volume xiv, number 3 endo-mailsmear layer more effectively than rotation. relieved reamers confined...

Endo-Mail July – September 2010

Endo-Mail

C O N T E N T SBarry Musikant

Systems Designed to Shape CanalsWithout Fear of Breakage 1

Doug KaseCaution: Dangerous Curves Ahead 2

Allan DeutschDo’s and Don’ts of EndodonticChlorhexidine Use 4

Amy Dukoff-ToroThe 3-D Image! 5

Sara KimCone Beam ComputerizedTomography in Endodontics 6

Volume XIV, Number 3 July – September 2010

Committed to Helping You Achieve the Highest Standards in Patient Care

Presented by Doctors Musikant, Deutsch, Kase, Dukoff, Bui & Kim119 West 57th Street • New York • NY 10019 • (212) 582-8161

(continued on page three)

ONE SIGN OF MATURITY is the understanding that we have to take

the good and the bad, that nothing is black and white, and that personal growth devel-ops as we understand these subtleties. A good example of balance is the incorpora-

tion of rotary NiTi into one’s practice. These instruments are significantly more flexible than stainless steel K-files and are en-gine-driven. Com-pared to the sole use of K-files, the use of rotary NiTi gives the dentist the increased benefit

of shaping curved canals to about a 25/06 without distortion to the outer wall. Being engine-driven, rotary NiTi instruments also reduce the hand fatigue associated with the manual use of K-files. Against these advan-tages, the dentist learns to take precautions against the instruments’ increased tendency to separate. In taking these precautions, canal preparations have been changed from step-back to crown-down to reduce the amount of engagement of these instruments along their length. The manufacturers also recommend single usage to further reduce the incidence of breakage. The net result is a canal shaped with minimal distortion, in a timely fashion. These results are more quickly achieved and with less chance of distortion than results achieved with K-files alone. One could say that the above example represents what experience brings to the successful implementation of new technol-

Systems Designed to Shape Canals Without Fear of BreakageBarry Lee Musikant, D.M.D.

ogy: a balance between the advantages and disadvantages of NiTi metallurgy, taking precautionary steps that mitigate NiTi’s shortcomings while taking advantage of NiTi’s greater flexibility to shape canals in an undistorted way. Having used rotary NiTi for a substantial period of time, I would agree that if K-files were the only alternative for thorough canal shaping, we would indeed need to employ NiTi with all the noted precautions. However, this is distinctly not the case. While maturity and balance in our approach are desirable professional traits, these qualities can be employed in the use of systems that don’t require such a fine balancing act. For example, employing relieved reamers—either manually with a tight watch-winding stroke or in a 30-degree reciprocating handpiece—does away with the main disadvantage of rotary NiTi, the tendency to separate. Using relieved ream-ers doesn’t just reduce this possibility. It virtually eliminates separation. The reason is not based on new metallurgy. Rather, the technique minimizes the two factors that cause separation, torsional stress and cyclic fatigue. Minimizing their impact means that the metal is never subjected to stresses that lead to breakage. Stainless steel’s present-day metallurgical characteristics are more than adequate for the instruments’ safe repetitive use in short arcs of motion. By changing the flute design from that of a file to that of a reamer and then creating a flat along its entire working length, the instrument is designed to have the following advantages over a K-file:

1. It is far less engaging along its length, reducing the amount of resistance as the instrument nego-

tiates to the apex.2. Its more vertically oriented flutes

cut the dentin more effectively when used with the horizontally employed watch-winding motion.

3. Its greater flexibility due to the incorporation of the flat along its length results in less work-hard-ening from the incorporation of fewer flutes and varying degrees of heat treatment that produce an increasing amount of dead softness or adaptability to curved canals.

These design features lead to secondary advantages, including:

1. An increased tactile perception of what the tip of the instrument is encountering, giving the dentist the ability to differentiate between a solid impediment and a tight canal. The former will have no immediate tugback while the latter has tugback from the start.

