roots international No. 3, 2011

Cover / Editorial / Content / Efficient and ergonomic apical resection using the Kaiserswerth algorithm / White lines or white lies? / Subscription / A race to the apex— Crown-down in 1! / Do we treat patients based on radiolucency? ―A case report / Are endodontists invited to the treatment planning party? / Is rotary NiTi the new paradigm? / CBCT study of root-canal morphology of mandibular first molars in a Spanish population / “Patient education needs to be part of the daily activities of a practice”; Interview with Dr Reena Gajjar - Canada / “The Scanner mode is going to revolutionise dentistry” / Connectivity in the dental world / Six steps to a chartless practice / Industry news / International Events / Submission guidelines / Imprint / Subscription

Open PDF View E-paper Edit Epaper Edit Epaper ads save

Table of contents

Open Link

Open Link

Open Link

issn 1616-6345

roots
international magazine of

Vol. 7 • Issue 3/2011

endodontology

3

2011

| case report
White lines or white lies?

| opinion
Is rotary NiTi the new paradigm?

| practice management
Connectivity in the dental world

[2] => RO0110_01_Titel

High-tech apex locator for
precise length determination
Sets new standards with respect to user-friendliness and design

• Unique 3-D style colour touch screen
• Smart user interface
• Foldable, pocket-sized design

VDW GmbH
P.O. Box 830954 • 81709 Munich • Germany
Tel. +49 89 62734-0 • Fax +49 89 62734-304
www.vdw-dental.com • info@vdw-dental.com

Apex locator

Endo Easy Efficient®

[3] => RO0110_01_Titel

editorial _ roots

Dear Reader,
_Endodontics is changing—for better or for worse, that depends on your point of view.
Recently, the introduction of new endodontic files aroused the endodontic community.
We have seen the arrival of the Self-Adjusting File (SAF), with its revolutionary design and
atypical shaping approach. Other recent developments are the WaveOne and Reciproc files,
which use a reciprocating movement instead of a continuous rotating movement.

Dr Rafaël Michiels

While these innovations offer some advantages to the existing files, we should remain
wary. In the last couple of years, a number of innovations have been hyped for a while and
then disappeared.
If we take a good look at them, then it is my opinion that this is mainly because there
is not much new about them. The WaveOne and Reciproc files, for example, are simply
automated versions of the “old” balanced force technique propagated by Dr Roane in 1985.
“Obturation in three dimensions”, the slogan employed by many current obturation devices,
has been possible since Dr Schilder’s classic article in 1967. Many more examples can be given
this way.
There are many other classic articles that describe materials, techniques, anatomy, etc.
If you are an optimist, you could say that the recent inventions make it easier and more
predictable to achieve the goal of a root-canal treatment according to the fundamental
principles. If you are a realist, then you recognise that the problem lies herein: there is a
general lack of knowledge of the basic literature in endodontics. If you are not armed with
this knowledge, then you are vulnerable to marketing and aggressive sales representatives.
We ourselves have the responsibility of stopping this loss of critical thought. We have to keep
ourselves up to date by attending congresses, following independent courses and reading
the literature. If we manage to do this and if we succeed in teaching our students and
colleagues to do the same, then I am sure we can change endodontics for the better with
many new materials, techniques and devices to come.
I am honoured to contribute to this edition of roots and hope you will enjoy this issue
and can use it to improve your endodontic treatment.
Yours faithfully,

Dr Rafaël Michiels
Hasselt, Belgium

roots
I 03
3
_ 2011

[4] => RO0110_01_Titel

I content _ roots

page 6

I editorial
03

page 10

I feature

Dear Reader

34

An interview with Dr Reena Gajjar, My Dental Hub

| Dr Rafaël Michiels, Guest Editor

38

An interview with Dr Ladislav Grad &
Dr Matjaz Lukac, Fotona d.d.

I case report
06

page 14

Efficient and ergonomic apical resection
using the Kaiserswerth algorithm
| Prof Marcel Wainwright

I practice management
40

Connectivity in the dental world
| Shane Hebel

10

White lines or white lies?
| Dr Rafaël Michiels

44

Six steps to a chartless practice
| Dr Lorne Lavine

14

16

18

A race to the apex―Crown-down in 1!
| Dr Philippe Sleiman

I industry news

Do we treat patients based on radiolucency?
―A case report

47

| Dr Sander Loos

I meetings

Are endodontists invited
to the treatment planning party?
| Dr Daniel Flynn

International Events

I about the publisher
49
50

I opinion
24

48

| Acteon/VDW

| submission guidelines
| imprint

Is rotary NiTi the new paradigm?
| Dr Barry L. Musikant

I research
28

CBCT study of root-canal morphology
of mandibular first molars in a Spanish population

Cover image courtesy of Prof Marco Versiani
and Prof Manoel D. Sousa Neto, Ribeirão Preto
Dental School, University of São Paulo.

| Dr Óliver Valencia de Pablo et al.

page 18

04 I roots
3_ 2011

page 24

page 34

[5] => RO0110_01_Titel

He
lp

us

su 1
pp 20
or Ye
t S ar
OS s W
Ch &H
ild .
re
n’s
V

illa

ge
s!

Cordless
with an extra-small head

An extra-small head. No cord. And full power. The Entran cordless handpiece provides
complete freedom of movement and, thanks to its extra-small head, also gives
optimum access to the treatment site. The torque-controlled automatic direction
change and the five torque levels set new safety standards in cordless endodontics.
People have Priority! W&H supports the humanitarian organization SOS Children’s Villages.
Get involved! Further information at wh.com

Endodontics. Cordless!

[6] => RO0110_01_Titel

I case report _ apical resection

Efficient and ergonomic
apical resection using the
Kaiserswerth algorithm
Author_ Prof Marcel Wainwright, Germany

Fig. 1_OPG showing active infection
at sites 16, 36 and 46.
Fig. 2_Bone block, stored in Ringer’s
solution.

Fig. 3_Surgical site after removing
a bone block and performing apical
resections on tooth #36.
Fig. 4_The MAP System.
Fig. 5_Autoclavable box with
syringe, mixing cup and tips.

Fig. 3

Fig. 1

Fig. 2

_Thanks to minimally invasive techniques,
such as ultrasonic surgery and the availability of reliable restorative materials, the surgical revision and
rehabilitation of endodontically treated teeth have a
significantly better prognosis than only ten years
ago. Apical resection is a challenging surgical procedure―not least because of the limited accessibility of
the surgical field. Instrumentation of an apical resection case therefore requires a surgical technique that
is as simple as it is safe and ergonomic.

_Case I
A 34-year-old male patient presented at our
clinic for the first time. The orthopantomogram
(OPG) yielded an accidental finding of apical translucencies at teeth #14, 36 and 46, which had been
insufficiently treated endodontically. Clinically, these
translucencies were asymptomatic and diagnosed
as instances of chronic apical periodontitis or apical
osteitis (Fig. 1).

This report presents two clinical cases in illustrating a system for applying retrograde endodontic
filling materials that has proven a consistently viable
option in our clinical practice.

Together with the patient, we planned for an
apical resection of tooth #36 in conjunction with
a retrograde root-canal filling with subsequent
removal of the non-salvageable teeth #16 and 46.

Fig. 4

06 I roots
3_ 2011

Fig. 5

[7] => RO0110_01_Titel

case report _ apical resection

Following extensive consultation and patient
education, surgery was performed under local infiltration anaesthesia. With our protocol, block anaesthesia is unnecessary in 98 % of all surgical interventions in the mandible, and dispensing with it
minimises the risk of iatrogenic nerve damage.
An incision was performed in the marginal
gingiva, with a mesiodistal relief incision, followed
by preparation of a full flap for adequate access to
the surgical site. Using the Piezotome 2 (Acteon), a
buccal bone window of adequate depth was prepared
to gain access to the apical region at tooth #36 in
order to perform the apical resection. It is helpful for
the preparation to provide for undercuts in order to
facilitate subsequent removal of the bone block. As no
rotary instruments were used and because ultrasonic
surgical instruments have a vaso-constrictor effect,
the surgical field remained impressively free of
bleeding and afforded a clear view of the site. The
bone block was stored in Ringer’s solution to facilitate
subsequent repositioning (Fig. 2). The root apices were
then exposed and ultrasonically removed (Fig. 3).
After apical resection, our protocol called for
thorough removal of all soft tissue using instruments,
followed by complete decontamination of the cyst
lumen using a diode laser. Care had to be taken to
ensure that the laser tip did not make direct contact
with the bone. Retrograde preparation of the root
canals was also performed ultrasonically, which only
takes a few seconds when using the Piezotome 2.
Following chlorhexidine-digluconate and sodiumhypochlorite rinses, the retro-prepared root canals

Fig. 6

were dried with paper points. In our clinic, we have
had excellent success with the MAP (Micro-Apical
Placement) retro system (PDSA), which has been on
the market for many years (Fig. 4). The system comes
in a sterilisable metal container (Fig. 5). The tripleangled endo tips (Fig. 6) greatly simplify the uptake
and application of the material, with the syringe
facilitating “injection” (retrograde obturation) of the
root canal to a depth of several millimetres. This
well-targeted application of the restorative material
keeps the surgical field open (Fig. 7).
On application of ProRoot MTA (DENTSPLY
Maillefer), the material was allowed to set, the crosssection surface of the resected area was smoothed
and polished, the resection lumen was filled with a

Fig. 7

Fig. 10

Fig. 6_Endo tips with different
angulations.
Fig. 7_Applying MTA using the
MAP System.
Fig. 8_The bone block is repositioned
and secured with bone cement
(VitalOs).
Fig. 9_Post-op OPG detail following
apical resection of tooth #36.
Fig. 10_Base-line status of tooth
#14 following apical resection alio
loco and reinfection.
Fig. 11_Surgical site 14 following
the semilunar incision.
Fig. 12_Retrograde ultrasonic
preparation (Piezotome 2).

Fig. 8

Fig. 9

Fig. 11

Fig. 12

roots
I 07
3
_ 2011

[8] => RO0110_01_Titel

I case report _ apical resection

Fig. 14
Fig. 13_Mixed ProRoot MTA
prior to application.
Fig. 14_Applying the MTA
using the MAP System.
Fig. 15_Resected and
retro-filled tooth #14.

Fig. 16

Fig. 13

Fig. 15

quick-hardening bone cement (VitalOs,
PDSA), and the bone block was returned to its place (Fig. 8). The postoperative radiograph shows the site
following apical resection and retrograde root filling (Fig. 9).

radiograph (Fig. 16) shows an efficient retrograde
filling of both root canals following revision of tooth
#14. Owing to a projection artefact, the restorative
appeared beside the canals, when it was in fact
clinically located exactly within.

_Conclusion
Fig. 16_Revision treatment
outcome for tooth #14.

The patient was prescribed Amoxicillin 750 mg and
Ibuprofen 600 mg post-operatively, as well as Arnica
C30 to prevent swelling. Post-operative healing was
uncomplicated and the sutures could be removed
after eight days. Swelling was minimal, and the
patient reported virtually no post-operative pain.

_Case II
A 65-year-old female patient presented with an
apical resection on tooth #14 that had been performed alio loco five years before. The patient was
looking for help because the site had become infected
again. She reported pain at tooth #14 on occlusal
contact and percussion. A local digital radiograph
clearly showed the area of apical resection, the two
root-canal fillings, and a cystic peri-apical radiolucency (Fig. 10). Since this was a surgical re-entry case,
the same incision technique was used as chosen by
the primary treatment provider, i.e. a crescent-shaped
incision as described by Pichler (Fig. 11). The procedure
was otherwise the same as in Case I. Following retrograde ultrasonic preparation (Fig. 12), ProRoot MTA
was mixed to a working consistency and applied
using the MAP System (Figs. 13 & 14). This clean and
efficient application mode and controlled handling
shortened the surgical procedure and reduced postoperative complaints (Fig. 15). The post-operative

08 I roots
3_ 2011

Apical resection is a routine procedure in our
clinic. Thanks to the use of ultrasonic surgery, the
surgical laser and the MAP System, this procedure is
reliable, predictable and simple, and we have preserved the natural teeth of many patients. Being an
oral implantologist myself, I do not perceive anything
contradictory in looking at these treatment methods;
rather, apical resection is a complementary treatment
mode and an attempt to preserve teeth over the
longer term that would otherwise be considered
lost._
Editorial note: A complete list of references is available from
the author.

_contact

roots

Prof Marcel Wainwright
Dental Specialists and White Lounge Kaiserswerth
Kaiserswerther Markt 25–27
40489 Düsseldorf
Germany
www.dentalspecialists.de

[9] => RO0110_01_Titel

:PTWSPJP[`PZ[OLYLHSPUUV]H[PVU

6US`VULZ[LYPSL5P;PPUZ[Y\TLU[WLYYVV[JHUHSPUTVZ[JHZLZ
+LJYLHZLZ[OLNSVIHSZOHWPUN[PTLI`\W[V
9LJPWYVJH[PUN[LJOUVSVN`YLZWLJ[PUN[OLYVV[JHUHSHUH[VT`
:PUNSL\ZLHZUL^Z[HUKHYKVMJHYL

 

www.dentsplymaillefer.com

[10] => RO0110_01_Titel

I case report _ obturation

White lines or white lies?
Author_ Dr Rafaël Michiels, Belgium

canal systems, which clearly demonstrate the complexity of those systems.

Fig. 1

Fig. 2

Fig. 1_Parallel diagnostic
radiograph.
Fig. 2_Eccentric diagnostic
radiograph.

_With the recent development of new file systems—WaveOne from DENTSPLY Maillefer and RECIPROC from VDW—endodontists have been having
controversial discussions about their usefulness. This
is partly due to the aggressive marketing of these
products. Great emphasis is laid on simplifying the endodontic procedure. The thought behind this is that
creating a simpler shaping protocol will allow the dentist to produce standardised shapes more easily and
thus enhance the cleaning of these canals. However,
endodontics is not, nor will it be, a simple procedure.
There is no such thing as a perfectly round canal. In
1925, Hess already demonstrated that we should not
speak of root canals, but rather of root-canal systems.1
Many other studies have confirmed Hess’s findings. Only a few months ago, a micro-CT study guide
titled The Root Canal Anatomy Project became available online, offering high-resolution images of root-

If we take another approach to these new file systems, we have to ask ourselves: Do they deliver something new? And the answer is: No, they do not. They
re-introduce the concept of reciprocating motion according to the balanced force technique by Roane.2
This reciprocating motion does lead to less separation
of files, which is an advantage of the current rotary
systems.3–5 When looking at the final size that the
Primary WaveOne file creates, we notice that it is the
similar to that achieved with a ProTaper F2 file
(DENTSPLY Maillefer). Therefore, one WaveOne file
creates the same shape as four ProTaper files (S1, S2,
F1 & F2), which leads to a quicker preparation of the
root canal.
The shortened preparation time allows more time
for cleaning, but it would be delusional to think that
this would happen in reality. As we live in a an era in
which time is money, quicker preparation will most
likely result in less cleaning, thus increasing the number of suboptimal root-canal treatments (RCT). The
new file systems also propagate the ‘single-use’ concept, which eliminates the possibility of cross-contamination or contamination with prions. Although
the risk of contamination is very low when using sterilised instruments, it is true that with the pre-sterilised
WaveOne files, the risk is zero.
Overall, the new reciprocating file systems have
some advantages compared to older rotary files, but
the practitioner should be aware that they only shape
canals. They do not clean them!
This leads me to the title of this article…

Fig. 3_Opening cavity.
Fig. 4_Calcified pulpal tissue in
the middle of the palatal canal.

