issn 2193-4673 • Vol. 18 • Issue 1/2022 roots international magazine of endodontics 1/22 including special interview ROOTS SUMMIT “is not to be missed” case report Automatic assistance: Freedom to navigate root canals technique High-end technology for simplicity
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editorial | Steve Jones Co-chairman ROOTS SUMMIT ROOTS SUMMIT 2020 2021 2022! “Third time’s the charm” is our rallying cry as we close in on this year’s ROOTS SUMMIT. When the world entered a pandemic two months before the originally scheduled dates, we thought we would reschedule the event for a couple of months later. Who knew it would be a couple of years? To appreciate the global appeal of ROOTS SUMMIT, you need look no further than our speakers list, which includes dentists from the Czech Republic, Egypt, France, Guatemala, India, Israel, Italy, Lebanon, Portugal, Romania, Spain, Switzerland, Syria and the US. After this extremely stressful, upsetting and isolating time for all, many of our participants are suddenly af- fected by war on their border. Let’s hope that the mad- ness of this war in Ukraine will soon end. During this heartless and brutal time, it is more important than ever that we get together as friends, learning and improving our skills together. The ROOTS Facebook group of around 30,000 mem- bers and ROOTS SUMMIT represent the camaraderie, fellowship and mutual interest endodontists around the world share. We do it every day online, but the strength of our online community over the last 20 or so years has been greatly enhanced by meeting on a semi-annual basis. Those who were in Berlin in Germany in 2018 had the experience of sharing their passion and profession with friends from around the planet, and many signed up immediately for the next ROOTS SUMMIT. At last count, we had people coming to join us from over 30 countries. We are extremely appreciative of the fact that all our lecturers have stuck with us, as have the 40 sponsoring companies and a couple of hundred participants. The sponsors should be especially thanked, as they come to ROOTS SUMMIT because that is where research ﬁ nd- ings are translated into clinical practice better than any other meeting. They do not come to ROOTS SUMMIT because they have purchased a spot on the podium. They come because of the quality of the speakers and the enthusiasm and passion the participants have for endodontics! We all thank them for this open and ethical approach. We are accepting registrations up to and including 26–29 May, and we hope that you will consider joining us in the beautiful city of Prague in the Czech Republic for the best and most inclusive meeting in endodontics. Steve Jones Co-chairman of ROOTS SUMMIT roots 1 2022 03
| content page 08 editorial ROOTS SUMMIT 2020 2021 2022! Steve Jones ROOTS SUMMIT special ROOTS SUMMIT “is not to be missed” An interview with Dr Gianluca Plotino ROOTS SUMMIT 2022— “I can’t wait to experience the best endo meeting again” An interview with Dr Jenner Argueta ROOTS SUMMIT means “practical lectures, enough time for the topics, no need to skip anything” An interview with Dr Daniel Černý Lecture programme, abstracts and speaker information case report Automatic assistance: Freedom to navigate root canals Prof. Eugenio Pedullà page 24 Digital technology in endodontics Dr Bartlomiej Karaś Root canal therapy of necrotic primary molars— using a single-ﬁle reciprocating system Drs Benjamín Rodríguez & Jenner Argueta technique High-end technology for simplicity Adj Prof. Philippe Sleiman page 30 The golden era of root canal shaping Dr Ahmed Shawky interview Laser protocol for peri-implantitis treatment An interview with Dr Michał Nawrocki “The correct choice of an animal model is vital” An interview with Dr Alexis Gaudin research The key role of vitamin D in immune health and regeneration Prof. Shahram Ghanaati, Dr Karl Ulrich Volz & Dr Sarah Al-Maawi manufacturer news meetings International events about the publisher submission guidelines international imprint Cover image courtesy of FKG (www.fkg.ch). issn 2193-4673 • Vol. 18 • Issue 1/2022 roots international magazine of endodontics 1/22 including special interview ROOTS SUMMIT “is not to be missed” case report Automatic assistance: Freedom to navigate root canals technique High-end technology for simplicity 04 roots 1 2022 03 06 07 08 10 20 24 30 36 38 42 46 48 54 56 57 58
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| ROOTS SUMMIT special ROOTS SUMMIT “is not to be missed” An interview with Dr Gianluca Plotino By Franziska Beier, Dental Tribune International For your hands-on course, which will focus on how to use different ﬁ les for root canal anatomy, you encourage participants to bring well-preserved ex- tracted teeth to practise on. What instruments and clinical techniques will participants get to know during your workshop? During my workshop, the clinical procedures for treating root canals having various difﬁ culties will be explained and demonstrated on resin teeth in order to show the standard clinical techniques and the use of various instruments. I encourage all participants to bring natural teeth because trying the instruments on extracted teeth that have open access cavities will give them a better overview of the performance of the tools. I will show them how to integrate the reciprocat- ing instruments R-PILOT (VDW) and RECIPROC blue (VDW) and the VDW.ROTATE rotary ﬁ les into their practices. 4 DAYS OF ENDODONTICS 12 LECTURES Dr Gianluca Plotino register at www.roots-summit.com 14 HANDS-ON-COURSES Could you brieﬂ y summarise your lecture on mini- mally invasive approaches in endodontic procedures and tell us what the take-home message for attend- ees will be? Following the trend of minimally invasive dentistry, the concept of minimally invasive endodontics emerged. However, I prefer to call it anatomically invasive endodontics as all endodontic procedures must be guided by the original root canal anatomy. In my lecture, I will describe how to ﬁ nd a good balance between maximising the preservation of the tooth structure and keeping endodontic procedures safe and efﬁ cient. What are you personally looking forward to at the upcoming ROOTS SUMMIT? All lectures given by my colleagues and friends deserve to be followed with the utmost attention, and I will be there to learn. In addition, I will be happy to see so many friends in person after such a long time! Can you name three reasons why everyone inter- ested and involved in endodontics should come to the event? It’s one of the most important endodontic events of the year, one of the ﬁ rst to take place as an in-person event after a long time, and it has a great scientiﬁ c, cultural and social offering. It is not to be missed! ROOTS SUMMIT, one of the most exciting endodontic events of this year, will kick off in May in Prague in the Czech Republic. One of the speakers will be Dr Gianluca Plotino, who will contribute to the rich programme with a hands-on course and a lecture. In this interview, Dr Plotino, who maintains a private practice specialising in endodontics and restorative dentistry in Rome in Italy, gives a preview of his congress topics and explains why endodontists should attend the event. Dr Plotino, you will be very busy at this year’s ROOTS SUMMIT, as you will present two different topics. What do you ﬁ nd most rewarding about teaching? I love it when people thank me and tell me that my sug- gestions, tips and tricks have changed their professional lives! That is a priceless experience! 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. 06 roots 1 2022
ROOTS SUMMIT special | ROOTS SUMMIT 2022— “I can’t wait to experience the best endo meeting again” An interview with Dr Jenner Argueta By Franziska Beier, Dental Tribune International Dr Jenner Argueta from Guatemala is a speaker at ROOTS SUMMIT, which is hold from 26 to 29 May in Prague in the Czech Republic. During his hands-on course, the expert, who runs a practice that focuses on micro-endodontics and micro-restorative dentistry, will show attendees how to handle complex clinical scenarios with the help of 3D magniﬁcation. Prior to the event, Dr Argueta shared how this technology can bene- ﬁt dental professionals and what he is most looking forward to at the event. 4 Dr Argueta, what skills will participants learn in your hands-on course and how are these going to beneﬁt them in treating patients? As clinicians, we face complex clinical scenarios in every- day practice, such as root canals with ledges, radicular resorptions, perforations and areas having difﬁcult access during surgery. The objective of my workshop is to show attendees how to handle this type of situation in the most comfortable and predictable manner by using novel ma- terials, state-of-the-art equipment and 3D magniﬁcation. DAYS OF ENDODONTICS 12 LECTURES register at www.roots-summit.com During your hands-on course participants will ex- perience how to work with 3D magniﬁcation. What are some of the advantages for dental professionals of using such technology? Having the possibility of moving the optical pod of the 3D microscope to any angle in order to focus on any area of the oral cavity while maintaining the correct ergonomic posture is a priceless advantage of 3D microscopic tech- nology. This advantage is enhanced by high-deﬁnition 3D imaging with outstanding depth of ﬁeld, which is transmitted to a monitor that is perfectly positioned in front of the clinician. These advantages make the clinical workﬂow easier, more predictable and more enjoyable. Is your course open to experienced endodontists as well as to dental students? Certainly! The goal is to show simpliﬁed techniques for solving complex clinical situations, and these simpliﬁed techniques will be applicable for both dental students Dr Jenner Argueta and trained endodontists. However, experienced endo- dontists will experience at ﬁrst hand how 3D technology can contribute to their clinical practice. You have attended previous editions of the endo- dontic meeting. Looking back now, how would you sum up these events and how excited are you that you will be back at ROOTS SUMMIT in Prague soon? I attended ROOTS SUMMIT 2016 in Dubai in the UAE and ROOTS SUMMIT 2018 in Berlin in Germany. Both were high quality events in terms of organisation, science, lectures, camaraderie and friendship. I can’t wait to ex- perience the best endo meeting again. It is time to get the ROOTS family reunited in Prague! 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. roots 1 2022 07
| ROOTS SUMMIT special ROOTS SUMMIT means “ practical lectures, enough time for the topics, no need to skip anything” An interview with Dr Daniel Černý By Franziska Beier, Dental Tribune International 4 12 14 DAYS OF ENDODONTICS LECTURES HANDS-ON-COURSES Dr Daniel Černý register at www.roots-summit.com Dr Daniel Černý, who has been the president of the Czech Endodontic Society since 2015, is one of many renowned and enthusiastic speakers at this year’s ROOTS SUMMIT. Ahead of the event, Dental Tribune International spoke with Dr Černý about what visitors can expect from the city of Prague and from his lecture topic and asked him how he applies the things he has learned at ROOTS SUMMIT in his daily practice. But if you want to delve a little deeper, I recommend visiting Prague Botanical Gardens on an early morning in May. From there, you can climb up to the historic Vyšehrad Fortress to sense a bit of early Prague history and enjoy the great views. Afterwards you can casually stroll through the winding streets of the Praha 1 district with its small shops, restau- rants and cultural institutions. Dr Černý, this year’s ROOTS SUMMIT will take place in your home country. Can you tell us a bit about the event venue and also about Prague itself? What are three city highlights which international participants should not miss? I am excited about ROOTS SUMMIT coming to Prague. There are those highlights you can ﬁ nd in every guide, such as Charles Bridge, the astronomical clock in Old Town Square or Prague Castle, and they are certainly worth a visit. The congress venue is quite new and technologically ad- vanced, and I believe the ROOTS community will enjoy it as much as I did last year when the annual meeting of the Czech Endodontic Society was held there. Together with Dr Radek Mounajjed, you will hold a lecture on the advanced adhesive endodontic/restorative concept. What can attendees expect to take away from it? 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. 08 roots 1 2022
ROOTS SUMMIT special | The concept is something we have been developing and prac- tising for the last 16 years. Its main message is that you can restore endodontically treated teeth with a high degree of pre- dictability. It may not be simple or foolproof but following the correct steps will take you safely to the desired result while maintaining teeth with large structural damage. In this concept, we combine knowledge from modern biology of endodontics, adhesion to hard tissue, material science, biomechanics and occlusion. We want to present the key ideas that deﬁ ne this approach: reasonable structural savings, replacing the struc- ture with similar material, adhesion and the fail-safe principle. What are some of the highlights of this year’s ROOTS SUMMIT that you are personally looking forward to? I can imagine that the social events in Prague might be quite epic. The scientiﬁ c programme of the congress is classic ROOTS SUMMIT: practical lectures, enough time for the top- ics, no need to skip anything. I am interested in Dr Catherine Ricci’s lecture on large lesions and Dr Hugo Sousa Dias’s lecture on the management of pulp canal obliteration. I also want to learn more on bioceramics from Dr Meetu Ralli Kohli and, of course, it is always nice to hear new thoughts from Dr Stephen Buchanan. Relatively easily. It is not that difﬁ cult since we all share similar ideas, and my knowledge gain is often in the clinical applications and from the tips on how to integrate new ideas into the current knowledge. If I don’t apply what I have learned directly, then at least I have understood it and can subconsciously integrate it into my approach. And for this reason, I think meetings like ROOTS SUMMIT are better than hasty depersonalised scientiﬁ c meetings or just reading. We are social beings; we like to see and hear one another. This will be your second time at ROOTS SUMMIT. What would you like to tell all the endodontists around the world who have not booked their ticket yet? Why should they attend this year’s edition? I would give them three different reasons for booking their ticket. Firstly, because of the ROOTS SUMMIT programme and clinical approach as I described earlier. Secondly, be- cause of the city of Prague in spring—beautiful, blossoming, welcoming and friendly. And ﬁ nally, because of the oppor- tunity to meet old friends after having been locked up for two years! How do you translate the things that you pick up at ROOTS Summit into your daily practice? With four years since the last event in Berlin, this has been the longest break in ROOTS SUMMIT history. I think we should all make the most of it right now. Carpe diem! 4 12 AD 14 DAYS OF ENDODONTICS LECTURES HANDS-ON-COURSES register at 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.
