b l i S n a i r d A r D © alone.4 Surfactants also improve tissue dissolution and oxidising potential. NaOCl solutions are only chemically effective against the or- ganic component of canal debris, and so EDTA, a chelator, is also used to remove the inorganic component of canal debris, including the smear layer. SmearOFF (Vista) is a 17% EDTA solu- tion which also contains surfactants as well as chlorhexidine (a powerful antibacterial solution). A commer- cial alternative to SmearOFF is QMix (Dentsply Sirona). Unlike QMix (which contains chlorhexidine and EDTA), SmearOFF can be mixed with Chlor-XTRA without a rinsing step, as no unwanted precipitates are pro- duced by their mixture (Figs. 5–7). The clinician should know where he or she is in the canal at all times when irrigating. Recommended needle gauges vary depending on the size of the initial and prepared fi nal canal shape. For the majority of canals, a 27-gauge needle is adequate, but in fi ne canals, a 31-gauge needle can be appropriate. Needle tip designs can include side-ported and close-ended or side-vented among many possible confi gurations. The placement of a NaOCl solution like Chlor-XTRA to remove bacteria and organic material and SmearOFF to remove the smear layer and inor- ganic debris using a 27- or 31-gauge needle approximately 2mm from the apex ensures penetration of these irrigants into the apical third. Irrigation needles should never be locked by the canal walls. Irrigant delivery is always passive and the needle is moved gently, slowly and vertically a few millimetres at a time during extrusion. Under the surgi- cal microscope, irrigant delivery, as described above, occurs with precise control. It is noteworthy that larger syringes (10–12cm3) require more pressure to extrude the solution relative to a 3cm3 syringe. It is imperative that the clinician appreciate how much pressure he or she is using on the plunger. One unique alternative to plastic syringes is the Auto- Syringe (Vista) device, which accepts any Luer lock needle tip and extrudes ir- rigant at various speeds, depending on the setting selected. One of us (RM) uses it routinely (Figs. 8 & 9). tion methods enhance the antibac- terial effects of irrigants and result in cleaner canals relative to passive syringe irrigation. In addition, acti- vation removes the accumulation of air bubbles at the apex, which is otherwise known as vapour lock. Air bubbles left at the apex owing to pas- sive syringe irrigation diminish the apical penetration of irrigants. One of us (BG) utilises a combination of ultrasonically activated and apical negative pressure techniques (Endo- Vac) and the other utilises ultrasonic energy (EndoUltra). Regardless of which method is utilised to deliver irrigant to the apical third, it is most critical that the clinician activates the irrigant and does not rely simply on cold passive syringe irrigation. While protocols vary, activating each primary irrigant (both SmearOFF and Chlor-XTRA, for example) three times in each canal for 20 seconds is a sound clinical strategy (Figs. 10–12). Irrigant activation At present, there are many ways to deliver and activate irrigant for op- timisation. These methods include apical negative pressure (EndoVac, Kerr),5 sonic activation (EndoActiva- tor, Dentsply Sirona), ultrasonic acti- vation (EndoUltra, Vista),6 multison- ic activation (GentleWave, Sonendo),7 laser activation (PIPS, Fotona)8 and mechanical activation (Finishing File, Engineered Endodontics; Bassi Clean, Bassi Endo). All of these activa- GentleWave deserves a special men- tion, as it is unlike the other activa- tion systems available. GentleWave delivers a multisonically activated degassed solution (to remove air bubbles that dissipate energy) with negative to neutral pressure deliv- ered via a handpiece over the access in a closed system. The literature basis sup- porting the system shows impressive cleansing of the root canal systems, but a defi nitive high- level study on improved healing has not been published to date. The sys- tem costs approximately $80,000 per console and $50–$100 per one- time use handpiece. Its future appli- cation and expansion globally will be interesting to observe. And fi nally, the literature is conclu- sive that placing a post-endodontic coronal seal at the time treatment is completed, under a dental dam, is closely associated with endodon- tic success. Please note that all of the cases illustrated had some form of orifi ce barrier or build-up placed under the dental dam at the time of treatment. This article has stressed literature- based proven treatment principles over a particular manufacturer’s devices or technique recommenda- tions. Emphasis has been placed on an accurate diagnosis, conservative access, patency, minimal taper, ac- tivating irrigation, 3D warm obtura- tion and the placement of a post en- dodontic coronal seal at the time of treatment under the dental dam. We welcome your feedback. Editorial note: A list of references is available from the publisher. This article was ﬁ rst published in roots—the international magazine of endodontics U.S. edition vol. 9, issue 1/2019. About the authors Dr Brett E. Gilbert graduated with a DDS from the University of Maryland School of Dentistry in Baltimore in the US in 2001 and completed his postgraduate training in endodontics at the same dental school in 2003. He is currently a clinical assistant professor in the Department of Endodon- tics at the University of Illinois at Chicago College of Dentistry and on staff at AMITA Health Resurrection Medical Center Chi- cago, both in the US. He is a past president of the Illinois As- sociation of Endodontists. Dr Gilbert is a diplomate of the American Board of Endodontics. He was named a top ten young dental educator in America by the Seattle Study Club in 2017. In 2019, he was named to Academic Keys’ Who’s Who in Dentistry Academia. Dr Gilbert lectures nationally and internationally on clinical endodontics. He has a full-time private practice limited to endodontics in Niles in Illinois in the US. He can be contacted via his website, www.drbrettgilbert.com. Dr Richard Mounce, DDS, lives on the Or- egon coast and practises part time in Ea- gle River in Alaska, both in the US. He has lectured globally in more than 30 coun- tries, is widely published in dental trade magazines and has consulted for a large number of endodontic companies. His favourite current pastime is beach- combing with his dog, Zinho. He can be reached at richardmounce@ mounceendo.com.