Fig. 3

10 I roots
3_ 2011

Fig. 4

[11] => RO0110_01_Titel

case report _ obturation

Fig. 5_The cleaned palatal canal.
Fig. 6_The cleaned buccal canals.

Fig. 5

Fig. 6
Fig. 7_Gutta-percha cone-fitting.
Fig. 8_The pulp chamber after
obturation with gutta-percha.

Fig. 7

Fig. 8

_White lines or white lies?

_Case report

Most dental manufacturers bring gutta-percha
cones and obturators on the market that correspond
to the final finishing size of the conforming file system. The promoted obturation techniques are the single-cone technique and carrier-based obturation,
both of which have shown to be more prone to leakage than warm vertical condensation.6,7

The following case report is used as an example of
nice white lines on a radiograph. A 35-year-old male
patient was referred to our practice. Tooth #15 had
been treated by the referring dentist, who had found
four canals, of which two were palatal canals, which
is very rare. The referring dentist applied a standard
cleaning protocol with sodium hypochlorite. At first
sight, the treatment looked adequate (Figs. 1 & 2).
However, the patient kept complaining about the
tooth being sensitive when he was eating and he
complained of spontaneous pain from time to time.
The patient’s medical history was non-contributory.

This is without considering the studies that used
the flawed dye-penetration test for micro-leakage.
However, the discussion remains whether these techniques are better, worse or equal to warm vertical
condensation, and it is not likely that it soon will be
over.
Regardless of all this, the clinician is now presented with an ‘all-inclusive’ system for creating nice
white lines on a radiograph and this in a quick and
easy way, creating the illusion of perfectly executed
RCT. Cleaning has become the bottleneck for treatment time and it is tempting to reduce the total cleaning time, which results in suboptimal RCT. This does
not mean that all recent developments are for the
worse. To the contrary, dentists should be prudent in
their use. The only way to achieve this is to educate
dentists properly about the basic fundamental principles in endodontics.

Clinical tests were performed (Table I) and together
with the history and the radiographic findings we decided to retreat the tooth. The pulpal diagnosis was a
previously treated tooth and the apical diagnosis was
symptomatic apical periodontitis.

Table I_Clinical tests.

electric pulp test

positive

thermal test

positive

percussion

negative

positive

negative

palpation

negative

positive

negative

periodontal probing

normal

deep pockets

roots
I 11
3
_ 2011

[12] => RO0110_01_Titel

I case report _ obturation
about three minutes. Both fluids were ultrasonically
activated at the end of the treatment, three times
for 20 seconds. Passive ultrasonic irrigation was
performed with the Irrisafe tip (Satelec), as it provides
better results than manual dynamic or sonic activation, according to the literature. Figures 5 and 6 show
the canals after they had been dried with paper
points.

Fig. 9

Fig. 10

Fig. 9_Post-op radiograph (parallel).
Fig. 10_Post-op radiograph
(eccentric).

_Treatment

Initially, the tooth was isolated with a rubber
dam and an opening cavity was created through
the amalgam restoration (Fig. 3). The canals were
located and the opening cavity finished. Using a ProFile 25.06 rotary file (DENTSPLY Maillefer) at 300rpm,
the gutta-percha was removed. No chloroform was
necessary, as it appeared that
palatal
mesiobuccal
distobuccal
the canals had been filled
using a single-cone technique.
Flexile 15
K-file 10
K-file 10
As mentioned above, this techFlexile 20
Flexile 15
Flexile 15
nique might not be an ideal
Flexile 25
Flexile 20
Flexile 20
obturation technique. However,
Flexile 30
ProTaper S1
ProTaper S1
a more striking problem became apparent. The two palatal
ProFile 35.06
ProTaper S2
ProTaper S2
canals were separated by a
Flexile 35
ProTaper F1
ProTaper F1
piece of calcified pulp tissue
ProTaper F2
ProTaper F2
(Fig. 4). These pieces of tissue
ProFile 35.06
ProFile 35.06
harvest an incredible amount
Flexile 35
Flexile 35
of bacteria and if they are not
removed, they can easily lead
Table II_Shaping sequence. to persistent infection. It is not always easy to
distinguish the calcified tissue from (tertiary) dentine
and if the dentist does not use magnification, it is
practically impossible.
The calcified tissue was removed using ultrasound
with ProUltra tips (DENTSPLY Maillefer). After the
removal of the calcified tissue, there was only one
very wide palatal canal left. Both buccal canals were
also cleared from the gutta-percha and I searched for
a second mesiobuccal canal but was not able to find
one. From then onwards, complete cleaning and
shaping were performed (see Table II for shaping
sequence).
Cleaning was performed with 5% sodium
hypochlorite and a final rinse with 10% citric acid for

12 I roots
3_ 2011

A control radiograph (Fig. 7) was taken, fitting
gutta-percha cones in the canals. It appeared that a
small piece of amalgam had fallen into the palatal
canal and was stuck apically. I tried to remove it but
was unable to do so. I eventually decided to leave it
in place, since the effect on the final prognosis is
negligible. The canals were obturated with guttapercha and TopSeal (DENTSPLY Maillefer) using warm
vertical condensation (Figs. 8–10). The difference
from the original situation was very clear. The canals
were now properly cleaned, shaped and obturated.

_Conclusion
White lines on a radiograph are a 2-D representation of obturated canals. These lines do not give
away anything about the cleaning, shaping and
obturating techniques applied. Hence, they do not
tell us anything about the biology of the treated rootcanal system. Endodontic files are just instruments
that facilitate proper cleaning of the root-canal
system. Emphasis should be placed on respecting
this root-canal system and the fundamental principles of cleaning, shaping and obturating, rather than
creating beautiful white lines in an easy and fast
way._
Editorial note: A complete list of references is available
from the publisher. A video of the case is available on
www.dental-tribune.com/articles/content/id/6165 or
simply scan the QR code with you smartphone.

_about the author

roots

Dr Rafaël Michiels
graduated from the Department of Dentistry at Ghent
University, Belgium, in 2006.
In 2009, he completed the
three-year postgraduate
programme in Endodontics
at the University of Ghent.
He works in two private
practices limited to Endodontics in Belgium. He can
be contacted at rafael.michiels@gmail.com and via
his website www.ontzenuwen.be.

[13] => RO0110_01_Titel

You can also subscribe via
www.oemus.com/abo

I hereby agree to receive a free trial subscription of
(4 issues

Last Name, First Name

per year).
Company

I would like to subscribe to
for € 44 including
shipping and VAT for German customers, € 46 including shipping and VAT for customers outside of Germany, unless a written cancellation is sent within 14 days of the receipt of the trial
subscription. The subscription will be renewed automatically
every year until a written cancellation is sent to OEMUS MEDIA
AG, Holbeinstr. 29, 04229 Leipzig, Germany, six weeks prior to
the renewal date.

Reply via Fax +49 341 48474-290 to
OEMUS MEDIA AG or via E-mail to
grasse@oemus-media.de

Street
ZIP/City/County
E-mail

Signature

Notice of revocation: I am able to revoke the subscription within 14 days after my order by sending a written
cancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.

roots 3/11

Signature

OEMUS MEDIA AG
Holbeinstraße 29, 04229 Leipzig, Germany, Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-Mail: grasse@oemus-media.de

[14] => RO0110_01_Titel

I case report _ NiTi

A race to the apex—
Crown-down in 1!
Author_ Dr Philippe Sleiman, Lebanon

One of the characteristics of the R-phase of the
Twisted File (TF; SybronEndo) is that it gives the file
flexibility and a higher stress tolerance compared
with other alloys, which allows for a faster and safer
root-canal enlargement. Arrival at the apex can be
achieved with one file, if the practitioner is in favour
of this technique. Crown-down can be achieved with
a single file too, depending on the initial canal
anatomy.

_Technique
NiTi files are designed to enlarge and not to open
the canal. Thus, checking the canal patency prior to
any file enlargement in the environment of a proper
irrigating solution is necessary. We can face two different clinical situations related mostly to anatomic
considerations:

Fig. 1

Fig. 1_Immediate post-op of the
lower molar, showing the radiolucency around the mesial and distal
roots.
Fig. 2_Post-op after eight months,
showing very nice healing around
both roots.
Fig. 3_Pre-op X-ray, showing
the extrusion of the material into
the maxillary sinus.
Fig. 4_After removal of the Thermafil
and the paste that was attached to it
from inside the palatal root.

Fig. 2

_Is it really a race? It seems to me that dentists
are very eager to get to the apex as fast as possible
these days. For whatever reason, it makes us feel more
comfortable when we are able to put a file at the end
of a root canal. It signals mission accomplished for us.
Different manufacturers are advertising their
techniques, which use practically the same or a
slightly modified NiTi alloy in a multistep technique
with reciprocating motion. The quality of the dentine, the direction in which the debris is pushed or
evacuated and the internal stress on the file itself are
some areas of concern regarding these techniques.

Fig. 3

14 I roots
3_ 2011

1. In the upper centrals, laterals and premolars, for
example, and even in the distal canal in molars,
where we can identify the root-canal space on the
preoperative X-ray, no pre-flaring or pre-enlargement is needed. TF 25/.08 can easily perform
crown-down safely and quickly.
2. In a different clinical situation, such as the lower
molars and the mesial canals of the upper molars,
it is preferable to check the patency of the canals,
as they can be pretty tricky—especially the lower
mesial canals, as they present two curves in the
centre of the root canal. More importantly, the first

Fig. 4

[15] => RO0110_01_Titel

case report _ NiTi

of the two curves will not appear on the X-ray and
may become a perfect trap for NiTi files. In such
cases, after checking the patency, TF 25/.06 is a perfect file for crown-down. The 25/.06 may get you to
the apex in a few seconds or, if you have not reached
the apex after the first four strokes, you may need
to clean the file, irrigate the canal and try again. The
.06 taper is a very good choice for treating curved
canals because a larger taper inside a curve may
result in taper lock and lead to file separation.
Achieving crown-down in such a fast and hightech way may tempt us to neglect the irrigation protocol. Here, the use of ultrasonic activation can be of
great help to disinfect the canal space and remove the
smear layer when this is done with proper irrigating
solutions.
Reaching the apex with the crown-down technique may not be the ultimate technique for proper
root-canal enlargement, especially with respect to
the apical enlargement of the last 3mm of the canal.
According to a variety of studies, the crown-down
technique cannot be the sole instrumentation technique, and the last 3mm of the root-canal space
should be addressed in a different way. This subject
is a controversy amongst practitioners and amongst
schools owing to differences in the philosophy of
root-canal enlargement.
I personally support the idea of apical enlargement
and find the TF 40/.04 to be the best file to do the
job, as it offers the flexibility and safety necessary for
reaching the apex after the canal has been enlarged
with a 25/.08 or .06 file. In such a case, the total number of files used for the crown-down and apical
enlargement will amount to two NiTi files.

_Clinical cases
The patient was referred to the office to check
a possible crack in the mesial and distal root (Fig. 1).
Depth probing did not reveal a pinpoint pocket. After
I had done a bite test and carefully checked the access
cavity and the entries of the canals for potential
cracks, I decided to treat the root canal and check
the post-operative situation, since the patient was
desperate to save her tooth.
Upon establishing a direct/straight-line access
to the coronal part of the canal, a TF 25/.06 was used
for crown-down, which was followed by copious
irrigation activated with an ultrasonic file for 15 seconds for each solution used. Apical enlargement
was then done with a TF 40/.04, followed by a 15-second activation of sodium hypochlorite in order to
eradicate the organic part of the apical biofilm that
had been mechanically disrupted with the apical file.

The sodium hypochlorite was carefully removed from
the root-canal space using distilled water and ultrasonic activation. Sealing the canal was achieved with
Resilon (RealSeal, SybronEndo) in a modified vertical
compaction technique. At the eight-month followup, nice healing was observed (Fig. 2).
The second case was a bit more complicated
(Fig. 3). The patient was referred after she had received
a root-canal treatment but was still suffering from
pain and pressure in her sinuses. The pre-operative
X-ray clearly showed that obturation material inside
the palatal root had passed into the sinus cavity. Upon
opening the access cavity, I was surprised to see
that Thermafil carrier-based obturators (DENTSPLY)
had been used, which explained the extrusion of the
material into the maxillary sinus. A retreatment was
scheduled after the options had been discussed with
the patient. Three Thermafil obturators were successfully removed with a TF 25/.06 (Fig. 4). The patient felt
immediate relief, as air was escaping the sinus from
the palatal canal (Fig. 5).

Fig. 5

No sodium hypochlorite was used to irrigate the
canal. Chlorhexidine solution was activated slowly
with an ultrasonic file and apical enlargement was
done with the TF 40/.04, followed by an immediate
obturation of the root-canal space with Resilon using
a modified vertical obturation technique (Fig. 6).
The patient was impressed with the speed of the
treatment and expressed her gratitude for saving her
molar.
Proper cleaning and shaping of the whole rootcanal space have been recognised as a challenge,
particularly in curved and narrow canals. NiTi instruments can only prepare a certain percentage of the
root-canal space. Irrigation and sealing are the other
important steps in the microbial control phase
for successful endodontic treatment. A deficiency in
mechanical preparation or in the sealing of the root
canal could offer the remaining micro-organisms
an opportunity to re-colonise the filled canal space,
resulting in failure of the endodontic treatment.
I would like to thank Yulia Vorobyeva, interpreter
and translator, for her help with this article._

Fig. 6
Fig. 5_Air bubbles coming out of
the sinus via the palatal canal.
Fig. 6_Sealing of the root canal in
the same session.

_contact

roots

Dr Philippe Sleiman
Dubai Sky Clinic
Burjuman Business Tower,
Level 21
Trade Center Street,
Bur Dubai
Dubai, UAE
phil2sleiman@hotmail.com

roots
I 15
3
_ 2011

[16] => RO0110_01_Titel

I case report _ radiolucency

Do we treat patients
based on radiolucency?
―A case report
Author_ Dr Sander Loos, Netherlands

_Just after Christmas, on 26 December 2010,
a 76-year-old male patient, who was in great pain,
consulted the emergency dentist. The patient indicated that he felt a throbbing pain in his lower left
jaw. The pain was unbearable and had kept him
awake all night. The dentist took radiographs of
teeth #36 and 37 and an orthopantomogram (OPG;
Figs. 1 & 2).