| ROOTS SUMMIT special Speakers ROOTS SUMMIT 2022 Dr Francesc Abella (Spain) Dr Francesc Abella graduated in 2005 in dentistry from the Universitat Interna- cional de Catalunya, Barcelona, Spain. From 2005 to 2014, he com- pleted his master’s degree and PhD in endodontics at the same university. He works in a private practice limited to endodontics and restorative dentistry in Barcelona, and in clinical endodontics, his areas of special interest include CBCT in endodontics, microcomputed tomogra- phy, dental anatomy, dental traumatology, periapical pathology, adhesive restoration and restoration of endodontically treated teeth. Besides his work in private practice, he is involved in endodontic re- search projects in the postgraduate endodontic programme of the Universitat Internacional de Catalunya. Over the years, Dr Abella has given several lectures and hands-on courses worldwide. He is the author of several papers in peer-reviewed journals and part of the expert committee convened by the European Society of Endodontology on the use of CBCT. Dr Abella is also an active member of the Asocia- cion Española de Endodoncia [Spanish association of endodontics] and the secretary of the Sociedad Española de Odontología Conservadora y Estética [Spanish society of conservative and aesthetic dentistry]. Dr Stephen Buchanan (US) Dr Buchanan re- ceived his dental degree in 1978 from the University of the Paciﬁ c Arthur A. Dugoni School of Dentistry in San Francisco, US. In 1980, he completed the endodontic graduate programme at Temple University in Philadelphia, US. He began pursuing 3D anatomy research early in his career. In 1989, he established Dental Education Labora- tories, a state-of-the-art training facility devoted to hands-on instruction where he still teaches end- odontic treatment, retreatment and segmented ﬁ le retrieval. Early in his career, Dr Buchanan identiﬁ ed the power of video and ﬁ lm media in training and produced the award-winning video series, The art of endodontics. Dr Buchanan also holds a number of patents for dental instruments and techniques. Most notably, he was the ﬁ rst dentist to introduce 12 roots 1 2022 Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.
| ROOTS SUMMIT special Dr Meetu Ralli Kohli (India/US) Dr Meetu Ralli Kohli earned her BDS from the Government Dental College and Research Institute, Bangalore, India, and pursued her DMD and specialty train- ing in endodontics at the University of Pennsylvania, Philadelphia, US. During the course of her training, she received the esteemed Louis I. Grossman Award, Samuel R. Rossman Scholarship and Sherrill Ann Siegel award and scholarship for demonstrating excellence in patient care, clinical skills and research. She is Clinical Associate Professor of Endodontics and the Director of the Continuing Education and International Programme at the Department of Endodontics of the University of Pennsylvania School of Dental Medicine. She also maintains a part-time private practice limited to endodontics in Pennsylvania. Dr Kohli has published in national and international peer-reviewed journals and has contributed to books on microsurgical retreatment. Her publications have been recognised as best clinical research papers by the Journal of Endodontics. She is on the scientiﬁ c advisory board as a reviewer for the Journal of Endodontics, International Endodontic Journal and Quintessence International, and is the associate editor of the Color Atlas of Microsurgery in Endodontics. Dr Kohli has served on the American Association of Endodontists Constitution and Bylaws Committee and currently serves on its Research and Scientiﬁ c Affairs Committee. She is a diplomate of the American Board of Endodontics and an examiner for the Indian Board of Endodontics. Dr Radek Mounajjed (Czech Republic) Dr Radek Mounajjed graduated from the Damascus University Faculty of Dentistry, Syria, in 1994. He then completed his residency in general dentistry in 1997 and in prosthodontics in 2000, respectively. He com- pleted his PhD in 2004 at the Charles University Faculty of Medicine, Hradec Králové, Czech Republic. Dr Mounajjed has been working at the multidisci- plinary D.C.M clinic in Hradec Králové as a full-time prosthodontist since 2001, and at Palacký University Olomouc, Czech Republic, as an external teacher since 2012. Dr Mounajjed is the author of many publications and book chapters. He has presented more than 150 talks, both nationally and internationally, and has been invited to speak at Harvard University and Mayo Clinic, both US. On top of that, Dr Mounajjed is the co-founder of HDVI, an accredited dental continuing education centre in the Czech Republic. He is also a fellow of the Academy of Prosthodontics in the US and International College of Prosthodontists. Outside of dentistry, he enjoys building and ﬂ ying radio- controlled model airplanes. Dr Gianluca Plotino (Italy) Dr Gianluca Plotino graduated in dentistry from the Università Cattolica del Sacro Cuore, Rome, Italy, in 2002. He obtained his PhD there in 2009 and received certiﬁ cation as ﬁ rst and second level professor in 2018. Dr Plotino works in his own private practice limited to endodontics and restorative dentistry in Rome. He has received several international prizes, published more than 90 articles in scientiﬁ c peer-reviewed jour- nals on various endodontic and restorative topics, and contributed numerous chapters to textbooks. Plotino is an associate editor of the European Endodontic Journal and the Giornale Italiano di Endodonzia and serves on the editorial board of several other journals. He is a certiﬁ ed member of the European Society of Endodontology, an international member of the American Association of Endodontists, and an active member of the Italian Academy of Endodontics and the Italian Society of Conservative Dentistry. Dr Catherine Ricci (France) Dr Catherine Ricci grad- uated from the Univer- sité Paris Diderot (Paris 7) in France in 1983. In the same year, she be- came a certiﬁ ed member of the Société Française 14 roots 1 2022 Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.
| ROOTS SUMMIT special Lecture abstracts ROOTS SUMMIT 2022 Day 1: Friday, 27 May 2022 8:30–10:00 Digital planning in intentional replantation and auto-transplantation Dr Francesc Abella In recent years, primary endodontic treatment, nonsurgical retreatment and microscopical surgery have achieved success rates of around 90%. How- ever, there are situations in which the tooth cannot be saved using these techniques. The ﬁ rst part of this lecture will discuss intentional replantation. This is an accepted endodontic treatment procedure in which a tooth is extracted and treated outside the oral cavity and then reinserted into its socket to cor- rect an obvious radiographic or clinical endodontic failure. It should not be considered a last-resort treatment prescribed only for “hopeless” teeth as proposed by Grossman. Although intentional re- plantation is not a frequently performed procedure, it yields a tooth survival rate of 88% according to a recent meta-analysis. In addition, the new advances in computer-aided rapid prototyping (CARP) models (tooth replicas) and 3D-printed guiding templates allow us to apply this technique in a much more predictable way. In situations where the tooth cannot be saved, there is the option of performing an auto-transplant (both open and closed apex). The complications observed in the past can be overcome thanks to advances in diagnostic and surgical techniques, particularly CARP models and 3D-printed guiding templates. The digital planning not only allows for selection of the most suitable donor tooth according to tooth morphology, but also shows the ideal 3D position and the required dimensions of the alveolus during surgery. Moreover, the use of tooth replicas can reduce the additional socket time and possible donor tooth injury during the procedure. Through the results of two in vivo investigations, as well as clinical cases and videos, we will teach the digital step by step to plan all types of cases. After this lecture, participants should: 1) know the main indications for intentional replan- tation, as well as how to digitally plan the whole process; 2) know the advantages and possible complications of tooth auto-transplantation; and 3) know the indications for the different types of auto-transplantation: fresh extraction sockets, early extraction sockets with soft-tissue healing, early extraction sockets with partial bone healing, and surgically created sockets. 10:45–12:30 Large lesions: Endodontic or surgical treatment Dr Catherine Ricci Lesions are the result of the evolution of apical periodontitis and are due to bacterial proliferation. Sometimes, root canal disinfection allows, with 16 roots 1 2022 Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.
| Xxxxxx | ROOTS SUMMIT special Day 2: Saturday, 28 May 2022 8:30–10:00 Root to crown: Advanced adhesive endodontic/restorative concept Drs Daniel Černý & Radek Mounajjed Long-term data show that survival of nonvital teeth has always been a challenge. Both endodontic and restorative dentistry contribute critically to the treat- ment outcome. The presented concept of care has been developed by both endodontists and prostho- dontists over 18 years of cooperation. It is based on four main ideas common to both ﬁ elds: tissue pres- ervation (unnecessary hard dental tissue loss should be prevented); replacement with similar materials (lost tissue should be replaced with material of sim- ilar physical properties); adhesion (all components of reconstruction should adhere to each other) and safety (when failure occurs, it should not be catastrophic). Over the years, the protocol has been extended from nonvital teeth only to teeth with compromised integrity and challenged vitality. The endodontist delivers a ready-to-use abutment tooth free of pathology for the ﬁ nal reconstruction regardless of the tooth vitality. In this lecture, the decision-making process, material selection, complete workﬂ ow and long-term outcomes will be presented. After this lecture, participants should be able to: 1) identify clinically relevant factors for reconstruc- tion of nonvital teeth and teeth with challenged vitality; 2) indicate the need for different adhesive tools to construct the build-up of the abutment tooth with ﬁ bre posts and various resin composites; and 3) describe critical details of ideal ﬁ nal restoration considerations. A decision on intervention for an endodontically treated tooth with a periapical radio- lucency should be based on the technical feasi- bility of the treatment, systemic factors and patient values. This presentation will discuss a patient-focused clin- ical decision-making process regarding the manage- ment and preservation of natural teeth based on the principles of evidence-based medicine. After this lecture, participants should be able to: 1) identify the main reasons for the persistence of endodontic disease and possible treatment alter- natives; 2) recognise the possibilities and limitations of modern endodontic treatment; and 3) incorporate an evidence-based approach in the decision-making process on treatment choice. 15:30–17:00 Endodontic algorithms in decision-making and clinical workﬂ ow Dr Roberto Cristian Cristescu This lecture will focus on some decision-making steps during endodontic clinical procedures in the dental ofﬁ ce. The current standard of care requires dentists to base their actions on scientiﬁ c evidence and to be able to put that evidence into clinical practice while keeping in focus the patient’s quality of life during the treatment. We will follow some important guidelines for clinical endodontics and will exemplify them with clinical cases that reﬂ ect the diagnosis and treatment spectrum of a general dental ofﬁ ce. After this lecture, participants should: of nonvital teeth. 1) have a clearer decision-making algorithm for their 13:30–15:00 Evidence-based treatment choices in modern endodontic treatment Dr Igor Tsesis The treatment alternatives for apical periodontitis include nonsurgical endodontic retreatment, surgi- cal endodontic treatment, or tooth extraction, and in certain cases, a follow-up protocol may be con- sidered. The long-term prognosis, the alternatives in case of treatment failure, post-treatment quality of life, and patient’s preferences should all be rec- ognised and incorporated in the treatment choice clinical work; 2) be able to understand how to start making their own clinical decision ﬂ owcharts for different endodontic procedures; and 3) have a better understanding of the possible outcomes of different treatment paths. 17:15–18:45 Two-dimensional vs 3D endodontics Prof. Gianluca Gambarini This lecture will address the use of CBCT in end- odontics for diagnosis, the treatment plan, access cavity design, working length determination, man- 18 18 roots roots 1 2022 1 2022 Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.
