Cover / Editorial / Content / Mineral trioxide aggregate revisited: A cement for all seasons / The rationale and use of electronic apex locators / New endo program is established at University of Tennessee / X-Runner all-tissue ablative laser scanner / PIPS Laser Endo harnesses the power of the Lightwalker / Stropko Irrigator removes debris - making many procedures easier / Wykle Research expands its Calasept Endo line / Submissions / Imprint
Cover
01 - 01 viewEditorial
03 - 03 viewContent
04 - 04 viewMineral trioxide aggregate revisited: A cement for all seasons
06 - 09 viewThe rationale and use of electronic apex locators
10 - 14 viewNew endo program is established at University of Tennessee
15 - 15 viewX-Runner all-tissue ablative laser scanner
16 - 16 viewPIPS Laser Endo harnesses the power of the Lightwalker
17 - 17 viewStropko Irrigator removes debris - making many procedures easier
18 - 18 viewWykle Research expands its Calasept Endo line
20 - 20 viewSubmissions
21 - 21 viewImprint
22 - 22 viewArray
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[1] =>
roots
issn 2161-6558
the international C.E. magazine of
4
2013
_C.E. article
Mineral trioxide aggregate
revisited: A cement for all
seasons
_technique
The rationale and use of
electronic apex locators
_education
New endo program is
established at University
of Tennessee
North America Edition • Vol. 4 • Issue 4/2013
endodontics
[2] =>
[3] =>
editorial _ roots
I
How’s your
armamentarium?
One thing I find exciting about the specialty is the ever-expanding universe of tools and equipment
available to practitioners. When it comes to beefing up one’s armamentarium, there’s no better place to go
than a major dental meeting. From the latest files to the most innovative irrigation systems and beyond,
it seems there is always plenty to see and learn about at events such as the AAE and ADA annual sessions
or the Greater New York Dental Meeting.
Perhaps you picked up this copy of roots at one of these meetings.
That’s good, because in this issue you can read about how many of these specialized tools can be
used in clinical endodontic practice. Dr. Gary Glassman reports on the use of mineral trioxide aggregate
(MTA), which he says can “seal the pathway of communication” between the root canal system and the
surrounding tissues. Dr. L. Stephen Buchanan explains why his trusted electronic apex locator is the “most
indispensible” device he uses. Dr. John J. Stropko writes about his invention, the Stropko Irrigator, which
he designed to help make procedures easier by maintaining a clean field of vision.
Every issue of roots also contains a C.E. component. By reading the article by Dr. Glassman, then taking
a short online quiz about this article at www.DTStudyClub.com, you will gain one ADA CERP-certified C.E.
credit. Keep in mind that because roots is a quarterly magazine, you can actually chisel four C.E. credits per
year out of your already busy life without the lost revenue and time away from your practice.
To learn more about how you can take advantage of this C.E. opportunity, visit www.DTStudyClub.
com. You need only register at the Dental Tribune Study Club website to access these C.E. materials free of
charge. You may take the C.E. quiz after registering on the DT Study Club website.
I know that taking time away from your practice to pursue C.E. credits is costly in terms of lost revenue
and time, and that is another reason roots is such a valuable publication. I hope you will enjoy this issue
and that you will take advantage of the C.E. opportunity.
For those of you attending the fall meetings in New Orleans and New York City, be sure to say hello to
me in person. As always, I welcome your comments and feedback.