After another sleepless night, the patient consulted a different emergency dentist on 27 December.
The analgesics did not give him pain relief and he was
starting to become desperate. The second dentist
confirmed the original diagnosis and referred the
patient to an oral surgeon because an endodontist
was not available at short notice. He requested apical
surgery on tooth #37.

Although the radiograph did not show the full
anatomy of tooth #37 and its surrounding structures, the dentist diagnosed apical periodontitis (AP)
and advised an endodontic retreatment or extraction
and an implant. To make the patient comfortable for
the time being, he prescribed 500mg Amoxicillin and
Ibuprofen.

The following day, the oral surgeon took another
OPG and concluded that surgery was not the best
treatment option in this case because the apex was
located too close to the nervus alveolaris inferior
and access to the apices of tooth #37 was difficult.
He also confirmed the diagnosis of an AP and
suggested extraction or endodontic retreatment.
On 5 January 2011, the patient visited my office
for the first time. The pain had diminished but
not disappeared. Intra-oral examination showed a
well-restored dentition with a cantilever bridge on
teeth #35 to 37, with #36 and 37 functioning as
abutments. Tooth #37 showed an occlusal filling in
the crown. Palpation of the buccal fold was not
painful and there was no mobility of teeth #36 and
37. The pockets of #36 were within normal limits.
However, periodontal probing distal of #37 provoked strong pain and extreme bleeding. The distal
pocket measured approximately 6mm.
As the previously taken radiographs were not
available and the OPT was considered unsuitable for
proper diagnosis, a peri-apical radiograph (Fig. 3)
was taken. The radiograph showed that tooth #37
had previously been treated endodontically. The
mesial canals were filled with silver cones rather too
short of the apex. There also appeared to be some
gutta-percha and a large metal post in the distal

Fig. 1

16 I roots
3_ 2011

[17] => RO0110_01_Titel

case report _ radiolucency

Fig. 2

“The radiographic picture is only one means of diagnosis
… the picture may show a lot of rarefaction, but to use
it as the sole means of diagnosis is unwise.”

_contact

roots

―Thomas Philip Hinman, 1921―
canal. Additionally, radiolucency was noticeable
around the apex of the mesial root. According to
the patient, he had received endodontic treatment
about 15 years ago owing to pain following bridge
cementation. The tooth had been without symptoms since then.

symptoms of the AP may have temporarily disappeared and returned at a later stage. Nevertheless,
at that point we treated the patient based on history,
a radiograph and patient complaints rather than
merely on the basis of the radiolucency evident on
the radiograph.

Considering the history and my clinical and radiographic findings, my differential diagnosis was:

In May 2011, the patient returned to our office
once again. He was free of complaints, pockets were
within normal limits and there was no bleeding on
probing._

1. painful AP owing to reinfection or leakage;
2. painful marginal periodontitis distal of tooth #37
owing to poor oral hygiene;
3. vertical root fracture (VRF) of the distal root of
tooth #37.

Dr Sander Loos
Heuvelweg 21
3761 XL Soest
Netherlands
s.loos@acta.nl

As diagnosis 1 and 3 would have required rather
invasive therapies (retreatment or extraction), we
opted to rule out the local marginal periodontitis
first. Under local anaesthesia, the distal pocket was
thoroughly cleaned and the patient was instructed
to use dental floss distal of tooth #37 on a daily
basis.
On 31 January, three weeks after initial treatment,
the patient returned for evaluation and appeared
free of complaints. There was no bleeding on probing and pain could not be provoked.
It should be noted that by selecting this strategy,
neither an AP nor a VRF was definitively excluded as
a cause of pain. It should be taken into account
that owing to the patient being on antibiotics, the

Fig. 3

roots
I 17
3
_ 2011

[18] => RO0110_01_Titel

I case report _ conservative treatment planning

Are endodontists invited to
the treatment planning party?
Author_ Dr Daniel Flynn, UK

Fig. 1a

Fig. 1b

Fig. 1d

Fig. 1c

Fig. 1e

Figs. 1a–e_Good oral hygiene.
Gingival recession of 4 mm on the
buccal aspect of UR6 and the UL6.
BPE scores of 1 in all quadrants.

_This is an exciting time to be an endodontist in
practice. The availability of advanced technologies
aids in the provision of excellent treatment and has
transformed the perception of endodontics to that of
a dynamic, cutting edge specialty. It is now possible to
predictability treat an increasing range of complex
cases. Despite this, it is concerning that endodontists
only play a limited role in treatment planning in practice.

Figs. 2 & 3_Peri-apical radiographs.
Fig. 4_Technically inadequate RCT
and a peri-apical radiolucency.
Fig. 5_Peri-apical radiolucencies
associated with the mesial
and distal roots.

I have five to ten referrers who regularly send
patients for opinions prior to treatment planning. This
means, a majority of referrers do not wish to or just do
not consider the availability of our specialist skill and
knowledge. If a patient presents after the treatment
plan has been agreed on, consent signed and a financial plan put in place, it becomes much more difficult
to change direction. We need to ensure that we do not
become technicians working to the prescription of
referring dentists, but instead are actively involved at
the crucial initial decision-making stage.

Fig. 2a

Fig. 2b

18 I roots
3_ 2011

Fig. 3a

Fig. 3b

Endodontic treatment planning most often focuses on restoring individual teeth with less attention
paid to the role of these teeth in the mouth as a whole.
Dentistry has become more specialised over the last
decade. This has resulted in a reduced incorporation of
all the dental disciplines into treatment planning of
patients. Predicting the long-term serviceability of a
tooth in the context of a restorative treatment plan is
complex. The pendulum has swung over the years
from only extracting unrestorable teeth to replacing
restorable teeth with dental implants. We need to be
knowledgeable about dental implants and gain experience in complex treatment planning. It is encouraging to see that postgraduate courses are increasingly
including implant training and complex restorative
treatment planning in endodontic programmes. Once
these knowledge and clinical skills are present, the endodontist is in the best possible situation to be least biased in decision-making regarding tooth restorability.
The quest to obtain an evidence-based approach
for decision-making in dentistry is prominent at the
moment. There is no accepted standardisation tool for
assessing the overall status of teeth. In practice, decisions are therefore made based on available evidence,
previous clinical experiences, intuition and accounts
of successful treatments by colleagues or even dental
representatives. Social psychologists tell us that
human beings are “cognitive misers”, that is, we accept
that we have limited ability to process all the available
information and thus try to devise strategies to deal
with complex planning issues.
This is evident when we do treatment planning
sessions with general dentists. These sessions are
invaluable as a type of focus group so we can under-

Fig. 4

Fig. 5

[19] => RO0110_01_Titel

case report _ conservative treatment planning

stand the needs and wants of local practitioners.
These findings, it should be noted, are from a small
self-selected group and may not reflect what occurs
in practice in a wider context:
1. Many dentists make treatment decisions based on
radiographs alone without dismantling teeth and
assessing restorability.
2. There is a general perception that root-canal retreatment (RCT) has a 50/50 chance of “not working”
and that apicectomies are unlikely to be successful
in the long term.
3. Implant treatment has success rates close to 100%
and carries a low risk of complications in the long
term.

Fig. 6a

Fig. 6b

Fig. 7

Fig. 8

Heuristics are a simple, rule of thumb strategy for
solving problems. Its attractiveness lies in the fact
that in a busy practice one does not need to go
through a complex decision-making process for each
possible alternative. An example I often hear is, “If a
failed tooth has been root-canal treated and restored
with a post, we need to extract the tooth.” Once
established it is easy to reaffirm existing views, but it
is extremely difficult to change them.

whereas a large number of recent implant studies
have ignored biological and technical complications.4
As endodontists, implant technology is to be embraced. In fact, the advent of implants has made the
endodontist’s job a lot easier. It is our duty though to
stop the pendulum from swinging too far. We need
to disseminate the knowledge and prevent perfectly
restorable teeth from being artificially replaced.

It is also striking to note the language used when
general practitioners talk about treatment alternatives. Root-canal treatment (especially retreatment)
is associated with uncertainty and the possibility of
failure, whereas implant treatment is associated with
success and predictability.

Hard tissues
Teeth present:

Figs. 6a & b_Adequate amount of
tooth structure lingually and a little
ferrule present buccally.
Fig. 7_Completion and temporisation
of LL1 and LL6.
Fig. 8_Temporary bridge.

76543 / 34567
87 54321/1234567

Good margins on the PFM crown LL1 and the PFM
double-abutted bridge UR4, UR3 to UL3, UL4.
Crown de-cemented from LL6.
Table I

These perceptions exist despite excellent studies
demonstrating RCT and endodontic microsurgery to be
incredibly successful. Systematic reviews show that
RCT has a success rate greater than 80% over four to
six years,1 while outcome studies show that endodontic microsurgery has a greater than 91% success rate
after five to seven years.2 With good case selection, success rates greater than 80% are easily achievable for
RCT, as some of the studies included in the systematic
review were completed in the past when implants were
not an available treatment option and therefore heroic
endodontics were attempted in order to save teeth.
Traditional endodontic outcome studies have used
stringent criteria3 when evaluating the treatment,

Fig. 9a

According to Aronson,5 once a decision has been
made, most people are motivated to justify their
actions and beliefs. We seek to justify our actions and
tend to focus on the positive aspects of chosen treatment whilst ignoring any disadvantages. Likewise,
we downgrade the positives of the treatment option
we did not take. This phenomenon—dissonance—
occurs for most people following a difficult decision
especially, if the decision involved a great deal of time
or money. Meanwhile, the theory of irrevocability
suggests that once a final decision has been made, we
tend to be more certain that it was the right decision
than before, when more uncertainty was involved.

Fig. 9b

Fig. 9c

Figs. 9a–e_RCT was competed and
newly cast post and cores and temporary crowns were placed.

Fig. 9d

Fig. 9e

roots
I 19
3
_ 2011

[20] => RO0110_01_Titel

I case report _ conservative treatment planning
Figs. 10a–e_Endodontic microsurgery (a), resection (b & c), retropreparation (d & e), obturation with
gutta-percha and MTA.

Fig. 10a

Fig. 10b

Fig. 10c

Fig. 10d

Fig. 10e

_Case report

bridges. The current bridge was nine years old. The
patient suffered recurrent infections from her UL3/4
region and UR4 tooth. She had taken multiple courses
of antibiotics over that period and now wished to
determine and resolve the source of the problem. She
had a hectic work schedule, but was prepared to take
set days off in order to have as much treatment as
possible done in a sitting. She was happy with the
shape and colour of her existing bridgework and did
not wish to appear noticeably different following
treatment, as she was involved in work on television.
A removable option was not possible at any stage,
even as a temporary measure. Cost was not a primary
concern, although she desired value for money.

I use the following case presentation to promote
the possibilities of endodontics in treatment planning. This 36-year-old female patient presented for
consultation after she had already seen a restorative
dentist for treatment planning. She was highly edu-

Occlusal examination
Class I molar and incisal relationship.
RCP and ICP appeared coincident.
Protrusion was guided by the incisors.
Right side and left side excursions were in group function.

Table II

cated, demanding and costs were not a limiting factor. In my experience, only a small number of patients
chose to get a second opinion. Most accept the first
treatment plan proposed.

Figs. 11a–c_LL1 complete healing:
Pre-op (a), 1-year follow-up (b),
3-year follow-up (c).

The patient was asymptomatic on presentation.
A traumatic accident at the age of nine resulted in the
eventual loss of UR2, UR1, UL1 and UL2. Over 25 years,
the upper incisors had been replaced with three

Diagnoses
The patient visited the dentist on a regular basis
and her medical history was non-contributory. The
extra-oral examination revealed a medium to low
smile line but no other relevant findings. Besides soft
tissues, the intra-oral examination revealed nothing
relevant to the treatment. The patient had good oral
hygiene. We found gingival recession of 4mm on the
buccal aspect of UR6 and the UL6. Her basic periodontal examination (BPE) scores were 1 in all quadrants (Figs. 1a–e; Tables I & II).
Her radiographic examination showed that UR4,
UR3, UL4 and UL3 were the abutments for the doubleabutted bridge spanning from UL4 to UR4. Marginal
discrepancies were not visible (Figs. 2 & 3). The teeth
were restored with post restorations and had technically inadequate RCTs. UL3 and UL6 had no evidence
of apical periodontitis. There were peri-apical radiolucencies associated with the UR4, UR3 and UL4.

Fig. 11a

Fig. 11b

20 I roots
3_ 2011

Fig. 11c

LL1 was restored with a post/core and a crown.
There was a technically inadequate RCT and a peri-

[21] => RO0110_01_Titel

case report _ conservative treatment planning

Figs. 12a–c_LL6 complete healing:
Pre-op (a), 1-year follow-up (b),
3-year follow-up (c).

Fig. 12a

apical radiolucency approximately 5mm in diameter
(Fig. 4). LL6 had been restored with a screw post
(Dentatus) and had a technically inadequate RCT.
There were peri-apical radiolucencies associated with
the mesial and distal roots (Fig. 5).
Treatment plan
The patient’s chief concerns were to be infection
free, have an identical aesthetic appearance and for
the plan to be cost effective. The original treatment
plan was extraction of LL6, LL1, UR3, UR4, UL3 and UL4
and replacement with immediately loaded implants
at a cost of around £30,000.
In order to determine other possible options, we
had to dismantle the teeth and assess the restorability. In this process, communication is vital, as the patient needs to understand the uncertainties involved.
It is extremely difficult to give an accurate estimate of
treatment costs before initiating this course of action
and dismantling teeth will often commit the patient
to an expensive reconstruction no matter what the
findings.

Fig. 12b

Fig. 12c

2. There was a radiolucency present and a previous
root-canal filling.
3. The size of the radiolucency was greater than 5 mm.
4. A post was present and would be difficult to remove.
5. The tooth could be cracked or unrestorable.
6. Restoration would not result in a “predictable”
long-term result.
It is important that we address the misconceptions
that RCT is unpredictable if there is a radiolucency
associated with the tooth and that there is a critical
level where the size of the radiolucency has a definite
effect on the prognosis of treatment. It would be an
interesting research project to reproduce this survey
on a much larger scale to ascertain practitioners’
treatment decisions.

_LL6 and LL1
The teeth were dismantled and LL6 was found
to be restorable. However, the LL1 proved a more
difficult decision. There was an adequate amount of
tooth structure lingually; however, there was a little
ferrule present buccally (Figs. 6a & b). I placed great

Figs. 13a–c_UL4 healing:
Pre-op (a), 1-year follow-up (b),
3-year follow-up (c).