| case report Automatic assistance: Freedom to navigate root canals Prof. Eugenio Pedullà, Italy Introduction Mechanical root canal preparation with nickel–titanium (NiTi) instruments activated by endodontic motors has made root canal preparation more predictable in the clinical setting, as well as signiﬁcantly reduced working time and stress on the practitioner. Since the introduction in the late 1980s of cen- tric continuous rotary motion for NiTi ﬁles, new mechanised techniques have been proposed with the aim of minimising the risk of fracture of endodontic instruments by exploiting the beneﬁts of different kinematics in endodontic therapy. Thus, trans-axial, eccentric and reciprocating motion were introduced for the activation of NiTi instruments to shape root canals. In particular, reciprocating motion (better classiﬁed as partial reciprocation with rotational effect) has asymmetrical angles of rotation in the anti- clockwise and clockwise directions. Continuous rotation and reciprocation have advantages but also disadvantages. Indeed, the former allows easy progres- sion in root canals, but it does not protect the NiTi ﬁles from the risk of torsional fracture. Reciprocation increases ﬁle fracture resistance, reducing the screw-in effect but increas- ing the possibility of apical debris accumulation or extrusion. Therefore, hybrid motions have been designed to com- bine rotary and reciprocating movements, taking advan- tage of each. Hybrid endodontic motors have just two movements, changing the angle during activation, pass- ing from a complete (360°) rotation to a single asymmet- rical reciprocation with ﬁxed and asymmetrical angles (clockwise differing from anticlockwise) depending on the torsional stress applied to the NiTi ﬁle. However, digital technology can facilitate continuous control of the ﬁle movement. The CanalPro Jeni end- odontic motor (COLTENE; Fig. 1) allows fully automatic assistance in the shaping of root canals using different rotary motion, angle, speed and torque, automatically changed by the complex and patented algorithms of the motor. Rotary movement, speed and torque are 1 Fig. 1: The fully automatic CanalPro Jeni endodontic motor (COLTENE). 20 roots 1 2022
case report | 2 Fig. 2: Apex reached as signalled by the integrated apex locator on the touch screen monitor of CanalPro Jeni. continuously adapted to the prevailing conditions in the root canal. The ﬁle movement of Jeni motion is adapted to the changing pressure exerted on the instrument. Light pressure is applied steadily from coronal to apical. pressure on the ﬁle in order to obtain instrument ad- vancement. However, CanalPro Jeni will intercept this and immediately advise the dentist with a long beep and by activating reverse rotation to suggest the need to stop, remove the ﬁle and irrigate rather. The reaction time of CanalPro Jeni is in the millisecond range and thus signiﬁcantly faster than that of humans. This means greater safety, because of the reduced risk of NiTi ﬁle fracture and decreased subjectivity of treatment be- cause the advancement of the ﬁles is always automatically controlled by the motor. With CanalPro Jeni, the dentist just holds the contra-angle handpiece and the motor does the rest, adjusting to the root canal anatomy and thereby in- creasing the efﬁciency and reducing treatment errors. CanalPro Jeni not only changes the ﬁle movements, but also continuously indicates the position of the ﬁle in the root canal with its integrated apex locator (Fig. 2) and suggests rinsing with irrigants when ﬁle progression is compromised. This can guide the clinician to irrigate for longer in complex cases. The functionalities of CanalPro Jeni provide many advantages to dentists. The motor starts in continuous rotation; however, if the ﬁle is stopped and blocked in the root canal for any reason, the dentist will be safe and will be able to continue his or her work easily because the motor will activate the ﬁle with move- ments employing more reverse action until the ﬁle is unblocked. Safety is also increased by the signal to rinse. When pro- gression of the ﬁle is not allowed (such as in the case of debris accumulation), the clinician could exert greater Efﬁciency is ensured with CanalPro Jeni because the movement by the motor always ensures some degree of ﬁle advancement and cutting action. Therefore, it is possible to advance into the root canal without the need to perform the up and down motion controlled by the subjective tactile feedback of the clinician. Moreover, brushing motion with lateral cutting action on root canal walls to favour the progression of the ﬁle is also allowed by all the different movements effected by the motor. This consistent forward motion can ultimately save time during mechanical preparation. Root canal therapy and retreatment can be performed safely and efﬁciently. Different ﬁle systems can be selected in the control pro- gram via the touch screen. Presently, the HyFlex EDM, HyFlex CM, MicroMega One Curve, MicroMega 2Shape and Remover for HyFlex and MicroMega ﬁle systems (all COLTENE) are already pre-installed in the software. In ad- dition, the Doctor’s Choice program gives the clinician the freedom to choose even different movements, like twist off (continuous rotation), twist on (continuous rotation with an alternative movement automatically activated when the set torque is surpassed), and reciprocating motion with setta- ble milliseconds in order to decide how much and in which direction the NiTi instruments should be moved and the anticlockwise motion that is helpful when the tip is blocked. roots 1 2022 21
| case report 3 4 5 Fig. 3: Pre-op radiograph of tooth #35. Incomplete endodontic obturation and a metal post were visible. A radiolucent periradicular lesion was detectable laterally on the distal aspect of the root. Fig. 4: Final radiograph of the endodontic retreatment (with the dental dam still on the tooth) showing complete and compact ﬁlling of the endodontic space, including the ﬁlling of a lateral canal and a little extrusion of sealer though it in the site of the lateral radiolucent lesion. Fig. 5: Follow-up radiograph at one year of the endodontic retreatment of tooth #35. Healing of the lateral radiolucent lesion conﬁrmed the success of the endodontic retreatment performed with HyFlex Remover and EDM ﬁles activated by CanalPro Jeni. Case 1 In this ﬁrst case, periapical periodontitis of tooth #35 is pre- sented. The 44-year-old patient was ﬁrst diagnosed with acute pulpitis of a mandibular premolar in 2017. Tooth #35 received root canal therapy and was then obturated with gutta-percha and sealer and restored with a metal post and composite materials. Unfortunately, the success of the treatment was not long-lasting. In 2020, the patient pre- sented at our practice with acute pain symptoms and pain on percussion or biting. The preoperative periapical radio- graph showed periapical periodontitis even laterally on the distal aspect of the root of tooth #35 (Fig. 3). The patient ﬁnally agreed to the necessary endodontic retreatment. The ﬁrst step in retreatment is the complete removal of inadequate or aged gutta-percha ﬁlling. Therefore, after the removal of the composite and metal post with ultra- sonic tips, the 30/.07 HyFlex Remover ﬁle (COLTENE), activated by the automatic Jeni motion of CanalPro Jeni, was used for the gutta-percha disassembling procedure. The fast and continuous changes of the movement per- formed by the automatic Jeni motion, combined with the efﬁciency of the heat-treated HyFlex Remover ﬁle, al- lowed fast and safe removal of the previous obturation material. In a recent paper, it was reported that the use of the innovative CanalPro Jeni kinematics accelerates the time for removal of root ﬁlling materials.1 Indeed, within seconds, clean access to the apical third was achieved. 15 K-type ﬁle. After determination of the working length (WL), the HyFlex EDM ﬁle system, activated by the fully automatic Jeni motion of CanalPro Jeni, was used in the single-length technique. Thus, after the 20/.05 HyFlex EDM ﬁle reached the WL, the 25/~ HyFlex EDM OneFile and then the 40/.04 ﬁle were used to WL. Jeni motion al- lowed the ﬁles to reach the WL just by guiding the ﬁles in the apical direction and removing the ﬁles from the root canal and irrigating on the sounding of the long beep. After this, the reinsertion of the ﬁle into the root canal was deeper than the previous depth of insertion, and this procedure was repeated until the WL was reached. In this case, the 20/.05 ﬁle reached the WL in one pass, the OneFile in two passes and the 40/.04 ﬁle in one pass of the instrument. The 50/.03 HyFlex EDM ﬁnishing ﬁle was then used to 1 mm from the WL in order to create a stop for the 50/.02 master cone used for the micro-seal thermoplasticised obturation technique. The postoperative periapical radiograph showed perfect adaption of the obturation material used and ﬁlling of a large lateral distal canal that probably was the cause of the periapical lesion and symptoms of the tooth (Fig. 4). The one-year follow-up radiograph showed the healing of the periapical lesion, and the patient reported no symptoms during that time (Fig. 5). Case 2 Subsequently, when the untreated part of the root canal was reached, scouting was done with a #10 and A 32-year-old male patient presented at our practice, having been referred to us by his dentist for further endodontic evaluation of pain in the left side of his maxilla. During the 22 roots 1 2022
case report | 6 7 8 Fig. 6: Pre-op radiograph of tooth #26 showing decay under a previous composite restoration close to the pulp chamber that caused the patient pain. Irre- versible pulpitis was the diagnosis. Fig. 7: Periapical radiograph of tooth #26, the beam angulated mesially to verify the correct obturation of the separate mesiobuccal canal after endodontic treatment with the HyFlex EDM ﬁle system and CanalPro Jeni. Fig. 8: Post-op periapical radiograph of the endodontic treatment of tooth #26. initial examination, the patient experienced pain when a gentle jet of cold air was blown between teeth #26 and 27. The preoperative periapical radiograph conﬁrmed the sus- pected decay of the distal root of tooth #26 under its previ- ous composite restoration (Fig. 6). The patient was informed about the situation, and he agreed to endodontic therapy in order to obtain a predictable result of the treatment. The entire treatment was performed exclusively under the microscope. This allowed optimisation of the view of the work ﬁeld. Full preparation was performed with a sequence of ﬂexi- ble NiTi ﬁles using CanalPro Jeni. After placement of a dental dam, the access cavity was prepared, and coronal ﬂaring was obtained with the HyFlex EDM oriﬁce opener. In addition, to the composite in the canal entrance, the extreme curvature of the root canals, especially in the apical third of the distal one, presented a challenge. In the mesiobuccal, independent second mesiobuccal and distal buccal root canals, the 15/.03 HyFlex EDM ﬁle was followed by the next size ﬁles, 10/.05 and 20/.05. The palatal root canal was prepared with the same sequence, plus the use of the 25/~ HyFlex EDM OneFile and 40/.04 HyFlex EDM ﬁle. CanalPro Jeni suggested irrigation for the progression of the ﬁles with a long beep. This hap- pened more in the second mesiobuccal and distal root canals, where the preparation was more difﬁcult because of the narrow and curved anatomy. After a ﬁnal rinse and drying procedure with dedicated paper points, the carrier-based thermoplasticised gutta-percha obturation technique was used to ﬁll the root canals (Figs. 7 & 8). Conclusion Digital endodontic assistance systems such as CanalPro Jeni navigate the dentist step by step through mechanical and chemical preparation by adjusting the variables of ﬁle movement. The instantaneous control of CanalPro Jeni improves the safety and efﬁciency of root canal therapy, reducing the subjectivity of tactile feedback control and possible errors during endodontic treatment and retreatment. contact Prof. Eugenio Pedullà graduated in dentistry and dental prosthetics from the University of Catania in Italy in 2003. He obtained his PhD at the same university in 2007. From 2009 to 2014, he was a research fellow at the University of Catania, where he is now associate professor of conservative dentistry and endodontics. Prof. Pedullà carries out his clinical and research activities mainly in the ﬁeld of endodontics and conservative dentistry. Prof. Pedullà is an active member of the Italian Academy of Endodontics and Società Italiana di Odontoiatria Conservatrice (Italian society of conservative dentistry), an ordinary member of the Italian Society of Endodontics, an international member of the American Association of Endodontists and a member of the European Society of Endodontology. He can be contacted at firstname.lastname@example.org. roots 1 2022 23
| case report Digital technology in endodontics Use of dynamic navigation to access and shape canals in teeth with pulp canal obliteration after trauma Dr Bartlomiej Kara ´s, Poland 1 2a 2b Fig. 1: Intra-oral view of the initial situation. Visible discoloration of the right central incisor. Figs. 2a & b: CBCT scan, sagittal (a) and coronal planes (b). Visible pulp canal obliteration and periapical lesion. Introduction Pulp canal obliteration (PCO) is one of the complications which may occur in dental pulp after tooth trauma. It is also one of the mechanisms of pulp healing after trauma; how- ever, pulp necrosis too may occur as a result of trauma. PCO can be recognised clinically as early as three to 12 months after trauma. PCO is an effect of the deposition of hard tis- sue, such as sclerotic or reparative dentine; however, the underlying mechanisms of PCO are still unclear. Oginni et al. report that partial obliteration was present in 56.9% and total obliteration in 43.1% of 276 cases of teeth after trauma, and they suspect that the mechanism of formation of oblit- eration is related to damage to the neurovascular supply.1 The types of injuries mostly responsible for PCO have also been investigated. It was revealed that luxation, subluxation, intru- sion and concussion are the most frequent causes of trauma. In the case of concussion, teeth with developing apices have a better prognosis and a lower likelihood of developing PCO. 3a 3b 3c Figs. 3a–c: Planning of the virtual guide in Navident software (ClaroNav). The axis and depth of the preparation are shown. 24 roots 1 2022 Jacobsen and Kerekes report that, although PCO necrosis and periapical disease are rare, they can occur after many years after the trauma. Bastos and Cortes emphasise that crown discoloration can be present in many cases and can be a ﬁrst visible factor of PCO. Usually, the colour changes to dark yellow or even grey. Management of PCO owing to a lack of patency can be very challenging for clinicians. Creating a proper access cavity (one that will not sacriﬁce too much tooth structure) and lo- cating the root canal oriﬁce in the calciﬁed tooth requires experience and additional equipment, like a dental oper- ating microscope. According to Carvalho and Zuolo, using the dental operating microscope increases the probability of ﬁnding all the oriﬁces located in the pulp chamber ﬂoor. Boveda and Kishen state that creating a constricted access cavity should be very valuable in terms of a long-term prog- nosis, but can require an additional diagnostic protocol, for example capturing a CBCT scan before the treatment. Dynamic navigation Nowadays, thanks to the development of modern technol- ogies, it has become possible to perform treatment more conservatively and more predictably. The Navident dynamic navigation system (ClaroNav) is to a clinician what a GPS is to a driver. Navident uses a stereoscopic camera and marker (or reference) spheres so that the camera can track the movement of the operator. Also the system requires a CBCT scan of the patient and a digital guide, which is de- signed in the Navident software. After designing the guide, the clinician needs to register the patient’s teeth to calibrate the CBCT scan with a special tool (the wand). After regis- tration of the patient’s teeth, the clinician needs to calibrate the drill and the handpiece with dedicated markers. With
