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

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

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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 | 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 dejarami@mac.com roots 1 2020 09

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

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

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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. 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 | 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

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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 | 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

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 dba@yiannikosdental.com 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 dba@yiannikosdental.com www.dbamastership.com roots 1 2020 33

practice management | m o c . k c o t s r e t t u h S / o d u t s a v i i s i v © site or in your office, people will pause. Telling your own story and using your own images will help to build trust between you and your patients before they even set foot inside your office. What role does continuing dental education play in ensuring high standards of care in dentistry, and what opportunities are open to dental profession- als who want to engage in continuing professional development? Continuing education is crucial to the future of dentistry. Once you assume you know it all, you’re dead. It’s im- portant to keep learning, to keep thinking and to keep challenging yourself. Dentists must continually refine their thinking both in order to learn about changes in the field and to keep growing personally and professionally. “Authenticity is critical to building a strong social media presence.” Fortunately, there are now more opportunities than ever for continuing education in a variety of formats. We’re no longer constrained by time and geography. Webinars, virtual conferences and online courses are all easily available. But continuing education can also be as simple as creating a Facebook group with your col- leagues to share the latest news and to ask each other for help. Dentistry is a profession of passionate lifelong learners, and the opportunities are endless. roots 1 2020 35

high intake of low-fat dairy products and healthy lipids— mainly from seafood—as well as low consumption of refined sugars, red meat and saturated fats. The ben- eficial effects of diets rich in plant foods—such as the Mediterranean one—can be ascribed, at least in part, to the huge phytochemical diversity of plant foods. Food plants typically contain hundreds of bioactive phyto chemicals, including polyphenols. Probably, poly- phenols, a class of widespread phenylalanine derivatives, including flavonoids, stilbenes and proanthocyanidins, have been the most investigated dietary phytochemi- cals in recent decades and represent a paradigm of the relationship between food and health. What are some examples of food sources rich in polyphenols? All plant-derived foods and beverages are significant sources of polyphenols, including fruit, vegetables, pulses, coffee, tea, cocoa and red wine. As I previously said, these metabolites arise from phenylalanine, an aromatic amino acid produced exclusively by plants. This implies that meat does not contain polyphenols, even though it is essential for a well-balanced diet. You described polyphenols as bioactive components. What does that mean for our health? Dietary polyphenols possess a number of well-demon- strated biological activities, since they are powerful in vitro antioxidant, anti-inflammatory, vaso-dilating, anti-thrombotic, antimicrobial and anti-cancer agents. This means that they can play a role in the prevention of cardiovascular disease, neuro- degenerative disorders and certain types of cancers. Indeed, oxidative stress and inflammation are mechanistically in- volved in the aetio-pathogenesis of the main chronic degenerative diseases, including some oral diseases, such as periodontitis. “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.” feature | m o c . k c o t s r e t t u h S / e r u t c a f u n a M t s e r o F s y x o F © You were the first researcher to touch upon the role plant compounds could play in periodontal regeneration. The ultimate goal of periodontal treatment is to achieve periodontal soft- and hard-tissue regeneration. In this regard, polyphenols can be considered as bone tissue protectants, suppressing osteoclast differentiation and activation, impairing bone resorption and improving bone anabolism–osteoblast activity and bone matrix synthesis. Polyphenols are strong antioxidants and are present in red wine. Is there any hope for wine lovers that red wine could benefit oral health? Red wine is an alcoholic beverage, and obviously, I advise against using it to cure oral disease. Some years ago, we suggested that melatonin, another compound significantly present in some typical Mediterranean foods and beverages as well as, more generally, in many plant foods, could explain, at least in part, the health- promoting effects of the Mediterranean diet by acting in synergy or additively with polyphenols and other bioactive phyto- chemicals, such as carotenoids and glucosinolates. Melatonin, present in red wine, is a powerful antioxidant and anti- infl ammatory agent promoting bone metabolism in the oral cavity. roots 1 2020 37

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.

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