Dental Tribune Middle East & Africa Edition | 5/2021 ENDO TRIBUNE A5 The role of gold NiTi and magniﬁcation in our daily endodontic practice By CAPP / Dental Tribune MEA LONDON, UK: CAPP, Centre for Ad- vanced Professional Practices will hold a hands-on course on 14 Octo- ber that will focus on a role of Gold NiTi in an endodontic practice. The course will be led by Prof Edmond Koyess from Leabanon. In his presentation, Koyess will dis- cuss the problems related to shap- ing curved and calcified root canals. He will discuss the classification of NiTi files according to the evolution of design and processing and this will help interpret the scientific data related to the physical properties of the new generation “gold” NiTi files. This dental hands-on course will explain the recommended steps for safety and security in shaping narrow and curved difficult canals, and additionally will describe the dy- namics of reciprocating and continu- ous rotating files to achieve the goals of enlarging and cleaning the canal • • • Discuss the classification of NiTi files Understand the scientific data related to the physical prop- erties of the new generation “gold” NiTi files Explain the steps for safety and security. recommended To learn more about this and other dental hands-on courses offered by CAPP, please visit www.cappmea. com/courses. For more information contact: space. At the end of the lecture, Koy- ess will conclude on clinical-based experience and a comparison be- tween both types of files. It will iden- tify the indication of each type of file. Additionally, Koyess will conclude on take-home messages of security and efficiency in shaping difficult root canal systems. The main learning objectives for the hands-on course are: • Discuss the problems related to shaping curved and calcified root canals CAPP EVENTS & TRAINING Onyx Tower 2 | Ofﬁce P204 & P205 The Greens | Dubai | UAE P.O. Box: 450355 Mob: +971 50 2793 711 E-mail: email@example.com Artiﬁcial neural network evaluation might help predict postoperative root canal treatment pain By Dental Tribune International WUHAN, China: Patients frequent- ly suffer from postoperative pain, which is why information about pre- cise medication is urgently needed by dentists today. In a recent study, an artificial neural network (ANN) model was used to predict pain after root canal treatment (RTC), which is of clinical importance for doctors in order to improve the quality of treat- ment, establish optimised treatment plans and reduce the occurrence of medical disputes. In the field of nature-inspired algo- rithms, ANN has had the most recent rapid development. It is a system based on human brain structure and function imitation that can be ap- plied to analyse the relationship be- tween various predictors. ANN can be used to predict medical results by selecting proper neural network structures and training weight and can be used for disease diagnosis, prognosis and clinical decision-mak- ing. It is reported that ANN may make it possible to identify important varia- bles and predict post-treatment pain with high accuracy. This study by researchers from Wuhan University aimed at evaluating the accuracy of the back propagation (BP) artificial neural network model for predicting postoperative pain after RCT. The BP neural network model was developed using MATLAB 7.0’s neural network toolbox, and a func- tional projective relationship was y a b a x P / s i m a i l l i W - y m m a S © Root canal procedures are commonly perceived as painful dental treatments. Individual postoperative therapy could offer relief to many patients. established between 13 parameters, (including personal factors, inflam- matory reaction factors and opera- tive procedure factors) and the post- operative pain experienced by the patient after RCT. This neural network model was trained and tested based on data from 300 patients who underwent RCT. Of these cases, 210, 45 and 45 were allocated as the training, data validation and test samples, respec- tively, to assess the accuracy of pre- diction. Study authors Xin Gao and Xing Xin and their team found that the accuracy of this BP neural net- work model was 95.6% for the pre- diction of postoperative pain after RCT. clinical reference in the future. The scientists concluded that the BP network model could be used to predict postoperative pain after RCT and showed clinical feasibility and application value. Therefore, the proposed method could be used as a The study, titled “Predicting post- operative pain following root canal treatment by using artificial neural network evaluation”, was published on 26 August 2021 in Scientiﬁc Re- ports.