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| case report 4 5 Fig. 4: Calibration of the Navident device. The tracers and camera are shown. Fig. 5: Intra-op view of the software. the combination of the prepared guide, tracking markers and dynamic tracking of the camera, the dentist can see the actual position of the drill and its angulation with a lag of 0.3–0.5 seconds on the computer screen. According to avail- able data, the accuracy of the equipment is 0.1 mm and 1°, which is signiﬁcantly better than CAD/CAM-fabricated guides for endodontic treatment. It must be considered that the ac- curacy of the procedure may differ depending on the clinician. Case 1 A 36-year-old female patient came to the dental ofﬁce with discoloration and pain of the maxillary right ﬁrst incisor (Fig. 1). In the medical history taking, she reported a trauma approx- imately 15 years earlier. During the radiographic examination in the ofﬁce of her general dentist, PCO was revealed. She was referred for a CBCT scan and endodontic treatment. During the consultation, the CBCT scan was performed with the 9000 C 3D with a voxel size of 0.1 mm (Carestream). The CBCT scan revealed a highly calciﬁed pulp chamber and an almost invisible trace of the root canal (Fig. 2). The patient was informed about the new, beneﬁcial technol- ogy which can help to preserve additional tooth structure during treatment. Before the treatment, the CBCT scan was uploaded to the software and the virtual guide was planned (Fig. 3). This is one of the most important parts of the protocol because during the treatment the Navident software tracks the handpiece and shows the correlation between the clinician’s work and the already planned guide. If the depth or direction is missed on the guide, there is a very high risk of root perforation. During the clinical procedure, the jaw tracker was placed on the patient’s teeth and ﬁxed with impression material. Registration of the patient’s tooth position and calibration of the CBCT scan was performed with the help of the wand tool. The drill tag was attached to the handpiece, and the calibration of the handpiece and drill was performed with the calibration tool (Fig. 4). After all the registration and 6a 8a 6b 8b 7a 9a 7b 9b Figs. 6a & b: First stage of the access cavity creation (a). CBCT check, sagittal plane (b). The axis of the access cavity was visible. Figs. 7a & b: Hand ﬁ le scouting of the canal oriﬁ ce. Figs. 8a & b: Final preparation (a). The size of the access cavity and of the root canal oriﬁ ce was checked with the #80 hand plugger (b). Figs. 9a & b: Drying the canal before obturation. 26 roots 1 2022
| case report 10a 12 10b 11a 11b Figs. 10a & b: Obturation with gutta-percha (a) and the control radiograph (b). Figs. 11a & b: Occlusal check (a) and the control radiograph of the com- posite seal (b). Fig. 12: CBCT check, sagittal plane. Measurement of the root thickness conﬁrmed the size of the preparation. Healing of the periapical tissue was observed. Fig. 13: CBCT check, sagittal plane. The long axis of the root and the axis of the access cavity and root canal preparation 13 were visible. calibration procedures, the patient, tooth and guide were pre- pared for the access cavity creation. The access cavity was created with the EndoGuide bur (SS White Dental) with the aid of the Navident software. The greatest challenge of the procedure for the clinician is to work simultaneously with the fast-speed handpiece in the tooth and trace the position and angulation of the drill on the computer screen, potentially lead- ing to trouble with coordination in the ﬁrst procedures (Fig. 5). After reaching the depth of drilling on the prepared guide, another CBCT scan was performed to check the accu- racy of the access cavity (Fig. 6). According to the image, the angulation of the access cavity had changed slightly to the palatal side and the root canal was reached with the #10 K-ﬁle (Kendo, VDW; Fig. 7). Shaping of the root ca- nal was performed with Endostar E3 Azure (Poldent) up to size 30/.04. After the shaping protocol, the size of the root canal oriﬁce was checked with the #80 hand plugger, and it was indicated that the size was larger than #80 but smaller than #100 (Fig. 8). The irrigation protocol was per- formed with 5.25% sodium hypochlorite and 40.0% citric acid. Both solutions were activated with EDDY sonic tips (VDW), and sodium hypochlorite was additionally activated with elements free (Kerr) for intra-canal heating. The ca- nal was dried with paper points (Fig. 9) and obturated with warm gutta-percha using the continuous wave technique, and a control radiograph was performed (Fig. 10). The access cavity was sealed with a composite material, and another radiograph was performed (Fig. 11). The recall appointment took place four months after treat- ment. Healing of the periapical tissue was observed. Despite the limitations of the CBCT imaging related to the voxel size (0.1 mm), the size of the access cavity was found to be 1.1 mm ± 0.2 mm, conﬁrming the measurement per- formed during treatment (Fig. 12). Moreover, we could also 14 15a 15b 15c 16a 16b 16c 17a 17b 17c Fig. 14: Intra-oral view of the initial situation. Visible discoloration of the right central incisor. Figs. 15a–c: CBCT scan, sagittal (a & b) and coronal planes (c). Pulp canal obliteration was visible in both teeth, and a periapical lesion was present around the left incisor. Internal resorption in the right incisor was suspected. Figs. 16a–c: Planning of the virtual guide for the right incisor. The axis and depth of the preparation are shown. Figs. 17a–c: Planning of the virtual guide for the left incisor. The axis and depth of the preparation are shown. 28 roots 1 2022
case report | 18a 18b 19a 19b 20a 20b 20c 21a 21b Figs. 18a & b: CBCT check, sagittal plane. The axis of the access cavity was visible for both teeth. Figs. 19a & b: Drying the canal before obturation (a). The ﬁnal shape of the access cavity (b). Figs. 20a–c: Obturation with gutta-percha (a & b) and the control radiograph (c). Figs. 21a & b: Occlusal check (a) and the control radiograph of the composite seal (b). conﬁrm that the access cavity and the root canal prepa- ration had the same angulation, parallel to the long axis of the root, and remained in the centre of the root (Fig. 13). Case 2 A 30-year-old female patient presented to the dental clinic complaining of constant pain of the left central incisor. Moreover, the patient was unhappy with the aesthetics of both incisors and had a history of trauma (Fig. 14). CBCT examination was performed with the 9000 C 3D (Fig. 15). The CBCT scan revealed a periapical lesion around the left central incisor and PCO for 12 mm from the incisal edge. The root of the left incisor was approximately 5 mm shorter than the root of the right incisor, which could indicate api- cal inﬂammatory root resorption. Moreover, PCO was pres- ent in the right central incisor up to 12 mm from the incisal edge, and an irregular shadow in the central area of the root was present. This image could indicate internal resorption. There was no lesion in the periapical area. In both teeth, the size of the canals in the periapical area were narrower than the typical size of the canals in the central incisors. Before the treatment, the CBCT scan was uploaded to the software and the virtual guide was planned (Figs. 16 & 17). All the registration and calibration procedures were per- formed in the same manner as the previous case. The access cavity was performed with the EndoGuide bur with the aid of the software. After reaching the depth of drilling on the prepared guide, another CBCT scan was performed to check the accuracy of the access cavity (Fig. 18). The CBCT scan revealed that the angulation of the access cavity was suitable but that the depth was insuf- ﬁcient. The EndoGuide drill and Navident were used one more time to reshape the access cavity. After gaining pa- tency in the canal, the #10 K-ﬁle was used to establish the working length. The canal in the right incisor was shaped with Endostar E3 Azure up to size 40/.04, and the canal in the left incisor was shaped up to size 45/.04. In both canals, the irrigation protocol was performed with 5.25% sodium hypochlorite and 40.0% citric acid. Both solutions were activated with EDDY sonic tips, and sodium hypochlo- rite was additionally activated with elements free for intra- canal heating. The canals were dried with paper points (Fig. 19) and obturated with warm gutta-percha using the continuous wave technique, and a control radiograph was performed (Fig. 20). Finally, the composite sealing was performed and the occlusal check was done (Fig. 21). Conclusion Although dynamic navigation in endodontics is a very new and uncharted technology, the three teeth with massive PCO in these case reports proved that it offers very promising utility for endodontists. This technology requires further in- vestigation, but it appears that it could help many clinicians to treat teeth with PCO and perform non-surgical retreat- ment with a better outcome. Moreover, using this technology in preparing constricted access cavities appears to be very promising in terms of the survival of the treated teeth thanks to preserved tooth structure such as peri-cervical dentine. Therefore, digital solutions like Navident should be used more often in endodontics to gather more data and create a new standard for treating teeth with PCO in the future. contact Dr Bartlomiej Kara´s MAXDENT Ul. Hallera 53/2 53–325 Wrocław Poland email@example.com roots 1 2022 29
| case report Root canal therapy of necrotic primary molars—using a single-ﬁ le reciprocating system Drs Benjamín Rodríguez & Jenner Argueta, Guatemala Introduction Pulpectomy is a root canal procedure for pulp tissue that is irreversibly infected or necrotic owing to caries or trauma. The root canal pulp tissue is removed, and the canal is commonly shaped with hand or rotary ﬁ les.1 This pro- cedure is the standard of care when normal shedding coupled with the eruption of the permanent successor or long-term tooth retention is the priority goal and evidences a good healing outcome.2 Like in permanent teeth, it is crucial to achieve adequate disinfection in the root canal system of primary teeth.3 Premature extraction of necrotic primary molars leads to space loss, an important oral health concern in children because of the consequent improper arch length and altered successor eruption.3 Therefore, pulpectomy of primary teeth with severe pulp involvement should be considered the treatment of choice when indicated.3, 4 However, it represents a challenge because of the mor- phological complexities of the root canal system, presenting multiple roots, uneven apical resorption, fused roots, two mesiobuccal canals and two distobuccal canals in maxillary molars, as well as ﬁ ns and isthmuses, among others.2 The disinfection protocol involves biomechanical preparation with hand or rotary instruments and mainly employs 0.5–5.5% sodium hypochlorite (NaClO) and 17% EDTA.5 Additionally children are more prone to an- xiety and stress during dental treatment,4, 5 which may require, in addition to well-established paediatric behaviour management, techniques inherent to the endodontic ﬁ eld that help to make the procedure simpler and less time-consuming.6, 7 Stainless-steel hand ﬁ les have been traditionally and, to some degree, successfully used for pulpectomy proce- dures in primary molars.7 Despite this, when they are used exclusively, they have multiple drawbacks because of their rigidity, making it difﬁ cult to negotiate the canals properly and to avoid procedural errors like ledge formation and perforation.8 Rotary instrumentation was later introduced and has proved to be very beneﬁ cial in the practice of paediatric endodontics.8, 9 It takes less time, is less skill dependent and reduces the probability of errors that arise with hand ﬁ les. Consequently, rotary instrumentation facilitates the creation of better conical space for a superior obturation protocol.10 However, these systems almost al- ways require a long sequence, and may become fatigued, owing to the rotational movement, increasing the probability of ﬁ le fracture or distortion.11, 12 Continuous advances in the ﬁ eld of endodontics have resulted in reciprocating instruments that have been ap- plied in root canal therapy of permanent teeth. The clock- wise and anticlockwise movement produces less binding of the instrument to the dentine wall, resulting in a decrease in cyclic fatigue and instrument fracture.13 Reciprocating instruments advocate the use of a single ﬁ le for the entire root canal preparation. Being less time-consuming, it allows for a longer irrigation protocol. The technique used involves a cycle of instrumentation of in and out pecking motions of 2–3 mm in amplitude with slight apical pres- sure. Each cycle requires irrigation of the root canal with the irrigating solution and cleaning the ﬁ le ﬂ utes of all dentine remnants, debris and pulp tissue between each cycle.12, 13 In the research on primary molar pulpectomies, the results of the use of reciprocating instruments have been encour- aging so far, demonstrating good cleaning and shaping properties and shortened instrumentation time, thus being beneﬁ cial for the preparation of primary teeth.14–17 However, we found no in vivo studies or clinical reports on the use of the R25 ﬁ le (RECIPROC, VDW) in primary molar pulpec- tomy. In this article, we present a case series of primary molar pulpectomy using R25 in RECIPROC ALL motion in ﬁ ve primary molars with a diagnosis of pulp necrosis and periapical disease. Pulpectomy procedure All the patients’ parents (or legal guardians) were informed about the procedure protocol and prognosis and signed a written consent. The pulpectomy procedures were per- formed by the same operator, an endodontist with ten 30 roots 1 2022