In order to understand the decisions general practitioners make regarding when to extract or restore a
tooth, I completed a small survey to assess treatment
decisions for each tooth in this case. Ideally, the decision to restore or extract a tooth should be based on:
1. the quality, quantity and position of remaining
dentine;
2. the functional and aesthetic demands that will be
placed on the tooth;
3. the quantity and quality of surrounding alveolar
bone;
4. a cost-benefit analysis of each treatment option;
5. systemic factors;
6. potential to cause harm or adverse effects; and
7. patient preferences.
In this case, 40% of dentists wished to extract LL6
and replace it with an implant, while 80% wished to
extract LL1 based on the information provided above.
The reasons cited for extraction included:
1. A good treatment had already been completed and
failed.

Fig. 13a

Fig. 13b

Fig. 13c
Table III

Special tests
Tooth no.

LL6

LL2

LL1

UR4

UR3

UL3

UL6

TTP

Soft-tissue
tenderness

Sinus

Mobility

Periodontal
probing
Sensitivity tests

<3 mm <3 mm <3 mm <3 mm
N

<3 mm <3 mm <3 mm
N

roots
I 21
3
_ 2011

[22] => RO0110_01_Titel

I case report _ conservative treatment planning
porcelain fractured when sectioning through the
base metal substructure.
The bridge was sectioned and the underlying posts
and cores were removed with ultrasonic vibration.
The teeth were judged to be restorable. Root-canal
treatment was competed and newly cast post and
cores and temporary crowns were placed (Figs. 9a–e).
Fig. 14a

Fig. 14b

Figs. 14a–d_UR3/4 complete
healing: Pre-op (a), 1-year follow-up
(b), 3-year follow-up (c) and close-up
of healing UR3/4 (d).

Fig. 14c

Fig. 14d

importance on the fact the restoration had worked
in the past with this amount of tooth structure and
removal of the post was achieved reasonably atraumatically. The tooth had failed biologically rather than
mechanically.
Had this tooth failed mechanically, the treatment
of choice would have been a dental implant followed
by a resin-bonded bridge. Technically, implant placement would be very difficult in this case, as the interdental space was 5.5mm. There is a requirement of
at least 1.5mm of bone between the implant and
adjacent teeth, leaving only 3mm for the implant diameter. Not all implant systems have implants this
small and technically the treatment would need to be
executed ideally.
Surgical endodontics was also a treatment option
for LL1. The advantages of a cheaper, quicker solution
need to be balanced with long-term biological considerations. Technically, it may be difficult to complete a
retro-preparation to the level of the post, as the roots
on these teeth are generally lingually inclined. Also,
were I to do this case today, I would get a CBCT scan to
ensure that no lingual canal had been missed before
considering a surgical option, which can be present in
up to 40% of cases.
Following completion and temporisation of LL1
and LL6, it was time to move to the upper anteriors
(Fig. 7). Aesthetics are critical and was the patient’s
primary concern. She was adamant that the teeth look
the same as her existing bridgework. We elected to
construct a laboratory temporary bridge (Fig. 8) prior
to dismantling UR4 and UL4, in case some of the

_about the author

roots

Dr Daniel Flynn qualified from the Dublin Dental School and
Hospital, Trinity College (Ireland), in 2002. Dr Flynn recently
joined the EndoCare team headed by Dr Michael Sultan. He has
lectured in both the UK and Ireland and provides hands-on
courses for general practitioners. He also teaches Endodontics
at the Eastman Dental Institute for Oral Health Care Sciences.
For more information please contact EndoCare at
reception@endocare.co.uk or visit www.endocare.co.uk.

22 I roots
3_ 2011

The pathology associated with UR3 was treated
by surgical endodontics (Figs. 10a–e). This conservative approached allowed us to maintain the existing
bridge and aesthetics, which, along with dealing with
the infection, was the most critical factor for the
patient. As the canine was the patient’s longest tooth
that had a peri-apical lesion around the root for a
period, removing the apical 3mm was unlikely to
reduce the ability of the tooth to support the bridge
significantly. It also allowed us to make a more
favourable bridge design, as double-abutted bridges
were no longer desirable. However, that design had
worked in this case. Our approach also reduced the
cost of treatment significantly. The initial quote for
implant treatment was £15,000 to £30,000. The cost of
this treatment plan was just over £5,000. The patient
had one surgical procedure and recent studies suggest that there is a lower chance of complications
following endodontic treatment than following implant treatment.6 The bridge must be monitored over
time, as sectioning the UL4 and UR4 could result in
disruption of the cement layer. The patient, however,
had excellent oral hygiene and a low risk of caries.
At the 3-year follow-up, the patient was symptom
free and delighted that her objectives had been
achieved to date (Figs. 11–14). Of course, it’s early days
yet and in the fullness of time it may be proved that a
more aggressive treatment plan would have been a
more appropriate choice. The beauty of a conservative
treatment plan is that all the other options are still
available in the long term.

_Conclusion
I like to use this case to demonstrate that endodontists should not be forgotten in the treatment planning process. Rather than quoting success rates of
studies, it may be more effective to engage practitioners with examples for them to plan, demonstrate the
endodontic possibilities with long-term follow-ups
and let the results speak for themselves. Fear of failure
is a powerful emotion. It is a significant challenge for us
to spread the message to ensure that the true value of
predictable endodontics can be appreciated and that
perfectly saveable teeth are not removed._
Editorial note: A complete list of references is available
from the author.

[23] => RO0110_01_Titel

7IN A FREE TRIP TO
.EW 9ORK #ITY WITH
$ENTAL 4RIBUNE

4HE 'LOBAL $ENTAL 4RIBUNE !WARDS TO CELEBRATE EXCELLENCE IN DENTISTRY

4HEY WILL RECOGNISE OUTSTANDING INDIVIDUALS AND TEAMS THAT HAVE MADE
A UNIQUE AND SUBSTANTIAL CONTRIBUTION TO IMPROVING DENTAL CARE

WHETHER IN CLINICAL PRACTICE HEALTH POLICY DENTAL EDUCATION DENTAL
RESEARCH OR THE DENTAL INDUSTRY

!PPLICATIONS WILL BE JUDGED BY A JURY OF RENOWNED OPINION LEADERS FROM
ALL PARTS OF THE WORLD 4HE WINNERS WILL RECEIVE A FREE ECONOMY ¾IGHT TO
.EW 9ORK #ITY TO JOIN US AT THE !WARD #EREMONY WHICH WILL BE HELD AT
THE 'REATER .EW 9ORK $ENTAL -EETING ON .OVEMBER  

!LL $ENTAL 4RIBUNE READERS ARE CORDIALLY INVITED TO SUBMIT THEIR

APPLICATIONS ONLINE WITHOUT REGISTRATION FEES BY /CTOBER  
&OR PREREGISTRATIONS AND YOUR ONLINE APPLICATION PLEASE GO TO

AWARDSDENTAL TRIBUNECOM

[24] => RO0110_01_Titel

I opinion _ NiTi

Is rotary NiTi the
new paradigm?
Author_ Dr Barry L. Musikant, USA

not without its own shortcomings. K-files, for all
their limitations in apical negotiation, distorted shaping, impaction of debris and loss of length, rarely
break during usage. Rotary NiTi, on the other hand,
has made the dentist constantly aware of its vulnerability to torsional stress and cyclic fatigue, stresses
that routinely occur when shaping with rotary NiTi.

Fig. 1_Photograph of a K-file.
Note the high number of flues that
are more horizontal in orientation,
therefore contributing to poor
design under function.

Fig. 1

_Does rotary NiTi deserve the title of a new paradigm? In order to be determined to be a “paradigm”
it must represent a fundamentally new model. In the
case of endodontics, this new model of instrumentation differentiates itself from the old model by being
employed in a crown-down fashion rather than the
traditional step-back used with K-files.
Furthermore, the crown-down
technique is used with rotary NiTi
to minimise the engagement
along length, making rotary NiTi
somewhat less vulnerable to breakage, but at the same time requiring an increased amount of time for recapitulation.
The introduction of a new model constituting
a paradigm shift not only implies superiority of
the new model, but clearly defines the old system as
inferior, out of date and lacking the fundamental
intelligence that is incorporated into the new model.

Fig. 2_Illustration of a relieved
reamer used in a reciprocating
handpiece.

24 I roots
3_ 2011

What is most peculiar about this “paradigm shift”
is its dependence on the old model. Rotary NiTi
cannot be used unless the glide path is first created
using the K-files.1 Realising that the new model is
dependent upon the old model leads to some possible
insights. The shortcomings of the old model are still
present and the new model at best does not resolve
the old model’s shortcomings. Moreover, rotary NiTi is

Those supporting the benefits of this new model
state that crown-down has the advantage of pushing
less debris peri-apically, making endodontics more predictable. There is little in the endodontic literature that
supports this viewpoint and its supposed benefits.
An automated rotating crown-down approach
to shaping canals that is still dependent upon the
poorly designed K-file is really a dual system of canal
shaping with each portion of the system compensating for the weaknesses of the other. The K-files
engage the canal walls excessively, producing a poor
tactile perception of what the tip of the instrument is
encountering. This limitation can lead to ledging,
blockages and apical transportation. For this reason,
their use is limited as much as possible before
employing rotary NiTi.
Those using rotary NiTi must use the
K-files to create a clear pathway from
the canal orifice to its apex because
the tip of rotary NiTi instruments
is vulnerable to breakage if its
tip locks and binds apically.

Fig. 2

[25] => RO0110_01_Titel

opinion _ NiTi

with half the number of flutes and twice as vertically
oriented, will efficiently shave the dentine using the
same watch-winding stroke.

Fig. 3

It is only when the canal pathway is completely clear
along its entire length that the rotary NiTi instruments
can be used without fear of torsional stress. Even
then, a clear pathway does not eliminate all the
stresses that rotary NiTi will bear.
Rotation around a curve creates cyclic fatigue,
shortening the life of the NiTi instruments, with cyclic
fatigue accelerated, the greater and the more abrupt
the curve being negotiated.2 Compensation for this
vulnerability comes in two forms. The poorly designed
K-files (Fig. 1) may be used to shape the canals further
before switching to rotary NiTi or the NiTi instruments
may be used to shape more conservative preparations, not based on the biological needs of the canal,
but the metallurgical limitations of the NiTi instrument.
Perhaps the best way to illustrate the sleight of
hand in the marketing of rotary NiTi is to consider
a simple alternative: the use of relieved reamers
rather than K-files, instruments that work so well that
they can be used from start to finish. Whereas K-files
engage when a watch-winding motion is used and
only remove dentine on the pull stroke, the reamers,

Fig. 3_Photograph showing the
vertical flutes and flat of a relieved
reamer.

These instruments engage less along length, are
significantly more flexible and shave rather than cut
more efficiently. As long as patency is maintained,
these instruments will remain centred when being
negotiated apically and have the ability to work all
the walls upon withdrawal of the instrument.3 For
the most part, these instruments do all the shaping. It
is not a dual system because there is no need for
another system to compensate for any weaknesses.
The strengths that relieved reamers (Fig. 2) bring to
shaping canals, whether used in a manual watchwinding motion or in a 30° reciprocating handpiece,
are constant throughout the entire procedure (Fig. 3).

It could perhaps be said that
the use of relieved reamers sets a
new paradigm, but this is not strictly
the case. Reamer-designed instruments
have been around for years, but have not
been appreciated for their effective design. This is
understandable because they have rarely been taught
in the dental schools.
Somewhere along the way, K-files became the
instrument of choice in institutions of higher learning and so became ossified over the years without
proper justification. It was really the advent of rotary
NiTi that eventually highlighted the shortcomings
of K-files. That a system as expensive and vulnerable
as rotary NiTi is dependent upon initial instruments
of such poor design makes one realise that the edifice
of endodontics based on K-files is unsupported. To
be dependent upon a poor design makes no sense.

Fig. 4

Fig. 4_Photograph illustrating a
relieved reamer lacking the snapback qualities of its NiTi counterparts.

Fig. 5_Illustration showing an
asymmetrical instrument’s
ability to distinguish and clean
an oval-shaped canal.

Fig. 5

roots
I 25
3
_ 2011

[26] => RO0110_01_Titel

I opinion _ NiTi
_have a cutting tip that pierces rather than impacts
dentinal tissue and debris;4
_can be used both manually and in a 30° reciprocating
handpiece;
_on average cost 90% less than rotary NiTi on a peruse basis.
What any dentist might want to ask himself is
whether he is listening to the sizzle or tasting the
steak. The significant number of dentists who, while
being lured by the sizzle, are desperately waiting to
experience the steak, only to be disappointed by the
shortcomings inherent in any rotary NiTi system, is
amazing.
Fig. 6a

Fig. 6b

Figs. 6–8_Radiographs illustrating
the clinically excellent results
obtained using relieved reamers
in a reciprocating handpiece.

_contact

roots

Dr Barry Lee Musikant
Essential Dental Systems, Inc.
89 Leuning Street
S. Hackensack , NJ 07606
USA
info@edsdental.com

26 I roots
3_ 2011

Fig. 7

Fig. 8

If we simply brush away the use of K-files, the
subsequent use of rotary NiTi and all the marketing
that has gone along with its establishment as the
new paradigm, we are left with simple, inexpensive
yet highly effective tools that allow endodontics to
be performed with none of the procedural stress
associated with K-files. Relieved reamers provide the
dentist with the following advantages:

For anyone who has made a major investment in
rotary NiTi, it may be difficult to accept that there is a
simpler, more effective and far safer means of shaping
canals that costs a fraction of what rotary NiTi costs.

_virtually invulnerable to breakage;
_can be used six to seven times before replacement;
_will not break even if inadvertently used many more
times;
_can be negotiated apically with far less resistance
than K-files;
_more flexible, less engaging and more effective
at removing dentine from the canal walls than
K-files;
_do not snap back to the straight position like rotary
NiTi (Fig. 4);
_record curvatures;
_are confined to a tight arc of motion;
_stay centred when negotiating apically;
_can be used against any and all walls when being
removed from the canals;
_can differentiate between a tight canal and a solid
wall (Fig. 5);
_can differentiate between a round and oval canal;
_can shape even a highly curved canal to a minimum
of 35 without canal distortion;

These alternative systems do not have to be called
a paradigm shift. Rather, the paradigm shift must
happen in our minds, allowing the ability to judge
systems based on their performance rather than the
promise of that performance.
For examples of cases that highlight the clinically
excellent results using the alternative method discussed in this article, see Figures 6 to 8.
Knowing that nothing beats the old adage that
the proof is in the pudding, I make my long-standing offer to anyone who wishes to experience the
superior effectiveness of relieved reamers to K-files,
K-flex files and rotary NiTi to take the free oneon-one two-hour workshop I give in our New York
endodontics practice.
If you are interested, call +1 212 582 8161 and ask
for Evelyn to schedule the workshop, which is generally held on a Tuesday or Thursday from 7 to 9:30 pm.
The address is 119 W. 57th St.—a safe part of town for
out-of-towners who may have any trepidations._
Editorial note: A complete list of references is available
from the publisher.