2. The ability to incorporate a cutting tip that pierces tissue rather than

Barry Musikant


HERE IS our practice’s philosophy: we as endodontists help you (our

family of referrers) to be the best you can be! No, this is not an advertise-ment for the armed forces, but merely a statement of fact that through con-tinuing education we want those who want to tackle an endodontic prob-lem in their own dental chair to reach the level to

which the bar for standard of care has been raised in years of progress in our field. For a quick second, let me state the ob-

vious: we want your business! Shocking I know, but clearly our reality. We have taken great pride in the educational side of our office, help-ing those who want to do root canal

better and safer with less stress and less overhead cost. But let’s also remember that we are here to help you and your patients. There are some endodontic cases

program, after the hands-on demonstra-tion of the SafeSiders® technique, how she could find calcified canals within a calcified chamber. Besides that topic’s evolving into a full-day course, I pointed to the endodontic microscope and basi-cally said that you need one of these! So there goes the $64,000 question! When the case gets complicated, instrumentation that is absolutely necessary might not be available to the general dentist. As endo-dontists, our technologically advanced armamentarium includes endodontic surgical microscopes, 3-D scanning for advanced diagnosis, ultrasonic files for refined excavation, and much more. Thus the referral reinforces your expertise and maintains your position of treatment planning, direction, and control over the case. Hence making sure the patient is referred back to your office for contin-ued treatment is also one of our primary goals—whether after case completion or covering your on call for an emergency visit on a weekend. Thus I want to present my Top Ten Reasons why you may want to refer to your Friendly Neighborhood Root Canal Man! Number 10: You just don’t like root canal! Number 9: Two-rooted lower canines. They do exist. Number 8: Mid-root canal splits. Number 7: MB2 canals in an upper 2nd molar. They also exist! Number 6: Calcified canals filled with concrete. Number 5: Severe dilacerations or curves. Num-ber 4: Loved Avatar, so the tooth needs

that should be referred. A good practitio-ner must realize the complications of the case long before something happens that may undermine the relationship with the patient. We all love a challenge, but for the benefit of your patient and medico-legally as well, it is sometimes more prudent to share the risk with a specialist to avoid the stuff hitting the fan. When I do malprac-tice review to defend my fellow dentists, every “Bill of Particulars” contains in its list failure to refer to a specialist. So let’s face it; it’s what we are trained to do. At our last in-house course, an eager-to-learn colleague asked me at the end of the

Tales from the Chamber

Caution: Dangerous Curves AheadDoug Kase, D.D.S.

Doug Kase

FIGURE 1

FIGURE 2

FIGURE 3

FIGURE 4


impacts it. Reciprocation elimi-nates the chances that a cutting tip will produce a perforation.

3. The ability to distinguish be-tween round and oval canals, an advantage when one is deciding just how wide the preparation of a canal should be.

4. A flat that allows the instrument to orient itself in the most efficient pathway when negotiating tight canals to the apex.

The major advantage of 30-degree reciprocation over rotation is the elimina-tion of breakage. However, there are some beneficial secondary implications:

1. A paper by Venkateshbabu et al published in the Australian Endodontic Journal demonstrates that the tips of the instruments stay centered within the confines of the canal, producing less distortion than rotary NiTi systems produce.

2. On the pull stroke, the instru-ments can be worked aggres-sively against all the canal walls, removing debris in a circumfer-ential manner without the need to enlarge the entire canal to the width of the major diameter of an oval canal.

3. As has been pointed out by the Laurent paper, the back-and-forth “churning” action of the recipro-cating handpiece creates a motion that encourages the removal of the smear layer more effectively than rotation.