Fred Weinstein, DMD, MRCD(C),
FICD, FACD
Sincerely,
Fred Weinstein, DMD, MRCD(C), FICD, FACD
Editor in Chief
roots
4
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[4] =>
I content_ roots
page 10
page 06
I C.E. article
06 Mineral trioxide aggregate revisited: A cement
for all seasons
_Gary Glassman, DDS, FRCD(C)
page 15
I about the publisher
21
22
_submissions
_imprint
I technique
10 The rationale and use of electronic apex locators
_L. Stephen Buchanan, DDS, FICD, FACD
I education
15 New endo program is established at University
of Tennessee
I industry
17
PIPS Laser Endo harnesses the power of the
Lightwalker
18
Stropko Irrigator removes debris, making many
procedures easier
_John J. Stropko, DDS
Wykle Research expands its
Calasept Endo line
page 16
4_ 2013
4
endodontics
2013
Mineral trioxide aggregate
revisited: A cement for all
seasons
X-Runner all-tissue ablative laser scanner
04 I roots
the international C.E. magazine of
_C.E. article
16
20
roots
North America Edition • Vol. 4 • Issue 4/2013
issn 2161-6558
_technique
The rationale and use of
electronic apex locators
_education
New endo program at
University of Tennessee
I on the cover
From top: Stropko Irrigator, RootZX-mini electronic
apex locator, X-Runner all-tissue ablative laser scanner,
EndoVac irrigation device Master Delivery Tip. Clinical
image provided by Richard Mounce, DDS.
page 17
page 18
[5] =>
[6] =>
I C.E. article_ MTA
Mineral trioxide
aggregate revisited:
A cement for
all seasons
Author_Gary Glassman, DDS, FRCD(C)
_c.e. credit
This article qualifies for C.E.
credit. To take the C.E. quiz, log
on to www.dtstudyclub.com.
Click on ‘C.E. articles’ and
search for this edition (Roots
C.E. Magazine — 4/2013). If
you are not registered with the
site, you will be asked to do so
before taking the quiz. You may
also access the quiz by using
the QR code below.
_Pulpal and periradicular pathology develop
when the dental pulp and periradicular tissues become exposed to microorganisms. In experimental,
germ-free conditions, pulpal and periradicular tissues fail to show the development of pathosis and
associated lesions when exposed to bacteria.1,2 The
conclusion: Microorganisms are the main irritants
of the dental pulp and periodontium, and sealing the
pathways of communication between the root canal
system and the periradicular tissues is imperative if
bacterial leakage is to be prevented.
An ideal orthograde or retrograde filling material
that seals the pathways of communication between
the root canal system and its surrounding tissues
should be non-toxic, non-carcinogenic, biocompatible, insoluble in tissue fluids and dimensionally stable.3,4 Furthermore, the presence of moisture should
not affect its sealing ability; it should be easy to use
and be radiopaque for recognition on radiographs.4
Because existing restorative materials used in
endodontics did not possess these “ideal” characteristics,4 mineral trioxide aggregate (MTA) was
developed and recommended initially as a root-end
filling material and subsequently has been used for
pulp capping, pulpotomy, apexogenesis, apical barrier formation in teeth with open apices, repair of root
perforations and, most recently, in revascularization
cases. MTA has been recognized as a bioactive material.5,6
MTA has been shown to seal off the pathways of
communication between the root canal system and
surrounding tissues, significantly reducing bacterial
migration.7 It is made up of fine hydrophilic particles
that set in the presence of water, and it is composed
of tricalcium silicate, dicalcium silicate, tricalcium
aluminate, tetracalcium aluminoferrite, calcium sulfate dihydrate (gypsum) and bismuth oxide, which
provides it with radiopacity.8
Fig. 1
Fig. 2
Fig. 1_MTA Angelus (Angelus,
Londrina, Brazil) available in
resealable vials. (Photos/Provided
by Gary Glassman, DDS, FRCD(C) )
Fig. 2_Radiograph of a necrotic
lower left second premolar with
large periradicular radiolucency with
an incompletely formed root, both
longitudinally and laterally.
06 I roots
4_ 2013
[7] =>
C.E. article_ MTA
I
Fig. 3_EndoVac apical negative
pressure delivery system (Axis/
SybronEndo, Coppel, Texas).
Fig. 3
Portland cement is the most common type of cement in general use around the world, used as a basic
ingredient of concrete, mortar, stucco and most nonspecialty grout. It usually originates from limestone.
MTA is available as gray MTA and white MTA. The
crystalline structure and chemical composition of
gray and white MTA are similar, except for the presence of iron in gray MTA.