[27] => RO0110_01_Titel

1 ANNUAL DGET MEETING
ST

(% & ' # *, ' & ' '&*'$'!,
&
&* $ ( +% *'$'!,

10th ANNUAL DGEndo Meeting
(% &

' # *, '

& ' '&*'$'!,

& '

3–5 November 2011
Bonn, Germany//KAMEHA Grand Hotel Bonn

Speakers
Dr. Arnaldo Castellucci
Prof. Markus Haapasalo
Prof. Syngcuk Kim
Prof. Thomas Kvist
Dr. Roy Nesari
Prof. Manoel Sousa-Neto
Prof Junji Tagami
Prof. Marco Versani
Prof. Roland Weiger

Spring Academy 2012 // 2 & 3 March 2012 // Heidelberg, Germany
SUPPORTED BY DR. JOHANNES MENTE & KLAUS LAUTERBACH

2nd Annual DGET Meeting // 1–3 November 2012 // Leipzig, Germany

[28] => RO0110_01_Titel

I research _ root-canal morphology

CBCT study of root-canal
morphology of mandibular first
molars in a Spanish population
Authors_ Drs Óliver Valencia de Pablo, Jose María Abadal, Roberto Estévez, Federico Moreno-Sancho, Teresa PérezZaballos & Manuel Péix Sánchez, Spain

Fig. 1_Slices depending on the
number of canals in the MFMs
found using CBCT.

3 canals

4 canals

5 canals

_The objective of root-canal treatment is the rigorous mechanical and chemical cleaning of the entire
pulp cavity, its 3-D obturation with an inert material
and the achievement of an appropriate hermetic coronal seal to prevent micro-organism intrusion.1 Microorganisms are the most important aetiological factor
for pulp and peri-apical pathology. Pulp tissue not
completely removed from the root-canal system is the
main reason for failure of endodontic treatment in
molars. The cause of failure is the infection of the remaining tissue, which is either already or subsequently
infected by micro-organisms.2 This problem seems to
be aggravated by the presence of root canals unnoticed
by the clinician, coinciding with anatomical variations
or additional canals.3 In fact, the lack of knowledge
about root-canal anatomy has been identified as one
of the most common reasons for endodontic failure.4
The mandibular first molar (MFM) is the most frequently endodontically treated tooth.5,6 Furthermore,
it is the tooth with the greatest rate of endodontic
failure.7,8 The relative simplicity and uniformity of
the external surfaces of its roots quite often mask the
internal complexity.9 Generally, the MFM is described
as having three canals, two in the mesial and another
in the distal root.10 Recent studies demonstrate the
possible presence of three canals in any of the roots.11–14

28 I roots
3_ 2011

6 canals

7 canals

Various methods have been employed to study
the internal anatomy. The best-known and most frequently used method in the literature is achieving
transparency of the roots. In recent years, 3-D imaging technology has been introduced and cone-beam
computed tomography (CBCT) in particular is starting
to prove very valuable in dento-maxillofacial imaging. CBCT is a useful tool in implant dentistry, for
indentifying anatomic structures and for the evaluation of periodontal lesions,15–18 as well as many other
applications.
With regard to endodontics, Cotton et al.described
a number of cases in which CBCT was the definitive
diagnostic tool used.19 In these cases, CBCT showed
an MFM with an extra root that had not been diagnosed or treated initially. However, only a few studies
have used this modern diagnostic technique to
analyse canal configuration. Various researchers
have used CBCT to evaluate maxillary molars.20–23
CBCT has also been used to determine the number and
the morphology of the roots of mandibular molars in
patients.24–27
The following is the first in vitro study to use CBCT
technology to determine the configuration and morphology of the canal system of the permanent MFM.

[29] => RO0110_01_Titel

research _ root-canal morphology

_Materials and method
In collaboration with various Spanish National
Health Service centres, 53 permanent MFMs were
collected. The age and gender of the patients were not
known. Before extraction, the dentist confirmed that
the teeth to be extracted were MFMs, relying on their
position within the lower arch. Afterwards, this was
corroborated through the coronal anatomical analysis of the samples. After extraction, all samples were
cleaned and stored in 10% formaldehyde. All samples were submerged in 4% NaClO to dissolve any
remaining organic tissue. Manual curettes and ultrasonic scalers were used to dissolve any calculus that
remained on the root surfaces.
In order to locate and secure the samples within
the bite holder of the CBCT device, they were embedded in Plasticine. The scanning was carried out by an
expert radiologist, who had experience using CBCT.
The device used for the purposes of this survey was
the i-CAT (Imaging Sciences International) with a
voxel size of 0.2mm and a grey sale of 14 bits.
Owing to the characteristics of the CBCT, the position of the samples during scanning did not matter.
The entire volume was registered, not only the volume
that falls within a determined area as would be the
case using conventional techniques. Therefore, we
were able to study the results in any of the spatial
planes. All the samples were positioned starting with
the mesial root followed by the distal.
Once the 3-D images of every sample had been
processed, the data was analysed with i-CAT Vision
software (Imaging Sciences International), which
offers various views of the data. We used the multi-

2-1

2-2

2-1-2

3-3

3-2

2-3-1

2-3-2

3-1-2

planar reconstruction screen, as it allowed us to
analyse the images in slices for the three different
spatial axes. In addition, the screen showed a simultaneous interaction amongst the axes, allowing the
operator to rotate the inclination of the sample in a
way that allowed the observation of the curvature of
each root through independent axial slices.
The canal configurations observed in the samples
were grouped based on Vertucci’s classification.28
(Since 1984, different configurations to the ones
described by Vertucci have been proposed.) Table I
shows a schematic representation of the different
types of canal systems that are present in the roots of
the permanent MFMs as given in the literature.29

Fig. 2_Examples of different canal
configurations found in the mesial
root using CBCT.

Fig. 3_Examples of different canal
configurations found in the distal root
using CBCT.

1-1

2-1

1-2-1

1-2

2-1-2

3-1

2-3

1-2-3-2

3-2-1

2-3-2-1

2-4-3-1

1-3-2

roots
I 29
3
_ 2011

[30] => RO0110_01_Titel

I research _ root-canal morphology

Vertucci 1984
Type 1
1-1

Type 2
2-1

Kartal &
Cimilli 1997

Type 3
1-2-1

Type 4
2-2

Gulavibala et al. 2001

Type 5
1-2

Type 6
2-1-2

Type 7
1-2-1-2

Type 8
3-3

Sert et al.
2004

Peiris et al.
2007

Al-Qudah & Awawdeh
2009

Type 2a Type 2b Type 9 Type 10 Type 11 Type 12 Type 13 Type 14 Type 15 Type 16 Type 17 Type 18 Type 19 Type 20 Type 21 Type 22 Type 23
2-1
2-1
3-1
2-1-2-1
4-2
3-2
2-3
4-4
5-4
1-3
1-2-3-2 1-2-3
3-1-2
2-3-1
2-3-2
3-2-1
3-2-3

Table I_Configuration possibilities
of mandibular MFM roots according
to the literature.

_Results
The results of the total number of canals found,
the canal configurations in the mesial root and the
canal configurations in the distal roots are shown in
Tables II, III and IV. Figure 1 shows examples of the
slices from the molars, illustrating the number of
canals. Figure 2 shows examples of the different
configurations found in the mesial root, while Figure 3 shows examples for the distal root.

_Discussion
A literature review found that the number of
canals in the MFM varies and that there are differences between the findings of in vitro and in vivo
studies in this regard. We suggest that modifications of the access cavity and clinical effort to locate
the canals may be a possible explanation for these
differences.29 The calcification of the coronal portion
of the canal often does not permit adequate access
to the root and canal morphology, but this does not
mean that it has disappeared.
The calcification always follows a corono-apical
direction. Therefore, the most complicated part for
a clinician is to identify the entrance to the canal.
However, once this has been achieved, instrumentation is usually simple. Thanks to CBCT, it is possible to

observe axial slices of roots of any given height,
allowing us to count the number of canals independently of the coronal access.
Initially, we know that both the mesial and the distal root have just one canal and the dentine apposition inside them develops a canal system.30 On some
occasions, we were able to find up to four different
divisions at a given height. Clinically, it is extremely
difficult not only to detect their existence, but also to
access them with either manual or rotary instruments. In fact, when four canals were observed within
a root, the divisions between them were so tiny that
they disappeared after the instrumentation of the
main canals, resulting in a simpler “prepared” anatomy.
The above-mentioned facts may explain the lower
number of canals found in the literature compared
with the results obtained in our investigation.29
We obtained similar results to Forner Navarro
et al. for the number of canals in the mesial root
of the MFM using CT.11 In two different in vitro studies, they found the frequency of three canals within
the mesial root to be 14.8% and 12%. We obtained
a rate of 17% in our study, which made us question
the validity of other methodologies. Further analysis of the 3-D technique is necessary. In our opinion,
the main advantage of the technique is that it does
not alter the structure of the samples in any way.

Table II_Number of canals in MFMs.

30 I roots
3_ 2011

Number of canals

Number of molars

Incidence in %

41.5

29.4

28.3

1.9

[31] => RO0110_01_Titel

research _ root-canal morphology

A recent publication confirmed the afore-mentioned data.31 In the study, 48 access cavities were
prepared in vitro and modified in the mesial root of
MFMs. The pulp chamber was explored with a microscope and ultrasonic tips. The operator observed
the presence of a middle mesial canal in nine roots
(18.7%). This confirms that the proper elimination
of calcification and coronal interferences allows
access to a greater number of canals in the mesial
root of the MFMs.
The literature shows that Types II and IV of Vertucci’s classification of the canal system configuration are the most frequent in the mesial root.29 In our
study, 39.6% of the mesial roots—compared with
35% in the literature—showed two canals that were
linked in the apical third, a close correlation. In our
study, the Type IV configuration—two independent
canals—was less frequent (39.6%) compared with
the literature (52.3%). The presence of three independent canals was only seen in one case, but other
complex configurations, such as 3-2, 2-3-1, 2-3-2
and 3-1-2, were found, raising the number of mesial
roots with three canals to nine.
The configuration of the canal system of the
distal root offered more variety. The frequency of a

single canal (47.2% in our data compared with
62.7% in the literature) was lower, increasing the
number of cases involving more complex configurations. This is probably due to a higher rate of calcification in the canals in our samples. Most of our
samples were extracted owing to large decay lesions,
defective and not repairable restorations or coronal
fractures, with a considerable number showing clear
signs of prolonged chronic bruxism. All these factors
enhance the apposition of dentine on the inside of
canals, creating subdivisions of the main canal. We
found three configurations not yet described in the
literature:
_1-3-2: Initially, we observed a single canal, which
rapidly diverged into three. Towards the middle
third of the root, two canals joined to finish with
two different canals in the apical third.
_2-3-2-1: One of the roots showed two canals that
later divided into three. Towards the middle third,
two of them joined together and all of them finished in the same common foramen.
_2-4-3-1: In another distal root, we found the most
complex of all configurations in either a distal or a
mesial root. Two canals divided into four, fusing
afterwards into three and finally joined together to
finish at the same foramen.
AD

Quick, Effective and Safe
Only 3 instruments for most cases
Single-length technique
R1 - 15/.06

R2 - 25/.04

R3 - 30/.04

up to WL

www.iRaCe.ch

[32] => RO0110_01_Titel

I research _ root-canal morphology

2-1

2-2

2-1-2

3-3

3-2

2-3-1

2-3-2

3-1-2

Number of mesial roots

22

21

2

1

3

3

1

1

Incidence in %

39.6

39.6

3.8

1.9

5.7

5.7

1.9

1.9

Table III_Mesial root-canal system
configuration.

Another difference between our results compared
with the literature regarding the distal root was the
low frequency of the Type II configuration (5.7%
compared with 14.5%), which is in contrast with our
findings for configuration Type III. The explanation
seems to be simple: the results of in vitro studies were
consistently similar to our results, while the results of
in vivo studies were not. The problem is that when a
canal divides into two towards the middle third, the
only way to fill it is by instrumenting the canal to
enlarge the coronal portion, allowing direct access to
each of the canals. The consequence is that clinically
all Type III canals (1-2-1) become Type II canals (2-1)
after root-canal treatment has been completed.
Given the amount of information provided without
altering the samples, CBCT technology is a great aid
for the in vitro evaluation of the root-canal anatomy
of the permanent MFM. Michetti et al. compared CBCT
slices with histological sections to determine the
appearance of the second mesiobuccal canal in maxillary molars. They found no significant differences.32
Neelakantan et al. compared CBCT to four different
methods for the study of the morphology of the rootcanal system. Their results of CBCT were similar to
those obtained using a clearing technique, which is
considered the gold standard for this kind of study.33

Table IV_Distal root-canal system
configuration.

The radiation a patient has to endure depends
directly on the volume to be scanned, which makes in
vivo analysis using CBCT a clinical possibility.19 In fact,
the literature review has shown, that CBCT is a very
valuable and useful tool in obtaining a satisfactory
treatment outcome.34,35

_Conclusion
It has been shown that CBCT is a useful and
valid tool for in vitro evaluation of the morphology
of the root-canal system of the permanent MFM.
The most frequent configurations for the mesial
root were 2-1 and 2-2, but a high percentage of
roots (17 %) had three canals. Half of the distal
roots had only one canal, but the other half had
diverse configurations, with 1-2-1 the most frequent configuration. The CBCT results obtained in
this study also demonstrated more complex configurations, such as 1-3-2, 2-3-2-1 and 2-4-3-1,
which have not been previously described in the
literature._
Editorial note: A complete list of references is available from
the publisher.

roots

_contact

Dr Óliver Valencia de Pablo
Department of Endodontics,
Universidad Europea de Madrid
Avenida de Bruselas nº 64
28028 Madrid
Spain
oliver.valencia@uem.es

1-1

2-1

1-2-1

1-2

2-1-2

3-1

2-3

1-2-3-2

3-2-1

2-3-2-1

1-3-2

2-4-3-1

Number of mesial roots

25

3

10

2

1

4

1

1

2

2

1

1

Incidence in %

47.2

5.7

18.9

3.8

1.9

7.5

1.9

1.9

3.8

3.8

1.9

1.9

32 I roots
3_ 2011

[33] => RO0110_01_Titel

[34] => RO0110_01_Titel

I feature _ interview

“Patient education needs
to be part of the daily
activities of a practice”
An interview with Dr Reena Gajjar, Canada
It soon became apparent that the treatment plan
acceptance rate was increasing dramatically with
these materials.
My husband, Dr Ken Hebel, began employing
these materials and experienced the same response. Patients asking about treatment options
were presented with the printable materials to
review and take home. We both found that in addition to enhanced case acceptance, this material
was a referral driver.