case report | years of experience in primary molar pulp therapy. All the cases were non-vital teeth with a diagnosis of pulp necro- sis. Radiography conﬁrmed bone loss in the apical or furcal area, severe decay compromising the pulp chamber and at least two-thirds remaining of the root surface. All the children were cooperative and did not have systemic dis- ease or special care needs. Follow-up time ranged from 14 months to 36 months. The treatment protocol was performed in the following steps: – Local anaesthetic (1 carpule of 2 cm3 of 2% lidocaine hydrochloride with 1:100,000 adrenaline) was slowly injected and negative aspiration conﬁrmed. – Under complete isolation with a clamp and dental dam, the access cavity was performed with a high-speed #4 round bur under the operating microscope (OM-100, Ecleris), and the access was redeﬁned with a diamond bur. – The canals were searched with the aid of the DG16 endodontic explorer (Hu-Friedy) and negotiated with 10/.02 K-type ﬁles (SybronEndo; Kerr). – The ﬁnal irrigation protocol per root was 2 cm3 of alcohol and 1 cm3 of 17% EDTA for 1 minute, followed by 2 cm3 of alcohol, 5 cm3 of 2.5% NaClO and 3 cm3 of saline, and then paper points (Meta Biomed) were inserted to ensure canal dryness. – A mixture of zinc oxide eugenol (ZOE) in a powder–liquid form (Proquident) was delivered into the canals on a 40/.04 gutta-percha cone (Meta Biomed). Owing to its diameter at the tip, the cone was intended to fall short of the apical working length to avoid over-extrusion of the material. – An intermediate radiograph was taken to visualise the quality of obturation. If further condensation was re- quired, more ZOE paste of a harder consistency was gently plugged with a sterile cotton pellet. – Intermediate obturation was performed in the cavity above the ZOE using a glass ionomer luting cement (Ketac Cem Easymix, 3M ESPE). – At a second appointment, 15 days later, upon conﬁrming the absence of signs or symptoms of disease, a stainless- steel crown was adapted and cemented with glass ionomer in a powder–liquid form (Ketac Cem Easymix). 1 2 3 4 Case 1—Fig. 1: Initial situation. Fig. 2: Deep cavity and bone loss in the furcal area. Fig. 3: Three canals, lateral canal ﬁlling. Fig. 4: Fifteen-month control showing bone deposition in the furcal area. – The canal length was determined with an electronic apex locator (Root Zx II, Morita) and conﬁrmed with a peri- apical radiograph. From the measure obtained, 1 mm was subtracted to calculate the working length. – The irrigation was realised with 2.5% NaClO delivered passively 2 mm short of the working length in 27 gauge, 3 cm3 Luer lock endodontic syringes (PlastCare). – The root canal preparation was performed with a 21 mm long R25 ﬁle according to the manufacturer’s rec- ommendations in reciprocating motion (VDW.SILVER RECIPROC, VDW) in the RECIPROC ALL mode, without apical pressure, using in and out movements of 2–3 mm in amplitude, allowing the instrument to advance in the canal in a safe way until it reached the working length. – No lateral pressure against or brushing of the canal walls was done, in order to reduce the risk of weakening the thin tooth structure. Case 1 (Figs. 1–4) This female patient was 4 years and 7 months old and pre- sented with pain that had lasted for several days affecting the mandibular right second primary molar. On clinical examination, a buccal gingival swelling and facial initial oedema were noted, and the tooth was found to have deep occlusal decay. Pulp necrosis and a symptomatic apical abscess were diagnosed. The patient was prescribed medication to control acute infection and rescheduled after the antibiotic treatment. At the second appointment, no pain was reported and the buccal abscess had partially receded. A decision was made to perform pulpectomy and restoration. Over-extrusion of the obturation material was observed. The 15-month re-evaluation conﬁrmed no clini- cal or radiological signs of disease, and bone deposition was evident in the furcal area. roots 1 2022 31
| case report 5 6 7 8 9 Case 2—Fig. 5: Initial condition. Severe decay and buccal abscess. Fig. 6: Four long root canals were detected. Fig. 7: Obturation and temporary restoration. Fig. 8: Fourteen-month control showing the successor eruption process advancing normally. Fig. 9: Clinical aspect at ﬁnal evaluation showing healthy gingival tissue. Case 2 (Figs. 5–9) This male patient was 6 years and 7 months old and presented with severe tooth decay on the mandibular left ﬁrst primary molar without any symptoms of pain. He experienced slight discomfort to percussion and palpation of the buccal gingiva. A buccal abscess and no mobility were observed. The radio- graph showed a large area of interradicular bone loss. The tooth was diagnosed with pulp necrosis and asymptomatic apical abscess. Pulpectomy was performed, and at a second appointment, a stainless-steel crown was placed upon con- ﬁrming absence of signs or symptoms of disease. At the 14-month recall, no clinical pathology was detected and a nor- mal eruptive process of the permanent premolars was ob- served in spite of the extrusion of the obturation material. Case 3 (Figs. 10–13) This male patient was 7 years old and presented with mild pain that had lasted for several days. An extensive and deep cavity in the mandibular left ﬁrst primary molar was observed. There was no swelling of the gingiva, but the tooth was painful on percussion. The radiograph showed the severity of the decay but no consistent changes to the surrounding bone. Pulpec- tomy was the treatment of choice. The diagnosis of pulp ne- crosis was conﬁrmed once the access cavity had been per- formed, and three canals were located and fully negotiated. At a second appointment, 15 days later, the tooth was totally asymptomatic and the decision was made to restore with a stainless-steel crown. The 36-month control showed the tooth to be in normal function and completely healthy. Case 4 (Figs. 14–18) This male patient was 4 years and 6 months old and pre- sented with constant and spontaneous pain of the mandib- ular left ﬁrst primary molar that had lasted for several days but no facial oedema or buccal gingival swelling. Deep de- cay was observed but no mobility or deep probing depths. On the radiograph, the carious lesion could be seen to be 11 12 13 10 Case 3—Fig. 10: Initial radiograph. Fig. 11: Obturation and ﬁnal restoration. Fig. 12: Control at 36 months showing the normal eruption process despite the slow resorption of the zinc oxide eugenol. Fig. 13: Clinical aspect at ﬁnal evaluation showing healthy gingival tissue. 32 roots 1 2022
case report | 15 16 17 18 14 Case 4—Fig. 14: Severe decay. Fig. 15: Initial radiograph showing compromised pulp chamber. Fig. 16: Obturation of four root canals. Fig. 17: Thirty-month control. Fig. 18: Clinical aspect at ﬁnal evaluation showing healthy gingival tissue. compromising the pulp chamber and initial bone damage was observed in the furcal area. Pulpectomy was the treat- ment of choice. In the removal of the carious lesion, the pulp was exposed and no bleeding was observed. Pulp necrosis was diagnosed. Two mesial and two distal canals were located, and the tooth was obturated. At a second appointment, the tooth was asymptomatic and was re- stored with a stainless-steel crown. At the 30-month control, the tooth presented no symptoms and a normal eruptive process was observed on the radiograph. Case 5 (Figs. 19–23) This male patient was 5 years and 8 months old and pre- sented with distal deep interproximal caries on a maxillary left ﬁrst primary molar and an associated buccal sinus tract. The patient was asymptomatic and without a history of pain. Pulp necrosis with suppurative periapical periodontitis was diagnosed. Three canals were located and prepared for ob- turation. Apical over-extrusion with the ZOE was observed. Fifteen days later, the patient was asymptomatic and the sinus 19 21 20 22 23 Case 5—Fig. 19: Initial condition. Interproximal decay. Fig. 20: Initial radiograph showing apical bone loss. Fig. 21: Obturation of three root canals and ﬁnal restoration. Fig. 22: Thirty-month control showing bone healing around the mesial root and distal root tissue. Fig. 23: Clinical aspect at ﬁnal evaluation showing healthy gingival tissue. roots 1 2022 33
| case report tract had resolved, so the decision was made to restore the tooth with a stainless-steel crown. Follow-up after 30 months showed periapical healing of mesial apical area of previous radiolucency and no signs or symptoms of disease or pain. Ramazani et al. in their in vitro study compared two rotary systems and RECIPROC in mesiobuccal canals of primary molars.28 They conﬁrmed the RECIPROC system’s fast and good clean- ing and shaping ability. These were the ﬁrst studies to advocate the use of the RECIPROC system in the primary dentition. Discussion Dental caries is a pathology of wide prevalence in the world, and it affects the dentition in the early stages of life, being most common in susceptible populations because of a lack of dental education and limited access to quality healthcare services.18 It is well known that it is essential to avoid space loss during childhood in order to preserve the natural dentition. Loss of proper space can lead to mal- position of permanent teeth and compromises nutrition, speech ability and self-conﬁdence, among others.19 Primary molar pulpectomy is the treatment of choice to preserve primary natural dentition in teeth affected at the pulp– dentine complex and periodontally diseased as a result of bacterial invasion of the root canal system.20 Anxiety and stress regarding dental treatment in general are common, but must especially be taken into consideration when it comes to performing paediatric endodontic treat- ment.21 The search for and implementation of efﬁcient end- odontic techniques requires proper understanding of the root canal system anatomy, root canal instrumentation, dis- infection and obturation techniques, and the importance of coronal restoration.20, 22 When it comes to root canal instru- mentation, hand ﬁle techniques have been widely used in endodontics, but they are time-consuming, uncomfortable at some point and susceptible to procedural errors, especially if performed by clinicians with limited clinical experience.22, 23 Mechanically driven instrumentation came to change the way we shape canals, providing a faster way to enlarge the root canal system in a convenient geometry to allow the appropri- ate movement of the irrigating solutions inside the root canal system.23, 24 Instrument design, nickel–titanium alloys and the type of movement are factors to take into consideration, be- cause they will directly inﬂuence the instrument performance. In paediatric dentistry, chair time is a factor to consider: the shorter, the better for the patient to manage anxiety and feel comfortable. Single-ﬁle reciprocating instrument sys- tems can be beneﬁcial for paediatric endodontic treatment because they properly enlarge the geometry of the root canals, facilitate good shaping to enable proper distribution of irrigating solutions all along the working length and are less time-consuming than rotary and manual instru- mentation sequences.23, 25, 26 However, to the best of our knowledge, there is a lack of in vivo research on the use of reciprocating instruments in primary molar pulpectomy. Moraes et al. conducted an in vitro study employing a 3D-printed prototype of a maxillary primary central incisor.14 They concluded that the R40 ﬁle of the RECIPROC system was effective for instrumenting their 3D-printed model. Tyagi et al. in their in vivo study compared the use of a rotary system and the RECIPROC system for primary molar pulpec- tomy and evaluated the possible inﬂuence of the ﬁle system on child behaviour, among other factors.29 Their results re- garding clinical performance were in accordance with those of previous research. Nonetheless, they stated that the choice of ﬁle system did not signiﬁcantly alter child behaviour. Dalzell et al. conducted a micro-CT study in which they evaluated the instrumentation efﬁcacy of manual, Mtwo and RECIPROC blue ﬁles (VDW) in non-fused and fused primary molar roots and found signiﬁcant differences in cleaning and shaping effectiveness in both fused and non-fused teeth.30 Additionally, they found more proce- dural errors when the reciprocating instruments were used. This last ﬁnding is contrary to those of previous research and our clinical experience so far. Although we have not seen the clinical performance of the RECIPROC blue system, it shares the geometrical design and motion of RECIPROC. Barasuol et al. compared the shaping ability of hand, rotary and reciprocating ﬁles in primary teeth in a micro-CT in vitro study.25 Their results showed more canal transportation in the middle third of the root canal with the R25 ﬁle. They also found a shorter instrumentation time with the RECIPROC system compared with manual instrumentation. To the best of our knowledge, ours is the ﬁrst clinical report of the use of the R25 ﬁle in an in vivo scenario for primary molar pulpectomy. The long period of follow-up showed good results overall. These ﬁve cases were restored with complete stainless-steel crowns, and the time of their cementation was appropriate, avoiding recontamination of the root canal system. Our clinical experience over the years exceeds the cases re- ported here; however, these cases were presented because of their longer follow-up and proper stainless-steel resto- ration. The therapeutic success of our unreported cases follows the trend shown in this case series. Stainless-steel crowns are the preferred restoration for children at high risk of caries and teeth that have undergone pulp therapy. This may have contributed to the long-term success of treatment. Moghaddam et al. in their experimental study compared the cleaning efﬁcacy and instrumentation time of RECIPROC and Mtwo (VDW) in primary molars.27 They concluded that using systems such as RECIPROC for pulpectomy is beneﬁcial. The use of the operating microscope, coupled with the experi- ence of the operator in microscopic endodontics, may also have contributed to these results. The dental microscope is under- estimated and under-used in paediatric dentistry; however, its 34 roots 1 2022
case report | about Dr Benjamín Rodríguez earned his degree in dentistry from the Universidad Francisco Marroquín and his MSc in endodontics from the Universidad de San Carlos de Guatemala, both in Guatemala City in Guatemala. In 2019, after six years of endodontic clinical practice, he earned a postgraduate degree in oral and maxillofacial radiology from UIC Barcelona in Spain. advantages in locating canals in primary molars are clear, and its use is likely to become the standard of practice in dentistry. The improved ergonomics also allows longer working times without repetitive muscle strain and prevents postural issues.” More research is needed with longer follow-up and more cases and future investigations should focus on randomised clinical trials. Newer reciprocating instruments like RECIPROC blue could possess designs and metallurgical characteristics that are beneﬁ cial for use in primary molar pulpectomy and should therefore be investigated. Dr Jenner Argueta earned his degree in dentistry and master’s degree in endodontics from the Universidad de San Carlos de Guatemala in Guatemala City in Guatemala. He is a certiﬁ ed researcher at the Guatemalan national council for science and technology and teaches endodontics at the Universidad Mariano Gálvez de Guatemala in Guatemala City. He obtained the Certiﬁ cate of Proﬁ ciency in Endodontics from UB School of Dental Medicine at the University of Buffalo in Buffalo, New York, in United States. Dr Argueta also runs a clinical practice focused on micro-endodontics and micro-restorative dentistry. He was president of the Academia de Endodoncia de Guatemala (endodontic academy of Guatemala) from 2016 to 2020. Dr Argueta can be contacted at firstname.lastname@example.org. Editorial note: A list of references is available from the publisher. REGISTER FOR FREE DT Study Club – e-learning community AD THE GLOBAL DENTAL CE COMMUNITY THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y Tribune Group 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 instruc- tors, nor does it imply acceptance of credit hours by boards of dentistry.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 and Dental Tribune Int. GmbH.