Both contain bismuth oxide and calcium silicate
oxide. Portland cement is composed mainly of calcium silicate oxide and does not contain bismuth
oxide but does contain potassium. Calcium oxide is
added in both Angelus white and gray MTA (Angelus,
Londrina, Brazil) to reduce the setting time, which is
too long in MTA cements of other brands (Fig. 1).
MTA has a similar mechanism of action to calcium
hydroxide9 in that the main component of the material, calcium oxide, when in contact with a humid
environment, is converted into calcium hydroxide.10
This results in a high pH of 12.5, making its surroundings inhospitable for bacterial growth and producing
an antibacterial effect for a long period of time. But
unlike calcium hydroxide products, such as Dycal®
(DENTSPLY, York, Pa.) and MTA Angelus (Angelus,
Londrina, Brazil), it has very low solubility, so it maintains a hard, excellent marginal seal.
Finally, unlike most dental materials, MTA actually
needs moisture to set, so it thrives in a moist environment. Of the commercially available MTA products,
MTA Angelus is well suited for most of the indicated
endodontic procedures due to its setting time of 10
minutes, compared with the four-hour setting time
of the other commercially available MTA. It is also
packaged in air-tight bottles, allowing the practitioner to use only what is exactly needed, without
introducing undue moisture into the remainder and
without waste.11
_Endodontic revascularization
Treatment of the immature, non-vital tooth with
apical pathology presents several challenges. The
mechanical cleaning and shaping of such a tooth
with a blunderbuss canal is difficult, if not impossible, to achieve predictably. The thin, fragile lateral
dentinal walls can fracture during mechanical filing,
and the large volume of necrotic debris contained in
a wide root canal is difficult to completely disinfect.12
A new technique is presented to revascularize
immature permanent teeth with apical periodontitis. The canal is disinfected with copious irrigation and a combination of three antibiotics. After
the disinfection protocol is complete, the apex is
mechanically irritated to initiate bleeding into the
canal to produce a blood clot to the level of the
cementoenamel junction.
A double seal of the coronal access is then made,
first with MTA over the blood clot and then a bonded
composite. The combination of a disinfected canal,
a matrix into which new tissue could grow, and an
effective coronal seal appears to have the ability to
produce an environment necessary for successful
revascularization.13 The development of normal,
sterile granulation tissue within the root canal is
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[8] =>
I C.E. article_ MTA
Fig. 4_After the triple antibiotic
paste was inserted into the canal, a
temporary restoration was placed.
Fig. 5_Blood clot was induced and
MTA Angelus (Angelus, Londrina,
Brazil) was placed over top, and then
the tooth was restored with bonded
composite.
Fig. 6_Three-month recall reveals
excellent longitudinal apical and
lateral dentin development.
Fig. 4
Fig. 5
Fig. 6
Fig. 7
thought to aid in revascularization and stimulation of
cementoblasts or the undifferentiated mesenchymal
cells at the periapex, leading to the deposition of a
calcific material at the apex as well as on the lateral
dentinal walls.12
An access cavity was made, purulent hemorrhagic
drainage obtained, and the necrotic nature of the
pulp confirmed. The root canal was slowly flushed
with 20 ml of 5.25 percent NaOCl for 15 minutes.
It was delivered with the master delivery tip and
the macro canulae of the EndoVac apical negative
pressure delivery system (Axis/SybronEndo, Coppel,
Texas) (Fig. 3).
The canal was dried with paper points, and a mixture of ciprofloxacin, metronidazole and minocycline
paste as described by Hoshino et al.17 was prepared
into a creamy consistency and spun down the canal
with a lentulo spiral instrument to a depth of 8 mm
into the canal. The access cavity was closed with a
sterile cotton pellet placed in the chamber and blue
Cosmecore (Cosmedent, Chicago). (Fig. 4).
The patient returned three weeks later and was
asymptomatic. The access was opened and the canal
again flushed with 20 ml of 5.25 percent NaOCl for
15 minutes. It was delivered in the same manner as
in the first visit with the master delivery tip and the
macro canulae of the EndoVac apical negative pressure delivery system.