Dr Reena Gajjar

_My Dental Hub is premier web-based dental
patient education software. Accessible via your
computer or mobile device, including the iPad, it
provides patients with informative material on
major areas in dentistry, including 3-D animations.
Patients are then empowered to make educated decisions about the proposed treatment.
roots spoke to Dr Reena Gajjar about the idea
behind and the benefits of the software.
_roots: How did the idea for My Dental Hub
evolve?
Dr Gajjar: My Dental Hub (formerly Click &
Print) started back in 1996, when I joined my
husband’s prosthodontic practice. Having a background in computer graphics, I developed educational printable materials using images and
simple explanations for our practice. These were
used exclusively during patient consultations.

34 I roots
3_ 2011

This digital educational tool, facilitation of patient comprehension and acceptance of proposed
treatment manifested in a software program, was
originally called Click & Print, which contained
printable forms and a few animations that demonstrated dental procedures. Click & Print was sold on
a disk for several years. Four years ago, we started
to notice a shift in the way that companies were
doing business—becoming cloud based—and we
made the investment to convert our disk-based
product to a web-based product. The development
took over a year, but the investment proved to be
a smart decision, since we emerged as My Dental
Hub—the first cloud-based patient education and
practice-marketing solution.
As a cloud-based company, we have the ability
to constantly upgrade and update our product
offering, and customise our solutions to the needs
of our clients. As the dental industry starts moving
towards cloud-based solutions, we are well positioned to offer solutions to meet the needs of the
individual dental practice, as well as the collaborative needs of dental organisations.
_How do/did you obtain the information used in
the software? Do you collaborate with universities
and/or companies?

[35] => RO0110_01_Titel

feature _ interview

Most of the software content was written and
developed by Dr Hebel and me. We collaborated
with dental colleagues for some of the clinical content; however, all the 3-D animations are designed
and created in-house. The users of our program
play an important role in the development of our
content, since we develop content based on what
our clients need.

practice to do a consultation in three simple steps
and then e-mail the entire consultation to their
patients. It automates the consultation process.
It’s very simple and highly effective!

Users can link their practice website
to the Website Content template,
which is personalised with the
doctor’s logo and contact information.

My Dental Hub also offers mobile applications
(apps), available on iPad, iPhone and Android
tablets, containing all our animations and slide
shows. The iPad app is extremely popular in dental
practices as an easy way to explain treatment to
patients. It provides an exceptional presentation
on oral-hygiene instruction, which invariably is
a significant driver in any dental practice.

Users can also embed any of the
narrated animations or slideshows
directly in their practice website to
maintain branding and consistency.

Clients submit requests for content they would
like to see, and based on popularity and demand,
we develop the content. So, in fact, it is actually our
users that have guided the direction of the content
in the software. This is one of the tremendous
advantages of being a web-based company. As we
develop new content, we upload it to the program,
and it is immediately available to our users. No
need to wait for next year’s disk upgrade!
_Convincing patients to invest in dental treatment, e.g. an implant treatment, is a challenging
task. How will My Dental Hub help?
We believe that there are three primary components to case acceptance. Patients will invest in
dental treatment if they understand the problem
and understand the treatment that is being offered,
but more importantly, patients must understand
the value of the treatment and how that treatment
will improve the quality of their life (whether it is
related to improving function or aesthetics). The
content in My Dental Hub has been specifically
developed to address these components of patient
education in a language that patients will understand. The 3-D animations are used to visually
explain the procedure and the benefits of the treatment, and the printable (e-mailable) documents
serve as reinforcement of the animations and as
a resource for patients to review at home.
_What are some of the additional features the
software offers?
One of the key features of the software is the
ability to e-mail the animations and documents to
patients. This allows the dental practice to extend
their consultation from their office into the patient’s home, where patients can share and discuss
the recommended treatment with those involved
in the decision-making process.
My Dental Hub has several modules within the
program. We offer animations, image documents,
narrated slide shows, customisable text documents,
a document creator, a patient and photo management section allowing the practice to upload and
store patient images, as well as a presentation-creation module. Our newest module, Easy Consult,
has been extremely popular and is currently our
most-used module. Easy Consult allows the busy

roots
I 35
3
_ 2011

[36] => RO0110_01_Titel

I feature _ interview

Easy Consult allows the busy practice
to do a consultation in three
simple steps and then e-mail the
entire consultation to their patients.

In addition, we offer a product called Web Site
Content that allows users to place any of our
animations and slideshows on their websites or
linked to their website. High-quality animations
on a website allow patients to obtain information
about the procedures offered by the practice and

facility. External marketing includes websites,
advertising, mailings, etc. that are done virally
through e-mail or regular mail. Many dentists are
not trained in marketing and find it inherently
difficult to embrace marketing to grow their
business. Many do not know how, many just don’t
think they need to.
Many dentists do not take the time to educate
their patients or understand the value of patient
education. Many feel that patients will accept
treatment on the sole basis that the dentist told
them they need it. That may have been the way
it was, but we now live in an information-based
society, and if patients do not receive adequate
information from their dentist, they will seek it
elsewhere. (Hopefully, that won’t be the competitor down the street!)
We did a survey of our My Dental Hub clients
to determine how effective patient education was
in their practices. Our end users told us that they
had experienced an increased case acceptance
of 53%! This number indicates the importance
of educating patients, and the impact it has is
apparent in any business, including the business
of dentistry.
The process of patient education needs to be
woven into the daily activities within a practice.
This requires enhanced staff training and implementation. Many dentists do not invest the
time to integrate the process into their practice
procedures. Acceptance of a practice philosophy
mandates that training for implementation is as
important as training in the procedure.

Instant presentations make even the
most complex case presentations
easy, with supporting documents
ready to be printed or e-mailed.

36 I roots
3_ 2011

offer a powerful branding and marketing tool for
a practice.
_In your opinion, what are the most common
mistakes dentists make in patient education/
marketing their dental practice?
There are two types of marketing that dental practices should do—internal and external
marketing. Internal marketing includes posters,
brochures, discussions, etc. delivered within the

_Can My Dental Hub also be a helpful tool for
cutting through language barriers or communicating with disabled patients?
Absolutely! A picture is worth a thousand
words. Visual images and especially animations
tell a story, even if the words cannot be understood. Many of our dentists use our iPad app for
that reason. Even with the narration turned off,
patients use the iPad to browse the animations
and learn about the different dental procedures
offered by the practice. Most of us are visual
learners. In situations in which there may be
a communication barrier, we find that our client
base uses the animations as a component of
informed consent.
_Is the software available in different languages?
The software is currently only available in
English; however, we are working on translating
the software into Spanish and French. We have

[37] => RO0110_01_Titel

feature _ interview

many international practices that have requested
translations and our goal is to offer the program
in multiple languages, thus catering to an international clientele.

animations to patients to show them a dental
procedure, no one would have believed it possible.
Today, this is the way of the world and the way
business is being done.

_How much does the software cost? Are updates available free of charge?
My Dental Hub is a suite of products and is
subscription based. All updates are included in the
subscription fee. The full package includes animations, slideshows, documents, patient and photo
management, presentations, and Easy Consult.
The software comes with an unlimited licence,
which means that within a practice, there can
be an unlimited number of computers and users.
The subscription also includes unlimited training,
unlimited support, all updates and upgrades, all
new content, an unlimited number of e-mails,
unlimited storage of patient data, photos and
documents and daily backup. We offer special
pricing for American Academy of Periodontology
members (we were chosen as their exclusive
patient-education provider), and other organisations. Pricing can be found on our website. We also
offer a “lite” version of the software that provides
access to all of our animations and narrated slideshows on both computers and mobile devices.

I believe that with the incorporation of digital
tools into a dental practice, “elegant simplicity
and seamless connectivity” with patients and

Hundreds of videos with narration
can be accessed easily.
Industry leading, stunning animations
explain dental procedures in a clear,
concise manner.

colleagues will become the standard. Those who
embrace today’s technology will be tomorrow’s
industry leaders.

A simple photo management module
organises patient photos and
offers easy to use editing tools.

Web Site Content allows the practice to link
their website to the entire library of narrated
animations and slideshows so patients can
browse through all the content and/or they can
embed specific content directly into their website.
We also offer a free ten-day trial that can be
requested on our website.
_In your opinion, how will digital tools change
the dental practice and the way in which doctors
communicate with their patients?
The entire world is digital—not “becoming”
digital. Dentists must embrace this new means
of doing business simply because it is now a
component of everything, from paying a bill in
a restaurant to travel, shopping and doing something as basic as reading.
In terms of communication, digital tools enable a dental practice to communicate quickly,
easily and effectively with patients or referrals.
No more printing, no more mailing, diminished
expense and waste.
Society is changing. People are more aware
of their environment and doing their part to go
“green”. With simple tools, a dental practice can
deliver high-quality education directly and exemplify “environmental friendliness” as well. Ten
years ago, if you had told people you could e-mail

We all live in a connected world. My Dental Hub
is about being at the epicentre of that connection
in the dental world.
For more information please call +1 877 789
4448 or visit www.mydentalhub.com._

roots
I 37
3
_ 2011

[38] => RO0110_01_Titel

I feature _ interview

“The Scanner mode is going
to revolutionise dentistry”
An interview with Dr Ladislav Grad & Dr Matjaz Lukac, Fotona d.d.

Our system is also perfect for surgical procedures.
For example, treating leukoplakia was a very invasive
procedure traditionally. With our laser, the lesions can
be vaporised with almost no bleeding or trauma,
which is a big advantage for patients and doctors. We
know of some clinics, where one laser is shared by different departments: three days a week, it is used in the
dental department; two days a week, the aesthetic
doctors and dermatologists use it for their patients.

Dr Ladislav Grad & Dr Matjaz Lukac

_The new LightWalker hard- and soft-tissue
dental laser system from Fotona was introduced at
IDS 2011. The system offers a wide range of dental applications and, according to the manufacturer, will
revolutionise dentistry in the coming years. roots
had the opportunity to speak to Drs Ladislav Grad and
Matjaz Lukac about the benefits of the system for
general dentists, as well as specialists.
_roots:Dr Grad, Dr Lukac, congratulations on the
launch of LightWalker! Would you please tell us about
its applications and how dentists can benefit from
using it?
Dr Grad: LightWalker has two laser sources,
offering a wide range of dental applications. The
laser can be used in all different dental specialties―
endodontics, periodontics, conservative dentistry,
tooth whitening, etc.―but there is more. Fotona is
a manufacturer of medical lasers and well known in
the field of surgical and dermatological lasers. Owing
to our background, we were able to include additional
indications. You see, in some countries, dentists can
perform aesthetic treatments, such as facial hair
removal or removal of vascular lesions.

38 I roots
3_ 2011

_What was the impetus for developing the new
laser?
Dr Lukac: We have been in dental lasers since the
early ’90s, and wanted to pool all of our experience—
in terms of use and technology—into a new system
without having to make any compromises. Amongst
the most exciting applications of LightWalker is the
photon-induced root-canal therapy that makes
treating even posterior teeth a simple procedure for
every general dentist. There is also a combined laser
wavelength procedure, the TwinLight, for periodontal
disease treatment. With TwinLight, hard-tissue calculus and soft-tissue epithelial lining can be removed.
General dentists can now treat perio patients’ disease
comprehensively, without scalpels or sutures, right in
their own practice. Amongst the aesthetic treatments, our patented TouchWhite tooth-whitening
method should be mentioned. It is extremely gentle,
yet shortens the whitening time by a factor of five.
Our patented quantum square pulse (QSP) technology allows the laser to ablate more efficiently and
with greater precision because the laser beam is not
affected by hard-tissue debris. We created this technology especially for this laser. By being able to ablate
more efficiently, the edges of individual craters are
virtually straight, creating a perfect cut and resulting
in higher levels of precision and maximum tooth
preservation in hard-tissue treatments.
_Where are your biggest markets at the moment
and which markets are you approaching?
Dr Grad: Currently, the biggest market for our
lasers is Europe. However, with LightWalker we plan
on becoming a global market leader.

[39] => RO0110_01_Titel

feature _ interview

_What additional features are you offering with
the laser?
Dr Lukac: There is one feature, the scanner mode,
which we think is going to revolutionise dentistry.
LightWalker is the first dental laser system in the
world that can accommodate laser scanning technology. The scanner-ready Er:YAG laser will be able
to provide consistent and even ablation in hard and
soft tissue. The speed and consistency of ablation
performed with a scanner is virtually impossible to
achieve with any other tool. It is the “weightlessness”
of the laser light that makes this possible. Our goal
now is to guide dentists in using the scanning ability
of the laser.
We also believe that one of the first fields that is
going to be revolutionised will be implantology. Now,
it is finally possible to drill larger diameter holes with
laser. Currently, mechanical drills are used, which
cause thermal damage and a smear layer, which can
lead to problems later on, such as infections. We are
currently conducting clinical research on this and we
don’t have FDA clearance yet, but that’s where we are
going.
_What effect do you foresee lasers are going to
have on dentistry?
Dr Lukac: The big selling point for this unit is its
wide range of applications. This is what is drawing
customers. As I said, this technology evolves so that it
is easy to use. It is a tool that can be used for a variety
of indications. I am predicting that soon there will be
no more laser-specific dental meetings because the
laser is becoming part of the regular dental practice,
thus laser will become part of general meetings.
Soon, lasers will be just another dependable tool that
dentists use without hesitation.

_How can dentists learn
about how to use this laser
effectively? Are you offering courses?
Dr Grad: Yes. Laser dentistry is currently not part
of the dental curriculum
taught at most universities.
There are, however, many possibilities for postgraduate dental education. We have reference doctors
in different states who offer local training courses.
We collaborate a great deal with Aachen University
in Germany, which is the leading educational and
research institution for lasers in dentistry. There are
specific dates reserved on which practitioners can
attend a training seminar at the university. It is very
important for users to establish a safe and confident
handling of this technology and education is the
way to go about establishing that. There is no turning
back. Without laser technology, there is no modern
dentistry._
For information on Fotona laser workshops please
go to www.fotona.com/en/dentistry/workshops/.

_contact

roots

Fotona d.d.
Stegen 7
1000 Ljubljana
Slovenia
info@fotona.com
www.fotona.com

roots
I 39
3
_ 2011

[40] => RO0110_01_Titel

I practice management _ world wide web

Connectivity
in the dental world
Author_ Shane Hebel, Canada

_We live in a time in which things are changing
exponentially and the way that we go about doing
business is drastically evolving. The Internet has become a major player in businesses that never thought
that it could apply to them. Instead of battling the
Internet with a long stick and keeping it out of the
dental industry, it has always been our philosophy to
leverage it in new and innovative ways that can be
used to the advantage of health-care professionals
worldwide.

You may ask why that is relevant to you. Fantastic, you say, more teenagers are uploading pictures of
the party they went to last night. You may be thinking that this massive amount of sharing has no more
value than the latest episode of Jersey Shore. However, this is where you may benefit from a change in
perspective! Although social media started as just
that, a place to socialise, it has expanded into a massive enterprise that has since evolved into a realm
with numerous applications for anyone in the world.