A6 ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 5/2021 Interview on environmental sustainability in endodontics By Monique Mehler, Dental Tribune International Over the years, researchers have investigated the total annual car- bon footprint of dental services in various countries. Now, a life cycle assessment (LCA) was conducted at the Faculty of Dentistry at Malmö University in Sweden in order to in- vestigate and evaluate the environ- mental impact of a routine two-visit root canal treatment. In an interview with Dental Tribune International, the three main authors Linnea Borg- lin, Drs Hal Duncan and Brett Duane shared some insights into the fi nd- ings. What inspired your research team to analyse the global resource use and environmental output of the endodontic procedure? Borglin: This study originated from a master’s thesis at Malmö University. Duane: Stephanie Pekarsi, our co- author, Linnea and I tried to think of three fairly resource-intensive el- ements of dentistry that we should study and decided on periodontal treatment, an examination and an endodontic procedure. This paper came from the third study. Were there any challenges you had to face during the LCA? If so, what were they? Duane: It was a challenge measuring all the elements. Also trying to fi nd specifi c energy use of equipment, for example the autoclave and the washing detergent used to wash den- tal clothing! Why did you decide not to include travel to and from the dental clinic in your assessment methodology? Research suggests that staff and patient travel make up the most signiﬁ cant percentage of carbon dioxide emissions. Duane: Travel was central to earlier English and Scottish studies. In this study, we wanted to concentrate on the materials and processes over which we have a greater degree of control; hence we excluded travel. AD Borglin: In this way, we could focus on identifying other environmental- ly harmful processes more specifi c to an endodontic procedure. I have been conducting some re- search regarding eco-friendly den- tistry, and my feeling is that sus- tainability is not a top priority for the average dental professional. Do you agree with this conclusion? And if so, what do you think are the main reasons that hold dentists back from reducing their carbon footprint? Duane: Many dentists are trying to survive fi nancially and juggling all the additional protections needed for patients so when you mention sustainability, you can get blank looks. I think it wasn’t a priority at all say 5 years ago, but there is a growing number of dentists, especially in the younger generation which realise the importance and relevance of this area of dentistry. There are so many barriers to dentists being involved in sustainability and there are few fa- cilitators. We need a comprehensive programme of education, an incen- tivisation programme; basically, sus- tainability needs to be normalised and embedded in everything we do. Do you have any tips for the endo- dontic team on how they can re- duce the environmental burden of endodontic care? Duncan: As modern root canal therapy uses a large number of in- struments such as fi les, which in many jurisdictions are considered to be of single use only, the drive to- wards more sustainable endodontics should fi rstly be aimed at reducing the number of patient visits. Single visit treatment will reduce factors such as the number of fi les, sterilisa- tion costs, and patient and operator time. A second way to improve sus- tainability would be to limit expo- sure and to consider vital pulp treat- ment for cases exhibiting symptoms of pulpitis. The employment of minimally techniques where possible reduces treatment times, cost and instrument use and, in doing so, the environmental bur- den. Finally, if local rules allow, and if compliance with cross-infection regulations can be ensured, instru- ments should be reused. invasive Editorial note: The study, titled “En- vironmental sustainability in endo- dontics. A life cycle assessment (LCA) of a root canal treatment procedure”, was published on 1 December 2020 in BMC Oral Health. 9 1 0 2 / 1 0 d e t a e r c – 9 1 0 2 / 0 0 / 0 0 0 V D A Y M N T N E B / R D B . y l n O x R a n o r i S y l p s t n e D 9 1 0 2 © dentsplysirona.com/trunatomy #trunatomy TruNatomy™ Irrigation Needle TruNatomy™ True, Natural, Anatomy TruNatomy™ Orifice Modifier TruNatomy™ Glider • More space for debridement & debris extraction • Respect of the natural tooth anatomy • Preservation of tooth integrity while allowing for appropriate irrigation, disinfection and obturation For a truly smooth, controlled and efficient experience. TruNatomy™ Prime Endodontic File TruNatomy™ Prime Absorbent Points TruNatomy™ Conform Fit Gutta-Percha Points . c n I