| technique High-end technology for simplicity Adj Prof. Philippe Sleiman, Lebanon use a rather simpliﬁed approach for treating the complex root canal anatomy. In this article, I will demonstrate this approach with reference to several cases. The oriﬁce opening is done with the 25/.08 Traverse ﬁle, which has a maximum ﬂute diameter of 1 mm. This is a ﬁle that I use in almost all of my cases. In straight canals, it goes as deep as it can and, in curved canals, is limited to working above the curve. In straight canals, ZenFlex offers a wide range of sizes, from 20 to 55, in both .04 taper and .06 taper. After using the ZenFlex for some time, the dentist can evaluate the size that he or she likes to use according to his or her experience and preferences and can use one ZenFlex ﬁle to ﬁnish the shaping. In this ﬁrst example, the patient was referred for treatment of a sinus tract of the anterior maxilla (Fig. 1). A gutta-percha cone was placed inside the ﬁstula, showing the way to the infection site. This was a straightforward case, prepared using the 25/.08 Traverse ﬁle in the upper part of the root canal, followed by a 10 K-File (Kerr) to determine the work- ing length and then a 40/.06 Traverse ﬁle taken to working length. Naturally, treatment involved complete chemical preparation and 3D sealing of the root canal space (Fig. 2). The next example was also a straightforward case. This was a maxillary lateral incisor with a necrotic pulp and a slightly resorbed apex. A 55/.06 ZenFlex ﬁle was used in a single-ﬁle technique to treat this canal (Fig. 3). In molars and narrow canals, a simple sequence is required in order to perform shaping. It can start with the 25/.08 Traverse ﬁle, taken to just above the curve, especially in mesial canals. Using a K-File, the dentist can determine the working length using an apex locator and use this length for preparation with rotary ﬁles. The K-File is also used to achieve patency. The second rotary ﬁle is the 13/.06 Traverse ﬁle, taken to working length, followed by the 20/.06 and 25/.06 ZenFlex ﬁles, also taken to working length. If the dentist is following an apical enlargement regime, a 30/.04 ZenFlex ﬁle can be used for the apical area (Fig. 4). Maxillary second molars are in my opinion one of the most challenging teeth to treat because of their position and unpredictable anatomy. In this example case, the patient was referred for irreversible pulpitis (Fig. 5). Looking at the preoperative radiograph, we can see the curvature of espe- cially the mesial and palatal root canals. The sequence used was as described before, starting with the 25/.08 Traverse 1 2 3 Since nickel–titanium (NiTi) ﬁles were introduced into root canal therapy, engineers have been seeking the perfect design and combination for optimal root canal therapy. Heat treatment and twisting of NiTi was a major breakthrough in this ﬁeld. It opened up the era of heat treatment for rotary ﬁles, and now almost all ﬁles in the market are heat-treated, creating great ﬂexibility, but putting aside cutting efﬁciency, cutting being the major task for rotary ﬁles in shaping root canals. The Traverse and now ZenFlex ﬁle systems (both Kerr) are produced using a novel heat treatment that combines cut- ting efﬁciency and ﬂexibility in one ﬁle and in the necessary places. This new technology in heat treatment adds value to our daily work, as ultimately what matters is the treat- ment that we offer to our patients. Safety and cutting efﬁ- ciency are apparent when using these ﬁles, allowing me to 4 Fig. 4: Technical card for small to medium canals. 36 roots 1 2022
technique | 5 6 oriﬁce opener as deep as it goes and just above the curve, followed by a 8 K-File for working length determination and the 13/.06 Traverse ﬁle used to working length in all canals. During the use of the 13/.06 Traverse ﬁle, I did not feel much resistance, so I decided to go ahead with the .06 taper sequence. The next ﬁle was the 20/.06 ZenFlex, followed by the 25/.06 ZenFlex ﬁle. Personally, I believe in apical enlarge- ment, and for that reason, I used the 30/.04 ZenFlex ﬁle as the ﬁnal enlargement ﬁle in this case. I used a medium cone as the master cone and achieved 3D sealing of the system (Fig. 6). Of course, I performed complete chemical prepara- tion, according to my sequence, during the procedure. In very narrow canals, the .06 taper ZenFlex ﬁle will be re- placed by the .04 taper one, in order to reduce taper lock, which occurs when a large ﬁle is trapped inside a single or a double canal curve. This can create a great deal of torsional stress and bending stress on the same spot, leading to severe damage of the ﬁle and even to ﬁle separation. The sequence is use of the 25/.08 Traverse ﬁle in the straight part of the canal, followed by 8 and 10 K-Files, taken to working length. The 13/.06 Traverse ﬁle opens the way for the 20/.04 ZenFlex ﬁle, which is followed by the 25/.04 ZenFlex ﬁle and additionally the 30/.04 ZenFlex ﬁle for apical enlargement (Fig. 7). A medium or ﬁne-medium cone can be adapted as the master cone. In this example case, the patient was referred by his treat- ing dentist, who had penetrated deep into the roots in trying to ﬁnd the canals and was not successful, but for- tunately no perforation had occurred (Fig. 8). Under the microscope and using ultrasonic tips, the canals were made accessible. On the radiograph, we can see that the canals, especially the mesial ones, are narrow and have small curves, particularly apically. The real challenge in this case was maintaining the original shape of the canal. For those reasons, the sequence with the .04 taper was cho- sen. Treatment was initiated with the 25/.08 Traverse oriﬁce opener, followed by a 8 K-File for working length deter- mination. The 13/.06 Traverse ﬁle was used all the way to the end of the working length, followed by the 20/.04 7 Fig. 7: Technical card for narrow canals. and 25/.04 ZenFlex ﬁles, both taken to working length. For apical enlargement, the 30/.04 ZenFlex ﬁle was used. A medium cone was used as the master cone in the distal root, and ﬁne-medium cones were used in the mesial root. A full sequence of irrigation was used during the treatment, and the system, which included a deep isthmus between the mesial roots, was ﬁlled in multiple levels from the middle to the apex, achieving beautiful 3D obturation (Fig. 9). contact Adj Prof. Philippe Sleiman is an assistant professor at the Faculty of Dental Medicine of the Lebanese University in Beirut in Lebanon and Adj Prof. at the UNC Adams School of Dentistry at the University of North Carolina in Chapel Hill, North Carolina, in United States. He can be contacted at email@example.com. 8 9 37
| technique The golden era of root canal shaping Dr Ahmed Shawky, Egypt After access preparation and location of anatomy, the next challenge facing the endodontic clinician is to select the proper ﬁle alloy and sequence for the shaping procedure in order to be able to shape the anatomy safely and predictably and with- out any procedural errors. This article will show the advan- tages of the MG3 instruments (Shenzhen Perfect Medical Instruments) and how we can customise the sequence of these ﬁles according the anatomy encountered and case difﬁculty for predictable root canal shaping with a high safety margin. Files First, I will go through the components of the basic assortment of the MG3 Gold ﬁle system (Fig. 1). The main advantage of this ﬁle system is the presence of different designs and cross sections in the same instrument kit, a smart thing for dealing with different anatomies. Starter ﬁle (oriﬁce modiﬁer, 20/.10) This ﬁle has a short working segment (9 mm) and 19 mm length. This improves accessibility in restricted areas (Fig. 3). It is used for mechanical pre-ﬂaring or oriﬁce modiﬁcation for elimination of coronal dentine resistance. It has a convex triangular cross section, which increases the blade strength, giving the instrument a high cutting efﬁciency. With this cross section, the instrument is subjected to excessive tor- sional load; therefore, this instrument must be used in brushing motion towards the outer walls and not pecking motion. Gliders (16/.02 and 19/.02) Another advantage of this system is that it has two glide path ﬁles (Fig. 4). They can be used sequentially, depend- ing on case difﬁculty. Sometimes, only one is used. The rectangular cross section provides four blades for better centring ability, avoiding transportation, and for high cut- ting efﬁciency for reproducible glide path preparation. The MG3 Gold ﬁles are machined with a variable pitch and helix (Fig. 2), allowing efﬁcient coronal evacuation of debris and preventing a screw-in tendency. This also reduces the torsional load on the instrument that would otherwise occur because of debris accumulation or excessive friction with the root canal walls. The small size and taper of these ﬁles make them extremely ﬂexible for negotiating mechanically difﬁcult curvatures. Owing to the small size of the gliders, it is recommended to use them with brushing motion ahead of pecking motion to avoid torsional failure. Pitch 1 2 38 roots 1 2022
Cross-Section Designs Cross-Section Designs 3 4 “The MG3 Gold with low shape memory and high cutting efﬁciency allows (...) to manage different cases with an excellent margin of safety and predictability.” Shaping ﬁles 20/.04 and 25/.06 The cross section of these shaping ﬁles is triangular (Fig. 5). This design provides sharp blades for enhanced cutting efﬁciency and reduces the metal core of the in- strument, as the size is increased to maintain ﬂexibility. The off-centre design also makes the instrument move in swaggering motion for better canal tracing and for avoiding transportation. The 35/.04 ﬁle is an optional ﬁle for increasing the preparation size in large root canals. It is used in zone pecking motion. The heat treatment imparts a wear-resistant surface with superior cutting behaviour and enhances cyclic fatigue resistance. The 25/.04 ﬁle can be used in body shaping and can be used as a ﬁnishing ﬁle in cases with anatomical lim- itations, such as severely curved canals. The 25/.06 ﬁle can be used for pressureless pre-ﬂaring and as a shaping or ﬁnishing ﬁle. Shaping ﬁle 35/.04 The cross section of this shaping ﬁle is off-centre rectan- gular (Fig. 6). This design provides sharp blades for en- hanced cutting efﬁciency and reduces the contact points of the instrument with the root canal walls. This reduces the torsional load on this larger size and provides better clearance of debris. Additional information Non-assorted reﬁlls of all sizes are available for the clinician to customise his or her treatment sequence up to ISO tip size 50. All ﬁles are available in lengths of 21, 25 and 31 mm (except the starter ﬁle, being of 19 mm in length). The recommended operation speed is 300–350 rpm, and the recommended torque is 2 Ncm for the glide path and shaping ﬁles and 3 Ncm for the starter ﬁle. Markings indicate taper: one marking for 2%, two for 4% and three for 6%. Precisely calibrated working length markings are en- graved on each instrument shank at 18, 19, 20 and 22 mm for easy reproduction of the recorded working lengths in each canal, especially in multi-rooted teeth of different lengths. Cross-Section Designs Cross-Section Designs 5 6 roots 1 2022 39
7 ration, only one large mesial oriﬁce was identiﬁed. Ultra- sonic modiﬁcation revealed the presence of two mesial canals originating from a single mesial oriﬁce (sub-pulpal bifurcation). Mechanical pre-ﬂaring with the 25/.06 MG3 Gold ﬁle, followed by mechanical body shaping with the 25/.04 ﬁle, created a smooth glide path down the two separate mesial canals despite coronal restriction. Following the reproducible glide path, shaping with the 20/.04, 25/.04 and 25/.06 ﬁles was not a difﬁcult task. How to use the MG3 Gold instruments Case 1 (Fig. 7) The patient presented to the clinic and was diagnosed with symptomatic irreversible pulpitis and apical peri- odontitis of a mandibular third molar. After access prepa- Case 2 (Figs. 8 & 9) A patient with a mandibular third molar diagnosed with irreversible pulpitis and symptomatic apical periodontitis was referred to my practice. Under high magniﬁcation, the canal entrances were negotiated using medium- 8 9 40
technique | 10 11a 11b 11c power ultrasonic instruments and D-perfect C Files (Shenzhen Perfect Medical Instruments). Special care was given to the coronal portion of the root canal, espe- cially to the mesiobuccal canal, owing to the scouted double curvatures. Pressureless mechanical pre-ﬂaring was done to reduce the coronal interferences (cervical dentinal triangle—red triangle), which can place huge stress on the shaping ﬁles, leading to procedural errors such as instrument separation and transportation, thereby increasing the difﬁculty of an initially straightforward case. Conclusion When dealing with anatomy, variability is the rule. This is the reason that the endodontic practitioner must be able to modify the sequence of the instruments and treatment approach according to the anatomy. The introduction of new ﬁle systems like MG3 Gold with low shape memory and high cutting efﬁciency allows the clinician to manage different cases with an excellent margin of safety and predictability. Mechanical pre-ﬂaring in such a case can be done using either the starter ﬁle (20/.10) or the apical 3–4 mm of the 25/.06 shaping ﬁle or even both. The mode of action of these ﬁles is brushing motion towards the outer walls. about Case 3 (Figs. 10 & 11) The patient presented with a mandibular ﬁrst molar with advanced symptomatic pulpitis and apical periodontitis. Taking into consideration the constricted appearance of the root canals on the digital radiograph, MG3 Gold was the best suited for the situation owing to the high cutting efﬁciency. Mechanical pre-ﬂaring with the 25/.06 ﬁle was done to facilitate body shaping using the 25/.04 ﬁle and a secured mechanical glide path to a ﬁnal size of 30/.04 in the ﬁve-canaled molar. Dr Ahmed Shawky, BDS, MSc, PhD, is a senior lecturer in endodontics at the Faculty of Dentistry of Cairo University in Egypt, and his ﬁeld of research is regenerative endodontics. He is a consultant in micro-endodontics and has conducted more than 25 certiﬁed continuing education endodontic training courses both nationally and internationally. He is an opinion leader for Dentsply Sirona Middle East and North Africa. roots 1 2022 41