Relieved reamers confined to a tight arc of motion represent an alternative to both K-files and rotary NiTi. With separa-tion eliminated as a cause of concern, the learning curve is substantially easier. The dentists can concentrate on the challenges that the canals pose without worrying about the impact of the canal anatomy on the integrity of the instruments they are using to shape the canals. If a system is correctly designed, canal negotiation should not require special steps taken to reduce the

possibility of instrument separation. The rules that must be followed should all be directed at negotiating the canals, not the prevention of broken instruments. From a practical point of view, the same approach that prevents breaking instru-ments also allows using them several times before replacement. In fact, overuse leads to dullness, not breakage, further reducing the anxiety that rotary NiTi instruments engen-der with their use. The natural consequence of using relieved reamers with a short arc of motion is drastically reduced costs. The metal composition and the system of use is less expensive to begin with. Combined with an average usage of 6–7 teeth, the costs compared to rotary NiTi are approximately 90 to 95 percent less expensive. In summary, we always want to use a sophisticated mindset when we are using any endodontic system. A system that is inherently more stable, removes the smear layer more effectively, and maintains the integrity of the original canal shape has many more advantages when weighed against its disadvantages. At a meeting some time ago, I was asked to enumerate the disadvantages of relieved reamers in the reciprocating handpiece. Without being ar-rogant, I said that the questioner was asking the wrong person because as the inventor of the system and the primary beneficiary of it I had done my best to design out all the obvious disadvantages. That doesn’t mean that the system cannot still be improved, but that it places the emphasis on increasing the advantages while the disadvantages have already been eliminated. For those who are intrigued by this ar-ticle’s claims, I have been giving free two-to-three hour one-on-one workshops for more than twenty years to help expose dentists to more rational endodontic techniques and tuition-based two-day workshops that include more than ten hours of hands-on experience. If you are interested in the free workshops, please call 212-582-8161. If you are interested in the tuition-based two-day courses, please call 201-487-9090.

Without Fear of Breakage(continued from page one)

a 3-D scan. Number 3: Did I say that you hate doing root canal? Number 2: Endodontist is your brother-in-law. And the Number 1 reason: Patient brags about new Mercedes she bought with last malpractice settlement. Okay, so here are some cases that may fall into one of the above categories. I want to admit that even for an endodontist these are a little nightmarish! The first case is a 27 mm lower molar with severe curves and dilacerations with close proximity to the mandibular nerve (Figure 1). Need I say more? This case was instrumented using 31 mm files starting with a #.06 (pink) file placed by hand to apex. A small 45-degree bend was placed at the tip to negotiate the apical curve or dilaceration. Once measurement was attained with an apex locator each subsequent file was hand-positioned the same way and attached to the reciprocating handpiece while in the mouth. After instrumentation to a #20 I opened the orifice with my Pleezer then stepped back a millimeter at a time to a #35 while making sure that I was clear to the apex each time with my #20. I then opened the apex to a #30. Due to the ex-treme curvature and length, I decided to use only a 30/.04 NiTi SafeSiders to the apex as my last instrument by shaving off approximately 2 mm of the handle and placing it in the handpiece to the extent of the modified handle, thus 27 mm. EZ-Fill® was placed up to the curve and then carried further to the apical architecture with a reamer, and the canal was obturated with gutta percha (Figure 2). The second case was a little more of the same, an upper second molar from the same nightmare. This too was instrumented and obturated in much the same manner (Figures 3 and 4). So not all cases are easy dream cases. Do what is within your comfort zone; refer those that are not. Your patients will be happy, you will be their hero, and you can sleep well at night. See you next issue.


Do’s and Don’ts of Endodontic Chlorhexidine UseAllan S. Deutsch, D.M.D.

Allan Deutsch

ONE OF THE largest causes of endo-dontic failure is infection. Infection

can be the reason for the tooth’s needing endodontics in the first place, or it can be the

cause of retreating an already endo-dontically treated tooth. The causes of infection include caries, fracture, excessive trauma from operative or prosthetic prepara-tion, leakage of res-torations, missed canals or anatomy