The canal appeared clean and dry, with no signs of
inflammatory exudate. A #30 K-file was introduced
into the canal until vital tissue was felt at a depth of
10 mm into the canal space. It was used to irritate the
tissue gently to create some bleeding into the canal.
The bleeding was stopped at a level of 5 mm below
the level of the CEJ and left for 30 minutes, so that the
blood would clot at that level.
After 30 minutes, the presence of the blood
Fig. 7_One-year recall radiograph
reveals that definitive endodontics
had been completed by the patient’s
new dentist.
_A case of mistaken identity
A 15-year-old girl of Asian descent was referred
to the author’s private endodontic clinic for evaluation on the lower left second premolar. The healthy
young patient with an unremarkable medical history
presented with a history of buccal swelling of the left
mandibular area and discomfort to direct pressure
on the tooth. On clinical examination, the patient
was asymptomatic, and the tooth appeared intact,
without caries. The presence of an enamel pearl on
tooth #45 suggested that one may have been present
on this tooth, which was fractured during function,
resulting in a microexposure and necrosis of the pulp.
The tooth had an open apex associated with a large
radiolucency (Fig. 2).
Periodontal probings were within normal limits
for all teeth in the lower left region. Diagnostic testing was negative to cold and electric pulp testing,
with mild sensitivity on percussion and palpation.
Because of the presence of a wider than 4 mm open
apex and thin dentinal walls prone to possible future
fracture,14 it was felt that an attempt to achieve regeneration of the pulp should be made by a technique
similar to that described by Rule and Winter15 and
Iwaya et al.16
08 I roots
4_ 2013
[9] =>
C.E. article_ MTA
clot to approximately 5 mm apical of the CEJ was
confirmed. White mineral trioxide aggregate, MTA
Angelus was carefully placed over the blood clot
and allowed to set for 20 minutes. After confirmation was achieved of its set, a bonded composite
was placed and the patient was scheduled for
follow-up in three months. Unfortunately, the MTA
was placed further apically then would have been
preferred (Fig. 5).
At the three-month follow-up appointment,
the patient was totally asymptomatic, and the
radiograph showed complete resolution of the radiolucency, with closure of the apex and thickening
of the dentinal walls. Pulp testing was inconclusive
(Fig. 6).
At the one-year follow-up appointment, the radiograph revealed that treatment had been performed
on this tooth by another dentist, different from her
original dentist who made the initial referral. The new
dentist, not familiar with revascularization treatment performed, had entered the root canal space,
cleaned it out and obturated it with gutta-percha
and sealer. Fortunately, the treatment was successful (Fig. 7).
_Conclusion
The future of endodontics is bright as we continue
to develop new techniques and technologies that
will allow us to perform treatment painlessly and
predictably and continue to satisfy one of the main
objectives in dentistry — being to retain the natural
dentition wherever possible and wherever practical._
_References
1.
2.
3.
4.
5.
6.
Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of
surgical exposures of dental pulps in germ-free and
conventional laboratory rats. Oral Surg Oral Med Oral Pathol
1965; 20; 340–349.
Moller AJR, Fabricius L Dahlen G, Ohman A, Heyden G.
Influence of periapical tissues of indigenous oral bacterial
and necrotic pulp tissue in monkeys. Scand J Dent Res 1981;
89; 475–484.
Torabinejad M, Pitt Ford TR. Root end filling materials: a
review. Endod Dent Traumatol1996;12:161–178.
Ribeiro DA. Do endodontic compounds induce genetic
damage? A comprehensive review. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2008;105:251–256.
Enkel B, Dupas C, Armengol V, et al. Bioactive materials in
endodontics. Expert Rev Med Devices 2008;5:475–494.
that is hard tissue conductive (7).
Moretton TR, Brown CE Jr, Legan JJ, Kafrawy AH. Tissue
reactions after subcutaneous and intraosseous implantation
of mineral trioxide aggregate and ethoxybenzoic acid
cement, hard tissue inductive, and biocompatible. J Biomed
Mater Res 2000;52:528–533.
7.