| interview Laser protocol for peri-implantitis treatment An interview with Dr Michał Nawrocki By Dental Tribune International insufﬁcient for me, and to be honest my knowledge of lasers, physics, indications and procedures was incom- plete at the time. Then in January 2016, I invited Dr Ilay Maden to my clinic to conduct a course and teach my colleagues and me about various Er:YAG and Nd:YAG procedures with the LightWalker laser. A few months later, I decided to extend my knowledge about lasers by attending the Master of Science in Lasers in Dentistry presented by Prof. Norbert Gutknecht in Aachen. Now, I cannot imagine continuing my daily practice and treat- ments without having LightWalker. Sometimes, I use it as an additional tool during certain procedures, but very often it’s a crucial and necessary tool for me to use to conduct a particular procedure. What procedures do you perform with laser? Laser can be used in all ﬁelds of dentistry; however, I am mainly focused on implantology and surgery, as well as prosthodontics. In prosthodontics, it can be used for sulcus conditioning, preparation for veneers and removal of complete ceramic crowns, as well as during more chal- lenging procedures like crown lengthening before tooth preparation. We can use it in gingivectomy (Nd:YAG laser) and bone recontouring (Er:YAG laser). All my surgery cases are ﬁnished with photo-biomodulation using the Nd:YAG Genova handpiece. I have observed that wound healing is much faster and better in such cases owing to pain reduction, disinfection, reduction of oedema and the laser’s analgesic function. Sometimes, I have to conduct an endodontic treatment during the procedure (which is quite rare and normally done by my colleagues), in which case I really appreciate the deep disinfection with Nd:YAG, which offers the highest bac- terial reduction in comparison with other wavelengths, and the Er:YAG SWEEPS (shock wave-enhanced emission photoacoustic streaming) procedure, which provides the most effective cleaning and disinfection. With surgical treatments, I use both wavelengths in almost all cases. Even when performing an easy and fast tooth extraction, I can use Er:YAG for granulation tissue removal, followed by Nd:YAG for disinfection, clot stabilisation and ﬁnally photo-biomodulation. Of course, I use laser before im- plant insertion, as well as when complications appear. Dr Michał Nawrocki Laser is becoming essential for every modern dental practice. Moreover, from an educational standpoint, there are many beneﬁts in terms of the personal and pro- fessional development of the practitioner. In this inter- view, Dr Michał Nawrocki explains how laser dentistry has helped to advance his practice and career and why dental laser, and Fotona’s LightWalker in particular, has become an essential part of his daily practice. Dr Nawrocki, you have been using laser technology since 2016. Looking back at your journey as a laser dentist, how has LightWalker impacted your every- day practice? I started my great adventure with Fotona’s LightWalker in 2016. Before that I had used a diode laser, but it was 42 roots 1 2022
| interview 1 4 8 10 2 3 5 6 7 Fig. 1: Initial situation. Fig. 2: Pocket depth measurements. Fig. 3: Bleeding on probing. Figs. 4 & 5: Use of the Er:YAG laser Varian tip for granulation tissue removal, implant surface decontamination and surface ablation of infected bone. Fig. 6: Photo-biomodulation with the Nd:YAG laser. Fig. 7: Final results after three months. No sign of inﬂammation. of the implant surface with Er:YAG; (3) surface ablation of infected bone with Er:YAG; (4) reduction of bacteria in the bone with the Nd:YAG laser; and (5) photo-biomodulation with the Nd:YAG laser (after ﬂap closure). In our non-surgical procedure, there are only four steps—I skip deep disinfection with the Nd:YAG laser owing to the 1,064 nm wavelength’s high absorption in titanium (it’s not possible without elevating a ﬂap to disinfect only the bone and not harm the implant surface). As I mentioned, the ﬂapless pro- cedure is most often my ﬁrst option, and when the defect is severe, I decide on a surgical procedure as the second stage. After the procedure, the same restoration is generally placed in the mouth (after corrections if necessary). Some- times, depending on the type of bone defect, I decide to conduct bone regeneration with the use of bone substitute and collagen membranes. In such cases, I have to remove the restoration and, after peri-implantitis treatment with the use of laser and bone augmentation, close the ﬂap with cover screws, leaving the patient with no restoration (pos- teriorly), not even a temporary one, for two to three months. What are the beneﬁts of LightWalker for the treatment of peri-implantitis in your everyday practice? As I mentioned, the treatment of peri-implantitis is a huge challenge nowadays; statistically, in 20% of cases peri- implantitis develops and in 40% of cases mucositis develops around inserted implants. Treatment with the use of Er:YAG and Nd:YAG lasers is very effective, fast and comfortable 9 11 12 Fig. 8: Initial situation. Fig. 9: Granulation tissue visible after ﬂap elevation. Fig. 10: Granulation tissue removal with Er:YAG laser. Fig. 11: Bone augmentation. Fig. 12: Final results with restoration two years post-op. 44 roots 1 2022
interview | 14 19 13 15 16 17 18 20 Fig. 13: Initial situation. Visible ﬁstula one year after loading. Fig. 14: Bone defect of 9.27 mm in diameter. Fig. 15: Flap elevation. Fig. 16: Granulation tissue removal with Er:YAG. Fig. 17: Implant resection. Fig. 18: CBCT scan on the day of surgery. No bone augmentation. Fig. 19: CBCT scan 1.5 years post-op. Visible bone regeneration. Fig. 20: Situation 1.5 years post-op. No sign of inﬂammation. for both patients and practitioners. We can use a minimally invasive, non-surgical treatment, which very often is highly effective, and thus avoid a surgical procedure. However, it’s very important that we use our lasers with proper pa- rameters to protect the soft and hard tissue and not alter the implant surface. We can thoroughly remove bacterial bioﬁlm from the implant surface without altering it, and we have the possibility of re-osseointegration. Of course, we have to be aware of risk factors and aim to avoid them, understand what the reason for the disease was and solve the underlying problem. Sometimes, it’s only improper oral hygiene, while other times, we must change or correct the restoration. Each case is individually treated. Could you share with us some of your more chal- lenging cases of peri-implantitis and explain how the treatment was performed? Case 1 was a patient who presented with deep pockets (9 mm), bleeding on probing and visible purulent effusion (Figs. 1–7) and was treated with a non-surgical protocol. In Case 2, the patient preferred a surgical procedure with bone augmentation, as a consequence of bone graft complication and graft exposure (Figs. 8–12). The implant apicectomy in Case 3 shows that one year after the immediate implantation with immediate loading there was inﬂammation around the implant apex. The rest was properly integrated (Figs. 13–20). What advice would you give to your dental colleagues who may be considering whether to incorporate laser technology into their practice? I can only advise them to use laser; there is no reason to hesitate. Laser technology really changes dental practice. Laser use provides new possibilities, new treatment protocols and many advantages in dental procedures. Our treatments are more comfortable, less painful (some- times even painless) and very often less invasive and more predictable. We have a great advantage of selective tissue removal based on the chosen laser wavelength and settings. Last but not least, it is better for our mar- keting, and patients now expect newer technologies. Editorial note: A shortened version of this interview was published in implants—international magazine of oral implantology, vol. 23, issue 1/2022. roots 1 2022 45
interview | should be available and have reasonable acquisition and care costs. The choice should also be directed towards the species requiring the fewest animals. Finally, the research should be conducted on the minimum number of animals to provide the maximum amount of information. What are some of the disadvantages of choosing an animal approach to studying pulpitis? The use of animal models in research is still debated from an ethical point of view. There is not an ideal animal model since they all have advantages and drawbacks. What are some of the hurdles in choosing the correct animal model to study dental pulp? Among the animal kingdom, rodents, rabbits, ferrets, swine, dogs and non-human primates have been used to model human pulpitis. The diversity of animals found in studies indicates the difﬁ culty of choosing the correct and most efﬁ cient model. Each animal model has its own characteristics that may be either advantageous or limiting, depending on the study parameters. Non-human primate models have certain limitations such as zoonotic risks, supply difﬁ culties and a high cost of purchase and maintenance. It is generally accepted that the immune systems of rats and mice are comparable; however, much more infor- mation is available for the mouse. Moreover, there are differences between the results obtained in mice and rats. For instance, several studies have shown that the immune parameters in mice are more sensitive to the effects of stress (as measured by corticosterone) com- pared with those in rats. Even if rodents are the mainstay of in vivo immunological experimentation, it is important to point out that the immune systems of mice/rats and humans are quite similar but also present some dif- ferences, especially when it comes to development, activation and response to aggression. It is, therefore, necessary to consider the possibility that a given murine model response may not occur in exactly the same way in humans. DAYS OF ENDODONTICS 4 How effective are in vitro experiments and other experimental alternatives for studying pulpitis, and are they gaining increasing popularity in dental research? “In the future, it might be possible to consider artiﬁ cially generated caries-inducing models.” Alternative methods are gaining popularity since they are becoming increasingly accurate. They involve 3D experiments and can combine new knowledge to implement the experiment. The overall aim is to limit animal suffering and to protect the welfare of animals. 12 14 What changes do you see in dental research on animals in terms of legislation, ethicality and the validity of ﬁ ndings? The rule of the three Rs was developed by Russel and Burch in 1959 and forms the basis of the regulation and the ethical foundation of the use of animals for scientiﬁ c purposes. It stands for replacement, reﬁ nement and reduction (in the number of animals). LECTURES HANDS-ON-COURSES There are higher costs involved with the use of larger animals such as swine and dogs. register at www.roots-summit.com How is pulpitis typically induced in animal models? There are three main dental pulp induction techniques found in the literature, varying according to the causal agent. The ﬁ rst technique consists of making cavities with burs under water spray until pulp exposure. The second method involves creating cavities under the same conditions as previously described, with or without pulp exposure. Once the cavity has been made, an exogenous supply of toxins, such as lipo- polysaccharide or human carious dentine, is placed either directly in contact with the pulp or at the bottom of the cavity so that the toxins diffuse through the dentinal tubules. More recently, a fourth R, responsibility, was added in order to focus on the integrity and honesty of scientists regarding the proper and reasonable use of laboratory animals. However, legislation differs from country to country. In your opinion, how will dental pulp be studied in the future? Will there be novel methods that will help researchers better understand the physiology of dental pulp? In the future, it might be possible to consider artiﬁ cially generated caries-inducing models that would represent a more elegant and closer-to-reality alternative to mechanical injury and lipopolysaccharide stimulation. This would also help to avoid off-target effects of the transgenic models. The third induction technique consists of using trans- genic animal models. Additionally, biological markers and other novel diag- nostic tools could help to successfully visualise pulp morphology, vitality and regeneration. 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. roots 1 2022 47
| research The key role of vitamin D in immune health and regeneration The evidence for supplementation Prof. Shahram Ghanaati, Dr Karl Ulrich Volz & Dr Sarah Al-Maawi, Germany & Switzerland A healthy immune system is the basis of general good health and a good immune defence. It has been proved that individual habits, nutrition and the environment have an inﬂuence on our health.1 A balanced and healthy diet in particular is the key to a healthy human body. An un- balanced diet can seriously impair the immune system and increase the risk of chronic disease as a result.1 In the last decade, chronic diseases such as diabetes mellitus, Endogenous synthesis Exogenous intake 7-dehydrocholesterol Vitamin D3 cholecalciferol Calcidiol (25-hydroxycholecalciferol) Calcitriol (1,25-dihydroxycholecalciferol) 1 Fig. 1: Diagram for endogenous synthesis and exogenous vitamin D3 intake. 48 roots 1 2022 obesity and cardiovascular disease have surged sharply in various countries. A major reason for this is an in- creasingly unhealthy living environment and increasingly unhealthy lifestyle choices, especially in industrialised countries.2 The role of food components and especially vitamins has become increasingly important in various areas. In 1928, the German biochemist Adolf Windaus was awarded the Nobel Prize in Chemistry for his work on the correlation between sterols and vitamins, which sparked further research interest in vitamin D.3 Vitamin D can be produced in a physiological way in the human body. Sunlight is essential for this endogenous synthesis, which takes place primarily in the skin, where 7-dehydrocholesterol is converted into cholecalciferol (vitamin D3) by UVB rays. In order to reach its biologically active form, cholecalciferol undergoes further conversion steps in the liver (calcidiol) and in the kidney (calcitriol). The latter is the biologically active form of vitamin D and acts as a transcription factor. After binding to the vitamin D recep- tor, calcitriol regulates the expression of various proteins in the cell. The physiological mode of action of calcitriol therefore resembles that of a hormone and not that of a vitamin. That is why vitamin D, as a precursor of calcitriol, should rather be regarded as a prohormone (Fig. 1).4, 5 The connection between vitamin D and parathyroid hor- mone was recognised shortly after its discovery. Within this context, the regulatory effect of vitamin D on the min- eral balance of the body and in particular the regulation of calcium and phosphate levels was emphasised.6–8 Fur- thermore, it was established quite early on that vitamin D plays an important role in mineralisation and bone forma- tion. Consequently, many studies have focused on the in- ﬂuence of vitamin D on skeletal health and the treatment of diseases such as osteoporosis. These ﬁndings have contributed to vitamin D being primarily associated with bone health in the public perception. However, some studies have shown the positive effect of vitamin D on the immune system too and thus on the gen- eral health of the body. Several studies have shown that vitamin D has a preventive effect on chronic diseases such as diabetes mellitus, hypertension and cardiovascular dis-