when doing the endodontics initially, inadequate instrumentation of the canal, and calcified canals. Endodontic infections are generally caused by multiple species of bacteria living on the canal walls or in the dentinal tubules. Figure 1 shows bacteria on the wall of the canal and in a dentinal tubule. Many times, the bacteria can be found in biofilms attached to the walls and entering into the tubules. The biofilm coats the bacteria in a film that makes it much harder to kill the bacteria—in other words, much more difficult to get rid of the infection. Luckily for us, the primary way to cure an endodontic infection is through instru-mentation and enlargement of the canal. The longer the infection has been around, the farther up the dentinal tubules the bacte-ria will have gone. In badly infected teeth, I recommend instrumenting to a number 45 or 50 if possible to the apex. In straight

canals, such as incisors and canines, we can even go to wider-diameter instruments if necessary. However, research has shown that instrumentation alone does not remove all the debris in the canal. A substantial amount of debris is left in the canal even after thorough instrumentation. In order to remove more debris we must irrigate the canal. The best irrigant to date is sodium hypochlorite, or Clorox. It will dissolve the debris and kill most of the bacteria. However, it does not kill all the bacteria. Therefore it needs a little help. Over the last ten to twelve years there has been more and more literature showing the bacterial killing ability of 2 percent chlorhexidine (CHX). It actually kills E. faecalis, a bac-teria shown to be prevalent in failed and infected root canals, better than sodium hy-pochlorite. Therefore, in order to increase my endodontic success rate in non-vital cases, I irrigate every non-vital case with 2 percent CHX (Figure 2). This practice has especially helped get rid of infections from failed root canal treatments. To use CHX successfully, we must be aware of several facts and put them into

practice clinically. First, for endodontic infections CHX works effectively only at the 2 percent strength. Peridex, which is a 0.12 percent solution of CHX, is not strong enough and will take more than six hours to kill the bacteria in the canal. This length of time is not acceptable for an in-office procedure. The 2 percent CHX will kill the bugs in two minutes. Therefore, when using CHX, I leave it in the canals for two minutes. However, before placing it in the canal we must remove the smear layer (Figure 3). The smear layer, produced by instru-mentation, obliterates the openings of the dentinal tubules into the canal and covers the bacteria that are on the walls of the canals. If the smear layer is not removed, the CHX will not penetrate into the tubules. If the CHX does not get into the tubules and against the canal wall, it cannot kill the bacteria. It must be in contact with the bacteria in order to kill them. Therefore, we must remove the smear layer and expose the canal walls and tubules. This can be done using 17 percent EDTA in water (Figure 4). The 17 percent EDTA must

FIGURE 1: Bacteria on the wall of the canal and in a tubule.

FIGURE 2: FDA cleared CHX by Essential Dental Systems.

FIGURE 3: SEM of the smear layer covering the canal wall and the tubules.

FIGURE 4: 17 percent EDTA in water by Essential Dental Systems.

FIGURE 5: Wall of the canal showing open dentinal tubules after smear layer has been removed by using 17 percent EDTA.


be in contact with the smear layer for a minimum of one minute for it to work. I accomplish this by irrigating with EDTA when I am instrumenting the canal with the NiTi SafeSiders®. This takes me no longer than one minute and removes the smear layer (Figure 5). Once the smear layer is gone, the 2 per-cent CHX can readily contact any bacteria that remain in the canal or in the tubules. Chlorhexidine is a very reactive chemi-cal; that is why it works so well in killing bacteria. However, because it is so reactive it reacts with both sodium hypochlorite and EDTA. It forms a precipitate with both of them (Figure 6). These precipitates should be avoided. Therefore, if there is any residue of EDTA or sodium hypochlorite in the canal it should be rinsed out. You can use either water or anesthetic solution to accomplish this step. Do not go directly from EDTA or NaOCl to CHX; you will get a precipitate in the canal. Currently, no one is quite sure what these precipitates are, but they do clog the canal and perhaps may interfere with obturation. To summarize the most important features:

1. Use 2 percent CHX only.2. Leave it in the canal for a mini-

mum of two minutes to work.3. Use 17 percent EDTA in water

to remove the smear layer before using CHX.