After a lot of research and brainstorming, we discovered that the real reason that people are online
and using products is because of a little thing called
connectivity. Many people are online because it allows
them to connect and engage with other people who
have similar ideas, views or interests. We knew that
our mission of serving as a communications and
learning hub was lacking, as we were not serving
every aspect of our clients’ needs in this area of
dentistry. This led to a few feverish weeks of programming, writing and networking to bring you the
latest suite in the ‘Hub’.

Let us take a few minutes to really dig into what
social media is and why it can benefit YOU. Who cares
about how it can benefit Lady Gaga or President
Obama. I want to know how it can benefit ME in my
life and why it is such a big deal.

_Introducing My Dental Buddies!
My Dental Buddies is a network of dental bloggers,
community members and dentists, who can collaborate to provide information to the dental community at large. This free initiative is a social network
that allows users to connect and engage with fellow
dentists around the world! This is a HUGE opportunity to learn in a collaborative and innovative way to
increase your efficiency and effectiveness in your
own personal practice.
In one day, more than 100 million people signed
onto Facebook. Twitter generated more than 300 million tweets. Approximately 3 million people ‘checked
in’ to their current location and 35,000 hours of video
was uploaded to YouTube. The Internet is an extremely
busy place for all of that to happen in a single day!

40 I roots
3_ 2011

Unfortunately, this time around our good friend
Wikipedia let us down. Wikipedia defines ‘social
media’ as “the use of web-based and mobile technologies to turn communication into interactive
dialogue”. Okay, so that tells us the specifics of what
social media does. It allows people to connect online.
Well, that’s cool. E-mail did that. Why is social media
so special?
Let us bring it down a peg and see if we can gain
some further insight. “If you make customers unhappy in the physical world, they might each tell
six friends. If you make customers unhappy on the
Internet, they can each tell 6,000 friends,” Jeff Bezos,
CEO of amazon.com, said. WOAH, now that provides
a lot of insight! Social media allows people to interact with thousands and thousands of people that
they would not have access to otherwise. And they
can tell them whatever they want. Uncensored.
Fantastic!
So, social media allows people to say whatever
they want online without being censored. Social
media is a +1 for free speech. However, we still have
not answered the question: what does that mean for

[41] => RO0110_01_Titel

practice management _ world wide web

you? Well, let us go down one step further with some
specific examples. If your customers are telling 6,000
people that they are at the dentist and they are lovin’
it—that’s really good. If they are telling 6,000 people
that your office is terrible—that’s not so good for you.
Being part of the social network and getting involved
in communication areas that your patients are in
will give you an unprecedented look into your ‘online
reputation’ and give you a chance to really see what
your patients are saying.
So now we’re spying!? Fantastic, just what you
want to do in the health-care industry. The news industry recently tried that and the resulting News
Corp and James Murdoch phone-hacking scandal
has resulted in worldwide embarrassment for both
the media industry and the governments in which
those companies operated. However, there are more
aspects of social media that are very beneficial to you,
and not in a creepy kind of way. When people think of
social media, their minds immediately jump to huge
websites like Facebook and Twitter. While these websites embody the values of social media, they’re not
the end-all and be-all of the social media landscape.
Social media is about connecting and collaborating online. Take a look at LinkedIn, tumblr, YouTube
and the many other social media websites out there
today. These are social media tools. These are social
networks. These are YOUR networks. They are places
where you can come to connect with fellow people,
to collaborate and to LEARN. That is the most important part of all of this! Social media provides an
extremely effective medium for active learning,
participation and collaboration.
Social media is one major player on the Internet,
but it is not the only way that the Internet is changing
the dental industry. The Internet has a vast array of
resources that are making our world faster paced,
more dynamic and more thought-provoking. It is also
changing the way that we compete and how we do
business. The health-care industry has long been a
profession in which competition is not considered a
large factor. Many individuals stayed with a healthcare professional for their entire lives and that was the
end of it. Once again, the Internet has played a part in
upsetting the status quo and changing the way that
people view healthcare. Websites like WebMD.com
and the online directories of health-care professionals in different areas have opened up the possibility of
competition where one did not exist before. Dentists
and other health-care professionals are starting to
have to change the way that they do things in order
to compete in this new marketplace.
One of the most important things that dentists do
in their practice is selling. Now, this is not the way

things have been done in the past. Many dentists still
operate under the belief that patients come to them
for health care, not to be sold to. However, let’s look
at some of a dentist’s vocabulary in sales terms and
see what happens:
diagnosis: which product will work best for the
patient
case options: pitching
case acceptance: making the sale
treatment: delivery of product
Are you still as convinced that sales do not exist in
the dental industry? The Internet is responsible for a
huge number of changes in the dental industry and
as a result health-care professionals are constantly
having to be innovative in order to survive in a more
competitive and dynamic workplace.
I stumbled across this cool article recently that
talks about innovation in the workplace, a fascinating read and very applicable to the dental industry!
This is one area where dentists are currently lacking.
It is so easy to fall into a set routine and not think
about new or different ways to do things. I mean, why
bother? Your practice is making money. Why do you
need to be innovative?
Emily Ford, The Sunday Times, recently wrote
an article on that very topic. Innovation is a huge
new part of the dynamic connected world. People
are constantly collaborating to come up with more
and more innovative solutions to problems and it is
important to keep up with this changing environment. Ford suggested a few tips for innovating at
work, which have been given a dental twist to make
them especially applicable to your practice.
Make innovation a priority
Always look for new ways you can do things, new
products you can use and new ways of interacting
with your staff and patients. Not only will it make
your days new and exciting, it will benefit your practice in the long run too!
Take risks and embrace failure
If you buy a new instrument and it does not work,
what did you lose? A little bit of time and money?
What would have happened if it worked? You may
have saved a ton of time, made the quality of treatment increase and made a patient’s ordeal less
painful. Do you think that it is worth it? I definitely do!
By embracing failure, you can learn new things
quickly, learn what works and what does not in your
practice, and ultimately help your practice to succeed
with the increased knowledge that you will have.

roots
I 41
3
_ 2011

[42] => RO0110_01_Titel

I practice management _ world wide web
Eyes on the future
Think of it this way: when you know where you’re
going, you can figure out the fastest and easiest
way to get there. By planning ahead, you can spend
time thinking of innovative and new ways of doing
things that will make your future endeavours that
much easier. By knowing where you’re going, you can
constantly be on the lookout for things that will help
you get there, making the whole process faster and
more efficient.
Foster creativity at all levels
Encourage your staff to do the same as you! Ask
them to be constantly thinking about ways they could
change the way that they do things. Would something
else work better than what they’re currently doing?
Could they use a new tool to make their job easier? No
one will know the answers to these questions better
than them, so have them start thinking about it! Your
staff are a huge resource in coming up with creative
and innovative ideas in your practice.
Break the rules
Ask a ton of questions! Why do you do something
a certain way? Has anyone ever tried doing it another
way? We get so entrenched in our beliefs, habits and
routines that over time we stop thinking about why we
do things and just do them. Bring that back! Question
the things you do everyday—ask yourself why you
do them and whether there’s a better way. Chances
are that you’ll find a few things that will make your
practice a more productive and efficient place!
Collaborate across boundaries
Everyone has insights to share. Your receptionist
or assistant may notice things that you do not. Get

_about the author

roots

Shane Hebel is currently a student studying
Finance and Accounting at the Schulich School
of Business. He is a sales and marketing executive
for My Dental Hub. He is involved in a number of organisations that promote collaboration, connectivity
and education, including Impact Entrepreneurship
Group, Standard International and, of course,
My Dental Buddies.
shane@mydentalhub.com
www.about.me/shane.hebel
www.linkedin.com/in/shanehebel
www.twitter.com/shane_hebel

42 I roots
3_ 2011

them involved in the process! Chances are that they
have some great ideas of things that you could be
doing in your practice that you are not. Using your
staff effectively is one of the best things that you
could do and by involving them in this process you
are giving them ownership of the success of the
practice and motivating them to make it better!
Innovating does not have to be a one-man show
either. The Internet is connecting us in ways that
we could not have even dreamed of in the past and
it is important to be involved in every way that you
can. Although the Internet provides both a valuable
resource and fierce competition for your time and
your professional career, it is not the only tool for
collaboration and shared learning that is out there
today.
Here is a new and interesting thought: why
don’t you ask your employees for their ideas? Your
employees may have a ton of cool and innovative
ideas for ways that you could make your practice
more efficient and effective. However, they are
probably not telling you these ideas! Why not? Well,
for starters, you never asked! Many people won’t
share their opinions about some things (especially
business) because they are scared that they will
seem like they do not know what they are talking
about. No one likes that feeling!! If your employees
know that their ideas are welcome you will probably
find them flooding in!
What does this all boil down to? It comes
down to connectivity and collaboration. That’s it.
Those two simple words are what the future of the
dental industry (and every other industry) is going
to come down to. The ability to collaborate with
other like-minded individuals, share ideas, innovate
and ultimately create a better working system are
what the Internet, social media and connective sites
are all about.
This is what we are about at My Dental Buddies.
My Dental Buddies is a connective website for you,
for dentists, staff and other health-care professionals in the dental industry. We recognise the importance of collaborating socially and innovating
together and want to bring that to you. It is a portal,
a blank slate that the users of the site can fill with
whatever content they feel is important to them.
That is the beauty of the uncensored Internet; whatever is most important to the largest number of people is what gets talked about. We strive to leverage
the Internet to make your dental practice the best
that it can be. Please help us to do the same!_
Editorial note: A complete list of sources is available from
the publisher.

[43] => RO0110_01_Titel

Bella Center
Copenhagen

Welcome
W
elcome
elc
to the 45th Scandinavian Dental Fair
The leading annual dental fair in Scandinavia

The 45th SCANDEF
SCANDEFA
FA
A invites you to exquisitely meet the Scandinavian dental market and
sales partners fr
from
om all over the world in springtime in wonderful Copenhagen
SCANDEFA
SCANDEF
FA 2012

Exhibit at Scandefa

Is organized by Bella Center
and is being held in conjunction
with the Annual Scientific
Meeting, organized by the
Danish Dental Association
(www.tandlaegeforeningen.dk).
(www
.tandlaegeforeningen.dk).

Book online at www.scandefa.dk
www.scandefa.dk
Sales and Pr
Project
roject
oject Manager
Manager,
err,, Christian Olrik
col@bellacenter.dk,
col@bellacenter
r.dk, T +45 32 47 21 25

175 exhibitors and 11.422
visitors participated at
SCANDEFA
SCANDEF
FA 2011 on 14,220 m2
of exhibition space.

Travel
T
ravel information
Bella Center is located just
st a 10 minute taxi drive fr
from
rom
om Copenhagen
Airport. A rregional
egional train runs
uns fr
from
rom
om the airport to Or
Orestad
restad
esta Station,
estad
only 15 minutes drive.

Check in at Bella Center’
Center’s
s newly built hotel
Bella Sky Comwell is Scandinavia’
Scandinavia’s
s largest design hotel.
The hotel is an integral part of Bella Center and has dir
direct
ect
access to Scandefa. Book your stay on www
www.bellasky.dk
.bellasky.dk

w w w. scandefa.dk

Fotos fr
from
om Bella Center
Center,, W
Wonderful
onderful Copenhagen

2
201
2012

[44] => RO0110_01_Titel

I practice management _ paperless practice

Six steps to
a chartless
practice
Author_ Dr Lorne Lavine, USA

_There is no doubt that the modern dental
practice has changed rapidly over the past fifteen years. Dentists have come to realise that
with new technology, they can create a practice
that is more efficient, costs less to run, and
allows for decentralisation of the front office.
Records that were primarily paper- and filmbased are being replaced by digital radiography,
electronic records, and there is a move towards
a paperless, or at the very least, chartless practice. Most offices realise that there will always be
paper in a dental practice. Whether it is walkout
statements, insurance forms or printed copies of
images, paper will forever be part of the dental
practice. That being said, there are a number of
practices that have truly eliminated their paper
charts. While the process is easier for a start-up
practice, with proper planning, existing practices can achieve this goal as well.
Many dentists are probably aware that the
Federal Government is mandating that all patient records be paperless by the end of the year
2014. The challenge for most practices is evalu-

44 I roots
3_ 2011

ating their current and future purchases to ensure that all the systems will integrate properly
together. While many dentists are visually oriented and thus tend to focus on the criteria that
they can actually see and touch, some of the
most important decisions are related to more
abstract standards. I have therefore developed
a six-point checklist that I feel is mandatory for
any dentist adding new technologies to his or
her practice, and I recommend that each step
be completed in order.

_I Practice management software
It all starts with the administrative software
that is running the practice. To develop a chartless practice, this software must be capable of
some very basic functions. For practices that
wish to eliminate paper, dentists need to consider every paper component of the dental chart
and try to find a digital alternative. For example,
entering charting, treatment plans, handling
insurance estimation and processing through
e-claims, ongoing patient retention and recall

[45] => RO0110_01_Titel

practice management _ paperless practice

activation, scheduling, and dozens of other
functions that are used on a daily basis. Many
older programs do not have these features and
if practices wish to move forward, dentists
will have to consider more modern practice
software.
It is important to understand that as much as
we would all prefer that our practice management software programs could handle all of
these functions, most fall short of this. Fortunately, there are a number of third-party programs that can provide functionality where the
practice management programs cannot, such as
programs that allow digitisation of forms that
require patient signatures and programs that
can reduce the process of entering progress
notes to a few clicks of a mouse.

_II Image management software
This is probably the most challenging decision
for any practice. Most practice management
programs offer an image management module.
Eaglesoft has Advanced Imaging, Dentrix has
Dexis, Kodak has Kodak Dental Imaging, and so
on. These modules are closely integrated with
the practice management software and tend
to work best with digital systems sold by the
company.
For example, having an integrated image
module makes it very easy to attach images to
e-claims with a few clicks of a mouse. However,
there are also many third-party image programs
that will bridge very easily to the practice management software and offer more flexibility
and choices, although with slightly less integration. There is no perfect system. The choice really
is between paying a premium for greater integration or paying less for greater flexibility.
Some of the better known third-party image
programs include Apteryx XRayVision, XDR and
Tigerview.

patient not see. Microsoft Windows has built-in
abilities to allow dentists to control exactly what
appears on each screen.
There are numerous ergonomic issues that
must be addressed when placing monitors, keyboards and mouses. For example, a keyboard
placed in a position that requires the dentist to
twist his or her back around will cause problems,
as will a monitor that is improperly positioned.
Another important decision for the practice will
involve deciding whether the dentist prefers
patients to see the monitor when they are completely reclined in the chair. If this is the case,
then the options are a bit more limited for monitor placement. There are some very high-tech
monitor systems that not only allow the patient to see the screen, but also create a more
relaxing environment for patients considering
long procedures.