| research its potential preventive inﬂuence in chronic and infectious diseases. However, these mechanisms of action still re- main largely unexplained for the respective indications. The correlation between vitamin D levels and the prev- alence of various chronic diseases has been shown in several clinical studies. A meta-analysis of 25 prospec- tive cohort studies has shown that low vitamin D levels increase the risk of developing cardiovascular disease. In about 10,000 patients, the risk of cardiovascular dis- ease was about 44 % higher than in people with healthy vitamin D levels.15 Another study showed a correlation between vitamin D levels and the development of hyper- tension. It examined 8,155 patients suffering from hy- pertension and vitamin D deﬁciency. After the vitamin D deﬁciency had been eliminated, 71 % of the patients no longer showed any symptoms or had measurably high blood pressure.16 A positive inﬂuence of vitamin D has also been demonstrated in the development of Type 2 diabetes mellitus. It was shown that the number of pa- tients in a prediabetic stage and with a vitamin D deﬁ- ciency was signiﬁcantly lower than in the untreated group, once the vitamin D deﬁciency had been eliminated.17 Furthermore, the potential of an anti-infectious or anti- viral effect of vitamin D has been increasingly investigated in recent years. As a result, vitamin D has gained greater signiﬁcance as a preventive or adjuvant therapy.11, 18 A systematic review has shown that a vitamin D deﬁciency is associated with a higher viral load in hepatitis B pa- tients.19 Furthermore, it was shown that vitamin D can in- hibit a herpesvirus infection through its anti-inﬂammatory and supportive defence effect.20 In addition, studies have shown that vitamin D supplementation reduces the prev- alence of inﬂuenza infections during inﬂuenza outbreaks.21 Another meta-analysis showed that the number of certain vitamin D receptor polymorphisms involved in processing of vitamin D correlates with an increased risk of a viral in- Vitamin D deﬁciency: 85.7 % 45.8 % 20.8 % 20.8 % 12.5 % > 30 ng/ml 20–30 ng/ml 10–20 ng/ml 0–10 ng/ml 15 10 5 0 s n o s r e p t s e t f o r e b m u N 2 Fig. 2: Distribution of vitamin D levels according to a pilot study conducted by the Clinic for Oral and Maxillofacial Plastic Surgery at Goethe University Frankfurt am Main. 50 roots 1 2022 fection. Based on the vitamin D-mediated improved im- mune defence and its potential role as an antiviral agent, its importance in the prevention of viral diseases is in- creasingly being investigated. Especially in the COVID-19 pandemic, vitamin D supplementation can play an im- portant role in preventing and defeating infection.22 Determination of vitamin D levels and deﬁnition of hypovitaminosis Vitamin D is a lipophilic molecule that is transported in the blood by carrier proteins. Approximately 80 % of these molecules are bound to the vitamin D binding protein in this manner. A further 10–15 % are bound to albumin and the rest circulates freely in the blood. The determination of the vitamin D level as part of a routine examination involves measuring the total concentration of all these forms. The 25(OH)D serum concentration is widely rec- ognised as a reliable marker of vitamin D levels.12 Similar to other vitamins and blood components, the vitamin D concentration is usually expressed in nanograms per mil- lilitre (ng/ml) or in nanomoles per litre (nmol/l). Both units are used, depending on the individual testing laboratory. Here, it must be noted that 1 nmol/l equals 0.4 ng/ml. The deﬁnition of a healthy vitamin D level and thus hypovita- minosis is a matter of much debate. In the literature, a vitamin D level of less than 30 ng/ml (75 nmol/l) is con- sidered a vitamin D deﬁciency (hypovitaminosis).13, 19, 23, 24 In various countries, studies have reported a general vitamin D deﬁciency. Observational studies have docu- mented that the prevalence of vitamin D levels of below 20 ng/ml (50 nmol/l) is as much as 24 % in the US, 37 % in Canada and 40 % in Europe.13, 24 The German Robert Koch Institute reported that 58 % of 18- to 79-year-olds in Germany have a level of below 20 ng/ml (50 nmol/l).25 This vitamin D deﬁciency pandemic was recognised as such several years ago. However, not much has been done in terms of supplementation and deﬁning a sufﬁcient dose. A pilot study examined the vitamin D levels of medical staff in the clinic for oral and maxillofacial plastic surgery at Goethe University in Frankfurt am Main in Germany. Out of 24 participants, 85.7 % had a vitamin D deﬁciency with a value below 30 ng/ml, whereas 45.8 % even had a value of below 10 ng/ml (Fig. 2). It is important to empha- sise that a healthy vitamin D value is considered to be between 40 ng/ml and 60 ng/ml. Current guidelines for vitamin D supplementation Given that, in most cases, endogenous synthesis of vitamin D is insufﬁcient owing to limited exposure to sun- light, the body’s vitamin D intake should also come from food or dietary supplements. The amount of vitamin D absorbed can be expressed in two units: micrograms (µg) and international units (IU). One microgram equals 40 international units (1 µg equals 40 IU). These units
research | must be considered when administering vitamin D. Since in most cases vitamin D intake via food is insufﬁcient for the body’s needs, supplementation with vitamin D preparations is an utmost necessity. In the literature, the current recommendations for doses to be administered are largely inconsistent and are mainly based on the esti- mated requirements of maintaining optimal bone health. The recommendations range from 400 IU/day to 4,000 IU/ day. The European Food Safety Authority recommends a dose of 600 IU/day for healthy adults.22 A similar rec- ommendation, a dose of 400 IU/day, has been published by the Scientiﬁc Advisory Committee on Nutrition in the UK.26 The Institute of Medicine Committee in the US rec- ommends a dose of 600 IU/day for adults under 70 years of age and a dose of 800 IU/day for those over that age.27 The American Association of Clinical Endocrinology rec- ommends a dose of 1,000–4,000 IU/day.28 The recently updated reference values of 2012 from the German Category Dose Administration duration Initial concentration Targeted concentration Side effects Prevention in pupils21 1,200 IU/day 12 months Not speciﬁed Not speciﬁed Cancer, cardiovascular disease30 2,000 IU/day 12 months 29.8 ng/ml 41.8 ng/ml Diabetes mellitus17 4,000 IU/day 12 months 28.0 ng/ml 52.3 ng/ml 4,000 IU/day 24 months 28.0 ng/ml 54.3 ng/ml None None None None Ventilated patients in intensive care31 Test persons with a vitamin D deﬁciency32 None None None None None None None None None None None None Hypercalcaemia as a result of over-physiological vitamin D concentrations roots 1 2022 51 50,000 IU/day 5 days 23.2 ng/ml 45.0 ± 20.0 ng/ml None 100,000 IU/day 5 days 20.0 ng/ml 55.0 ± 14.0 ng/ml None 25,000 IU/fortnight 2 months 7.6 ng/ml 19.0 ng/ml 25,000 IU/week 1.5 months 8.0 ng/ml 25.0 ng/ml 25,000 IU/week 2 months 8.4 ng/ml 35.6 ng/ml Test persons with a vitamin D deﬁciency33 1,000 IU/day 5 months 28.8 ng/ml 33.6 ng/ml 5,000 IU/day 10,000 IU/day 27.0 ng/ml 64.0 ng/ml 26.0 ng/ml 89.6 ng/ml Breast cancer patients with bone metastasis34 7,000 IU/day 4 months < 20.0 ng/ml Not speciﬁed Psychiatric clinic24, 35 5,000 IU/day 12 months 24.0 ng/ml 68.0 ng/ml 10,000 IU/day 12 months 25.0 ng/ml 96.0 ng/ml Test persons with a vitamin D deﬁciency36 100,000 IU/month (3,000 IU/day) 36 months 24.4 ng/ml 54.0 ng/ml Multiple sclerosis37 20,000 IU/day 12 months 21.6 ng/ml 44.0 ng/ml Multiple sclerosis38 50,000 IU/week (7,142 IU/day) Asthma, rheumatic arthritis, rickets, tuberculosis in the 1930s and 1940s24, 39 60,000– 600,000 IU/day 6 months 15.3 ng/ml 33.7 ng/ml Not speciﬁed Not speciﬁed Not speciﬁed Table 1: Overview of the vitamin D doses administered in selected randomised clinical studies.
| research Vitamin D test < 40 ng/ml ≥ 40 ≤ 80 ng/ml > 80 ng/ml 10,000 IU/day 5,000 IU/day 1,000 IU/day Monitoring after three months 3 Fig. 3: Vitamin D3 dose recommendation of the authors for healthy adults. Nutrition Society estimate the need at 400 IU/day for chil- dren and 800 IU/day for adults.25 The US research insti- tute GrassrootsHealth collected data on the safety of a dose of 10,000 IU/day and found no undesirable side ef- fects.24, 29 The European Food Safety Authority also clas- siﬁes a dose of 10,000 IU/day as safe, but recommends no more than 4,000 IU/day.22 Clinical supplementation protocols in randomised controlled clinical studies As opposed to the recommendations of various author- ities and institutions, relatively high doses of vitamin D have been administered in randomised controlled clinical trials, and these have in most cases led to the support of therapy. Various clinical supplementation protocols have been used with doses ranging from 1,000 IU/day to 100,000 IU/day. Two different strategies have been pur- sued: one option is to administer a relatively high dose, such as 100,000 IU, once a month to raise and maintain vitamin D levels; and the other option is to supplement with an adequate daily dose (between 5,000 IU/day and 10,000 IU/day) to cover the body’s daily requirements. Most studies have documented an observation period of up to one year and have paid particular attention to the analysis of the dreaded side effect of vitamin D intoxica- tion. However, no vitamin D intoxication was observed in any of these studies. A detailed overview of the respec- tive studies is given in Table 1. Not long after the discov- ery of vitamin D and the recognition of its role in main- taining mineral balance, many diseases, such as asthma, rickets and tuberculosis, were treated in the 1930s and 1940s with extremely high daily doses of vitamin D (be- tween 60,000 IU/day and 600,000 IU/day). These studies reported hypercalcaemia as a result of over-physiological vitamin D concentrations, which led to growing concern regarding vitamin D supplementation. It is important to note that these studies were carried out with much higher doses than the ones currently administered. 52 roots 1 2022 Authors’ dose recommendation for healthy adults Today, the importance of vitamin D for the general health of the body and the immune system is well documented. A vitamin D value of between 40 ng/ml and 80 ng/ml should be aimed for. In contrast to the doses recommended by various associations, there is increasing evidence in cur- rent research that a relatively high daily dose is neces- sary to reach these values. However, there are no uniform guidelines at this point. Based on the investigated data, we recommend a daily dose that is adapted to the indi- vidual needs of the patient. In the case of a vitamin D de- ﬁciency (< 40 ng/ml), a dose of 10,000 IU/day should be administered for three months to compensate for the de- ﬁciency. As a maintenance dose for a vitamin D level in the range of 40–80 ng/ml, a dose of 5,000 IU/day is recom- mended. If the level is higher than 80 ng/ml, it is advisable to reduce the dose to 1,000 IU/day. The vitamin D level should be checked every three months in order to ad- just the dose to the individual needs of the patient (Fig. 3). When supplementing vitamin D, it is equally important to take the patient’s medical history into consideration and, in the case of compromised organ function or metabolic disease, to individualise the dose accordingly. Editorial note: A list of references is available from the publisher. This article was ﬁrst published in implants—international magazine of oral implantology, vol. 22, issue 1/2021. about Prof. Shahram Ghanaati is a specialist in maxillofacial surgery and oncology, based in Frankfurt am Main, Germany. In 2013, he was appointed Director of the University Cancer Center of the Frankfurt University Hospital. He is the Senior Physician and Deputy Director of the Department of Oral and Maxillofacial Plastic Surgery of the Frankfurt University Hospital. In addition, he is the Director of the research laboratory FORM-Lab (Frankfurt Orofacial Regenerative Medicine). contact Prof. Shahram Ghanaati Universitätsklinikum Frankfurt Theodor-Stern-Kai 7 60590 Frankfurt am Main, Germany +49 69 6301-3744 firstname.lastname@example.org
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| manufacturer news Seiler Instrument celebrates its 77th anniversary this year US-based Seiler Instrument came from humble origins When Seiler Instrument launched in September 1945, the staff included just its founders: husband and wife duo Eric H. and Dora Seiler. Operations ran out of a small rented manufacturing and ofﬁ ce space located in downtown St Louis in Missouri. The company has come a long way since. Today, Seiler Instrument has about 240 employees, does business around the globe and boasts a nearly 13,800 m2 headquarters in the Kirkwood suburb of St Louis. Seiler Instrument was founded with a focus on repairing micro- scopes and surveying equipment. Eric H. Seiler, who was trained in Germany as an instrument maker, came to the US in 1923. “He was not only able to build instruments, but was also able to train people. That was the double beneﬁ t from him. He was a master of optics and able to train,” said his grandson Tom Seiler, executive vice president of the company’s geospatial and medical divisions. Even during its subsequent expansion, Seiler Instrument’s focus on optical instruments has not wavered. The company operates ﬁ ve major divisions: manufacturing, geospatial, medical, plane- tarium and design solutions. The company serves as a contract manufacturer for precision machining and optical instrument as- sembly and sells surveying software and instruments, microscopes, ZEISS planetarium equipment and theatre equipment for astrology and related ﬁ elds. Key to the company’s long tenure has been a “strong family unit”, according to Tom. The company is led by its third generation, which includes Tom, his brother Eric (Rick) Seiler Jr, who is president and CEO, and their sister Louise Schaper, director of compliance and planetarium division manager. Of the second generation, Eric P. Seiler remains chairman of the company and his wife, Hazel Elaine, is a board member. Four members of the family’s fourth generation are also involved in the company. Perhaps the greatest challenge for Seiler Instrument since its founding has been managing its growth and ﬁ nances without straying from the family-owned and closely held vision of the company, said Tom. “We have beneﬁ ted greatly from our strong relationships and support from UMB Bank over 40 years,” he said. Seiler Instrument celebrates its 77th anniversary this year, but Tom said the family is not slowing down. It is targeting several growth channels, including in its medical division, where execu- tives see opportunity for long-term strategic growth with 3D micro- scopes. The company hopes to achieve that through existing vendor relationships throughout the world. According to Dane Carlson, medical division manager, “Dentistry does not lend itself to good posture, causing injury. The dental microscope is a wonderful ergonomic tool, but Seiler’s new 3D microscope provides an even better ergonomic opportunity for the dentist. While using the 3D microscope, the dentist is not in a static position, and the 3D microscope allows the end user to manipulate the optical pod in a 360° rotation while the monitor stays directly in front of the dentist. This is the ﬁ rst 3D dental surgical microscope built with this unique design. This distinctive design allows the end user to learn the microscope quicker and be able to provide many direct vision angles not achievable with the traditional microscope.” While Seiler Instrument has grown signiﬁ cantly since its founding in the 1940s, Tom said it has not strayed from its roots. A point of pride for the company, he said, is a high number of ﬁ rst-generation immigrant employees “working to achieve the American dream”. “That’s exactly what our grandparents were. Our founder was a ﬁ rst-generation immigrant,” said Tom. www.seilerinst.com
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