4. Do not allow CHX to come directly in contact with EDTA or sodium hypochlorite; use a rinse between the reagents.

FIGURE 5

FIGURE 6: Appearance of different precipitates when in contact with CHX.

The 3-D Image!Amy Dukoff-Toro, D.M.D.

Amy Dukoff

THE THREE-DIMENSIONAL im-age provided by a CBCT scanner

is a valuable diagnostic tool for the dental practitioner. The image pro-vides information with greater depth

than its two-di-mensional coun-terpart. Because the 3-D image adds a dimension to the traditional 2-D radiograph, the additional in-formation gained provides the den-tal professional

with supplemental information about the area of concern in order to assist him or her in a diagnosis. The additional information improves the practitioner’s understanding of the patient, thereby improving patient care. The 3-D image is developed by utilizing a computer’s ability to pro-cess information acquired by volume rendering. Volume rendering is the creation of an image through a series of scans in three planes. The process uses the principles of thresholds, opac-ity, and color to analyze the data from the scans and present the images in a useful form. The density of the tissue becomes the image’s volume of interest (VOI). Volume of interest sets the interest in the tissue by its density range. Opac-ity ranges from transparent to opaque. Color is an aid that shows density differences. The volume of interest is essential in projecting the tissue’s three-dimensional quality. The resulting volume rendering im-age allows the user to see the internal structure as well as the surface. Also, the computer software allows the user to cut the 3-dimensional image, mak-ing “slices” of images, with each slice displaying a two-dimensional view in any plane desired. The “sliced” images can show the tooth’s mesial, distal,

buccal, and lingual dentinal integrity. The slice that the practitioner creates is projected in a neighboring frame on the monitor. The sliced image then can be rotated and enhanced to better view a specific area of interest. By displaying the sliced image in its own window, the software allows the practitioner to control the viewing of a particular region. As a diagnostic aid, the three-dimensional image provides valuable information to the practitioner. The three-dimensional image can be saved on a disc that can be read on any PC com-puter. A well-trained assistant on the dental team can provide the practitioner with the image for review. In our office, our dental assistants, including Etoy Jackson and Nichelle Nash, are able to perform the procedures. It is important that the dental team is enthusiastic about integrating cutting-edge technology into the patient care services that are offered. The three-dimensional dental image is an extremely useful diagnostic tool to use in providing patient care in the twenty-first century.

ENDO-TIP

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THE TOOLS that have advanced the field of endodontics include

microscopes, endoscopes, ultrasonic instruments, and the latest addition: Cone Beam Computerized Tomography

(CBCT). Tradi-tionally, CBCT has been used by oral surgeons to facilitate implant placement, but now endodontists like us are using it for diagnosis and treatment plan-ning.

CBCT, also known as volumetric imaging, produces a 3D image of the tooth so that you can see many slices in mesiodistal, buccolingual, and cross-sectional views. In endodontics, CBCT can be useful in these situations: find-ing calcified canals; searching for any missed canals like MB2 (Figure 1), distinguishing between internal and external root resorption and viewing the extent of damage, finding a third canal in a premolar, locating a sepa-rated instrument, and preparing for an apicoectomy. A patient presented with history of intermittent dull pain in the upper right area (Figure 2). He said that he had already taken antibiotics for a week because a sinusitis was suspected, but his discomfort had returned. On the referral form, his dentist had written “root canal treatment of tooth #2” with a big question mark. Upon examination, #2 and #3 were both slightly percus-

Cone Beam Computerized Tomography in EndodonticsSara Kim, D.M.D.

sion positive. The cold test of tooth #2 seemed to be normal, but #3 had a very brief delay before the cold was felt. However, the periapical x-ray showed no obvious problems. CBCT was taken, and it showed a small radiolucency around the apex of tooth #3’s palatal root as shown in Figures 3 through 5. When #3 was accessed, the palatal canal was totally necrotic, while MB, MB2, and DB were all vital. After the root canal treatment (Figure 6), the patient’s pain had gone away, and tooth #3 was indeed the culprit. No fractures were noted during the initial examination, but it was concluded that a hairline fracture probably existed in the palatal area thus causing the palatal canal to become necrotic since it was a virgin tooth. I think CBCT is an extremely useful imaging tool in endodontics. I do not think that scanning straightforward root canal treatment cases is necessary, but

CBCT scanning is definitely helpful for those difficult ones. CBCT can only enhance the quality of treatment that we bring to our patients. When you get a disk copy of the CBCT done on your patient, just remember to click on “ODView.exe” to view the 3D images. You will see how easy it is to navigate and how detailed the images are.