_IV Computer hardware
After the software has been chosen and the
operatories designed, it’s time to add the computers. Most practices will require a dedicated
server in order to protect their data and with the
necessary power to run the network. The server
is the lifeblood of any network and it is important to design a server that has redundancy
built-in for the rare times that a hard drive might
crash and can easily be restored. The workstations must be configured to handle the higher
graphical needs of the practice, especially if the
practice is considering digital imaging.

_III Operatory design
The days of a single intra-oral camera and a TV
in the upper corner are being replaced by more
modern systems. The majority of practices place
at least two monitors in the operatories, one for
the patient to view images or for patient education or entertainment, and one for the dentist
and staff to use for charting and treatment planning and any sensitive information concerning
the Health Insurance Portability and Accountability Act, such as the daily schedule or other
information that dentists would prefer that the

roots
I 45
3
_ 2011

[46] => RO0110_01_Titel

I practice management _ paperless practice
needs. All systems have pros and cons, and dentists will have to evaluate each system based on
a set of standards that are important to that
practice. For some dentists, it might be image
quality. For others, it may be the cost of the systems, the warranty of the sensor, the company’s
reputation, or the compatibility of the sensors
with their existing image management software.
Keep in mind that intra-oral cameras are still
an excellent addition to any practice, since they
allow patients to see the things that typically
only a practitioner could see.

_VI Data protection
With a chartless practice, protecting data is
crucial to preventing data loss due to malware or
user errors. Every practice, at a minimum, should
be using antivirus software to protect against
the multitude of known viruses and worms, a
firewall to protect against hackers, who try to infiltrate the network, and have an easy-to-verify
backup protocol in place to be able to recover
from any disaster. The different backup protocols are as varied as the number of practices, but
it is crucial that the backup is taken offsite daily
and can be restored rapidly. The modern term is
practice continuity. It is not only the data that
is being backed up that is important, but also
critically, the speed with which the system can
be restored and the practice can be up and running following a disaster such as a server crash,
fire or flood.
The computers placed in the operatories are
often different from the front desk computers in
many ways. They will have dual display capabilities, better video cards to handle digital imaging,
smaller cases to fit inside the cabinets, and
wireless keyboards and mouses. An often-overlooked consideration is that the smaller the
computer, the more heat it generates. Heat is the
number one enemy of computers, and since
many dentists will place their computers inside
a cabinet at the 12 o’clock position, having
proper ventilation is critical.

_V Digital systems
The choice of image software will dictate
which systems are compatible. Digital radiography is the hot technology at this time owing to
many factors. Dentists with digital radiography
report greater efficiency by having the ability to
capture and view images more rapidly, better
diagnostics, cost savings by the elimination of
film and chemicals, and higher case acceptance
through patient co-diagnosis of their dental

46 I roots
3_ 2011

For practices that wish to be chartless or paperless, it is crucial to evaluate all the systems
that need to be replaced with a digital counterpart, and to adopt a systematic approach to
adding these new systems to the practice. Most
practices would be well advised to replace one
system at a time, and become comfortable with
this new system before adding new technologies
to the practice. The typical practice will take 9 to
18 months to transition from a paper-based
practice to a chartless one._

_contact

roots
Dr Lorne Lavine
2501 W. Burbank Blvd., #303
Burbank, CA 91505
USA
drlavine@thedigitaldentist.com
www.thedigitaldentist.com

[47] => RO0110_01_Titel

industry news _ Acteon/VDW

Endo the confident way
_The current trend in surgical endodontics is using a minimally and noninvasive protocol to treat the entire
root canal, using an operating microscope and high-tech microinstruments.
Satelec presents the EndoSuccess Apical Surgery kit of five ultrasonic
instruments, developed to perform the exclusive
3-6-9 protocol for micro-apical surgery.
The active part of the instruments has a new diamond coating that enhances their efficacy, allowing
for more precise and controlled retro-endodontic

treatment and conserving more bone and
dental tissues. The root
canal is preserved and
the infection eradicated at its origin.
The first instrument to be
used in following the protocol
is the AS 3D universal tip with a 3mm working length.
Next is the AS 6D, which reaches 6mm. The AS 9D is
then used up to the coronal third (9mm) in certain
cases. Finally, the AS LD (left oriented) and AS RD (right
oriented) tips are used to treat premolars to a working length of 3mm._

_contact

roots

Satelec-Acteon
Equipment
17 Avenue Gustave Eiffel
33708 Mérignac
France
satelec@acteongroup.com
www.acteongroup.com

RAYPEX 6—
State-of-the-art technology
_For the precise location of the apical constriction, electronic means have been proven to be superior
to using radiographs. RAYPEX devices ensure precise
measurement and feature a unique zoom-in function,
which significantly aids endodontic treatment. The
latest model, RAYPEX 6, redefines user-friendliness
and design standards.

Its design, operation and user-friendliness were
developed to a high standard, resulting in a stylish
and handy casing, which can be folded flat when not
in use. The high-resolution touch-screen with a selfexplanatory user-interface is comparable with a
smartphone, and the menu guidance was designed
to ensure precise and fast navigation through the
functions.
For precise length determination, RAYPEX 6 uses
the latest multi-frequency technology. The 3-D graphic
display constantly indicates the position of the tip of
the file, while the automatic zoom-in function in the
region of the apical constriction enhances safety in
the critical section just before reaching the working
length. Acoustic signals allow for a “blind” localisation
of the apex.
RAYPEX 6 is ready for use—simply plug-in and
start. Any personalisation of display colour and tones,
for instance, can be done quickly.
RAYPEX 6 means precise length determination and
touch-screen convenience._

_contact

roots

VDW GmbH
Bayerwaldstr. 15
81737 Munich
Germany
info@vdw-dental.com
www.vdw-dental.com

roots
I 47
3
_ 2011

[48] => RO0110_01_Titel

I meetings _ events

International Events
2011
Czech Endodontic Society Annual Congress
1 October 2011
Prague, Czech Republic
www.e-s-e.eu
DGET Annual Meeting
3–5 November 2011
Bonn, Germany
www.dget.de
AAE Fall Conference
3–5 November 2011
New Orleans, LA, USA
www.aae.org

Pan Dental Society Conference
11 & 12 November 2011
Liverpool, UK
www.pandental.co.uk
Greater New York Dental Meeting
25–30 November 2011
New York, NY, USA
www.gnydm.org
BAET International Dental
Traumatology Symposium
16 December 2011
Brussels, Belgium
www.baet.org

2012
Second Pan Arab Endodontic Conference
11–14 January 2012
Dubai, UAE
www.paec2012.com
Swiss Society for Endodontology International
Conference
20 & 21 January 2012
Lausanne, Switzerland
www.endodontology.ch
DGET Spring Academy
2 & 3 March 2012
Heidelberg, Germany
www.dget.de
Skand Endo
23–25 August 2012
Oslo, Norway
nina.gerner@c2i.net
DGET Annual Meeting
1–3 November 2012
Leipzig, Germany
www.dget.de

48 I roots
3_ 2011

[49] => RO0110_01_Titel

about the publisher _ submission guidelines

submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
_the complete article;
_all the image (tables, charts, photographs, etc.) captions;
_the complete list of sources consulted; and
_the author or contact information (biographical sketch, mailing
address, e-mail address, etc.).

I

Image requirements
Please number images consecutively throughout the article
by using a new number for each image. If it is imperative that
certain images are grouped together, then use lowercase letters
to designate these in a group (for example, 2a, 2b, 2c).
Please place image references in your article wherever they
are appropriate, whether in the middle or at the end of a sentence.
If you do not directly refer to the image, place the reference
at the end of the sentence to which it relates enclosed within
brackets and before the period.
In addition, please note:

In addition, images must not be embedded into the MS Word
document. All images must be submitted separately, and details
about such submission follow below under image requirements.
Text length
Article lengths can vary greatly—from 1,500 to 5,500 words—
depending on the subject matter. Our approach is that if you
need more or less words to do the topic justice, then please make
the article as long or as short as necessary.
We can run an unusually long article in multiple parts, but this
usually entails a topic for which each part can stand alone because it contains so much information.
In short, we do not want to limit you in terms of article length,
so please use the word count above as a general guideline and if
you have specific questions, please do not hesitate to contact us.
Text formatting
We also ask that you forego any special formatting beyond the
use of italics and boldface. If you would like to emphasise certain
words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers.
Please do not use underlining.
Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line between paragraphs. Please do
not add tab stops.

_We require images in TIF or JPEG format.
_These images must be no smaller than 6 x 6 cm in size at 300 DPI.
_These image files must be no smaller than 80 KB in size (or they
will print the size of a postage stamp!).
Larger image files are always better, and those approximately
the size of 1 MB are best. Thus, do not size large image files down
to meet our requirements but send us the largest files available.
(The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more
space should there be room available.)
Also, please remember that images must not be embedded into
the body of the article submitted. Images must be submitted
separately to the textual submission.
You may submit images via e-mail, via our FTP server or post
a CD containing your images directly to us (please contact us
for the mailing address, as this will depend upon the country from
which you will be mailing).
Please also send us a head shot of yourself that is in accordance
with the requirements stated above so that it can be printed with
your article.
Abstracts
An abstract of your article is not required.

Should you require a special layout, please let the word processing
programme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes
or endnotes, please let the word processing programme do it for
you automatically. There are menus in every programme that will
enable you to do so. The fact is that no matter how carefully done,
errors can creep in when you try to number footnotes yourself.

Author or contact information
The author’s contact information and a head shot of the author
are included at the end of every article. Please note the exact
information you would like to appear in this section and format it according to the requirements stated above. A short
biographical sketch may precede the contact information
if you provide us with the necessary information (60 words
or less).

Any formatting contrary to stated above will require us to remove
such formatting before layout, which is very time-consuming.
Please consider this when formatting your document.

Questions?
Claudia Salwiczek (Managing Editor)
c.salwiczek@oemus-media.de

roots
I 49
3
_ 2011

[50] => RO0110_01_Titel

I about the publisher _ imprint

roots
international magazine of

endodontology

Publisher
Torsten R. Oemus
oemus@oemus-media.de

CEO
Ingolf Döbbecke
doebbecke@oemus-media.de

Published by
Oemus Media AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de
www.oemus.com

Claudia Salwiczek, Managing Editor

Printed by
Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de

Managing Editor
Claudia Salwiczek
c.salwiczek@oemus-media.de

Executive Producer
Gernot Meyer
meyer@oemus-media.de

Designer
Josephine Ritter
j.ritter@oemus-media.de

Copy Editors
Sabrina Raaff
Hans Motschmann

Messedruck Leipzig GmbH
An der Hebemärchte 6
04316 Leipzig, Germany

Editorial Board
Fernando Goldberg, Argentina
Markus Haapasalo, Canada
Ken Serota, Canada
Clemens Bargholz, Germany
Michael Baumann, Germany
Benjamin Briseno, Germany
Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
Heike Steffen, Germany
Gary Cheung, Hong Kong
Unni Endal, Norway
Roman Borczyk, Poland
Bartosz Cerkaski, Poland
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
L. Stephan Buchanan, USA
Jo Dovgan, USA
Vladimir Gorokhovsky, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA
Jorge Vera, Mexico

Copyright Regulations
_roots international magazine of endodontology is published by Oemus Media AG and will appear in 2011 with one issue every quarter. The magazine
and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable
to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed
for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty
representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.

50 I roots
3_ 2011

[51] => RO0110_01_Titel

Yo u c a n a ls o s u bs c r ib e v ia
w w w. o e m u s . c o m / a b o

would like to subscribe to
for € 44 including
shipping and VAT for German customers, € 46 including
shipping and VAT for customers outside Germany, unless
a written cancellation is sent within 14 days of the
receipt of the trial subscription. The subscription will
be renewed automatically every year until a written
cancellation is sent to OEMUS MEDIA AG, Holbeinstr.
29, 04229 Leipzig, Germany, six weeks prior to the
renewal date.

Last Name, First Name
Company
Street
ZIP/City/Country

Reply via Fax to +49 341 48474-290 to

E-mail

OEMUS MEDIA AG or via E-mail to
grasse@oemus-media.de

Notice of revocation: I am able to revoke the subscription within 14 days after my order by sending a written cancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.

Signature

roots 3/11

Signature

OEMUS MEDIA AG
Holbeinstraße 29, 04229 Leipzig, Germany, Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-mail: grasse@oemus-media.de

[52] => RO0110_01_Titel

2

1

•

1 – Intro Kit NiTi
2 – Universal Kit NiTi
3 – Surgical Retro Kit

3

Niti memory shape needles – flexible, bendable needle
- can be shaped to any required curvature – perfectly follows the canal anatomy
- the needle takes its initial straight shape during autoclave sterilization

•

NiTi Memory Shape Nadel

The MAP (Micro-Apical Placement) System, provides a unique
and efficient method for placing root-canal repair materials:
- either by orthograde obturation for the treatment of perforations, root-end fillings
and pulp-cappings using curved, straight or «memory shape» NiTi needles
- or by retrograde obturation after apical resection thanks to the specially designed,
triple-angled needles (left and right angled) and/or hooked needles

Designed & manufactured by

www.dentsplymaillefer.com

) [page_count] => 52 [pdf_ping_data] => Array ( [page_count] => 52 [format] => PDF [width] => 595 [height] => 842 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => roots international No. 3, 2011

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Content [page] => 04 ) [3] => Array ( [title] => Efficient and ergonomic apical resection using the Kaiserswerth algorithm [page] => 06 ) [4] => Array ( [title] => White lines or white lies? [page] => 10 ) [5] => Array ( [title] => Subscription [page] => 13 ) [6] => Array ( [title] => A race to the apex— Crown-down in 1! [page] => 14 ) [7] => Array ( [title] => Do we treat patients based on radiolucency? ―A case report [page] => 16 ) [8] => Array ( [title] => Are endodontists invited to the treatment planning party? [page] => 18 ) [9] => Array ( [title] => Is rotary NiTi the new paradigm? [page] => 24 ) [10] => Array ( [title] => CBCT study of root-canal morphology of mandibular first molars in a Spanish population [page] => 28 ) [11] => Array ( [title] => “Patient education needs to be part of the daily activities of a practice”; Interview with Dr Reena Gajjar - Canada [page] => 34 ) [12] => Array ( [title] => “The Scanner mode is going to revolutionise dentistry” [page] => 38 ) [13] => Array ( [title] => Connectivity in the dental world [page] => 40 ) [14] => Array ( [title] => Six steps to a chartless practice [page] => 44 ) [15] => Array ( [title] => Industry news [page] => 47 ) [16] => Array ( [title] => International Events [page] => 48 ) [17] => Array ( [title] => Submission guidelines [page] => 49 ) [18] => Array ( [title] => Imprint [page] => 50 ) [19] => Array ( [title] => Subscription [page] => 51 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

[cached] => true )