Sara Kim

FIGURE 2

FIGURE 3

FIGURE 4

FIGURE 5

FIGURE 6FIGURE 1


We’re Here 7 Days a Week to Support Your Practice!(212) 582-8161

Adding a New “Dimension” to Our Practice We would like to introduce the latest addition to our practice, although we haven’t given him a name yet. As a matter of fact we’re not even sure if it’s a “him” or a “her”! We are now the proud owners of the Morita CBCT 3-D Scanner. In keeping with our belief that the only way we can succeed is if you succeed, the incorporation of the CBCT scanner for endodontic diagnosis has become an essential benefit that we can now provide to your patients and your practice as well. Its use as an invaluable tool in 21st cen-tury endodontics has now become our standard of care when dealing with complicated diagnosis and ultimate treatment planning in the endodontic arena. The amazing and accurate 3-D imaging is an adjunct to our overall philosophy of providing the utmost service and cutting-edge endodontic diagnosis and treatment for our dental colleagues, family of referrers, and their patients in a practical and educational environment. As our history clearly illustrates, excellent service in combination with endodontic excel-lence and education becomes a win-win situation for all! If your practice needs to take advantage of this new technology and a patient requires a digital panorex or CBCT scan for your own diagnosis and treatment planning, please feel free to call our office for an appointment.

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We are available to assist in all of your endodontic needs, including re-cements and 24-hour emergencies. Our doctors and our courteous and professional support staff provide the highest quality care for your patients.

Musikant, Deutsch, Kase,Dukoff, Bui & Kim119 West 57th Street, Suite 700New York, NY 10019

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119 West 57th Street, Suite 700New York, NY 10019

Essential Dental Seminars sponsors The Three R’s Of Rational Endodontics

Essential Dental Seminars reserves the right to cancel any course at any time. Essential Dental Seminars is a division of Essential Dental Systems, Inc. Some of the products talked about during this course are manufactured and sold by Essential Dental Systems, Inc. Dr. Barry Musikant & Dr. Allan Deutsch are co-owners of Essential Dental Systems, Inc. Seating is limited. There will be at least 1 instructor per 6

attendees at each course. The first 20 dentists to register and receive confirmation will be in attendance. Course is limited to dentists only.

Course Description In this lecture and hands-on participation course we take a rational approach to endodontics with new and innovative techniques. You will learn to rationalize access, instrumentation, and obturation systems without the fear of separation and hand fatigue Goals and Objectives •Learn to gain access to the pulp chamber safely without perforating the furcation •Clean and shape canals without distortion or fear of instrument separation •Implement an easy, thorough, and economical technique for obturating canals •Learn to create superior seals within 60 seconds •Seal canals without stress and with next to no post-operative pain

Location:119 West 57th Street New York, NY 10019 Date: September 21, 2010 Time: 6:30PM-8:30PM Fee: FREE

Please contact Evelyn at 212-582-8161 before September 14, 2010

Space is limited. Cancellation is

requested at least five days prior to course date.

2CE Credits

Course Instructors Dr. Barry L. Musikant Dr. Allan S. Deutsch Dr. Douglas Kase Dr. Amy Dukoff Dr. Young Bui Dr. Sara Kim

All lecturers are endodontic specialists who are graduates of board-approved postgraduate programs. For more information on their qualifications, visit www.essentialseminars.org

Essential Dental Seminars 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.

Dental Board of California * CE Provider # RP 4378

Permit Expiration: 12/30/2011

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