Torabinejad M, Hong OU, Pitt Ford TR. Physical properties
of a new root end filling material. J Endodon 1995; 21;
349–353.
8. Dentsply Tulsa Dental. ProRootTM MTA Root canal repair
material; Material safety data sheet (MSDS).
9. Arnaldo Castellucci, MD, DDS. The Use of Mineral Trioxide
Aggregate in Clinical and Surgical Endodontics. Dentistry
Today, March 2003.
10. Duarte MA, Demarchi AC, Yamashita JC, Kuga MC, Fraga
Sde C. pH and calcium ion release of 2 root-end filling
materials. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2003 Mar;95(3):345–347.
11. Boksman L, DDS, Friedman M, MTA: The New Material of
Choice for Pulp Capping, Oral Health Dental Journal August
2011.
12. Shah N, Logani A, Bhaskar U, Aggarwal V, Efficacy of
Revascularization to Induce Apexification/Apexogensis in
Infected, Nonvital,Immature Teeth: A Pilot Clinical Study
JEndo, Volume 34, Number 8, August 2008 pp 919–924.
13. Banchs F, Trope M, Revascularization of Immature
Permanent Teeth With Apical Periodontitis: New Treatment
Protocol? J EndoVol. 30, No. 4, April 2004 pp 196–200.
14. Cvek M. Prognosis of luxated non-vital maxillary incisors
treated with Endod Dent Traumatol 1992;8:45–55.
15. Rule DC, Winter GB. Root growth and apical repair
subsequent to pulpal necrosis in children. Br Dent J
1966;120:586–590.
16. Iwaya S, Ikawa M, Kubota M. Revascularization of an
immature permanent tooth with apical periodontitis and
sinus tract. Dent Traumatol 2001;17:185–187.
17. Hoshino E, Kurihara-Ando N, Sato I, et al. In-vitro
antibacterial susceptibility of bacteria taken from infected
root dentine to a mixture of ciprofloxacin, metronidazole and
minocycline. Int Endod J 1996;29:125–130.
_about the author
roots
Gary Glassman, DDS,
FRCD(C), graduated from
the University of Toronto,
Faculty of Dentistry in 1984;
and graduated from the
endodontology program
at Temple University in
1987, where he received the
Louis I. Grossman Study
Club Award for academic
and clinical proficiency in
endodontics. The author of
numerous publications, Glassman lectures globally on
endodontics, is on staff at the University of Toronto, Faculty
of Dentistry, in the graduate department of endodontics, and
is adjunct professor of dentistry and director of endodontic
programming for the University of Technology, Jamaica. He
is a fellow of the Royal College of Dentists of Canada and the
endodontic editor for Oral Health dental journal. He maintains a private practice, Endodontic Specialists, in Toronto,
Ontario, Canada. He can be reached through his website,
www.rootcanals.ca.
roots
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_ 2013
[10] =>
I technique_ using apex locators
The rationale and
use of electronic
apex locators
Author_L. Stephen Buchanan, DDS, FICD, FACD
_Electronic apex locators (EALs) are my best friend
when performing a root canal. Of all the devices I
use in practice, my RootZX-mini (Fig. 1) is the most
indispensable. This is borne out by the fact that most
endodontists use an EAL to determine length in every
root canal they treat.
The rationale for using an EAL in every single
canal you treat? A short review of the anatomy
literature reveals conventional radiography to be
no greater than 80 percent accurate for length
determination, vs. 97 percent accuracy with EALs.
One of the worst endo concepts — ever — has been
the procedural recommendation that we treat root
canals a certain distance from the root apex — a
strategy based on the average position of root canal
foramina.
Unfortunately, none of our patients is average.
Every single root canal you enter for the next 35
years of practice will be different than the one before. So how is it going to work when we arbitrarily
assign apical preparation sizes based on averages?
Not so good, actually. When we decide all small
canals should be enlarged to a #35 file size at the
end of the prep, we will often have one of two
untoward outcomes: apical damage or incomplete
preparation.
So it is with length determination.
With an EAL, you will know immediately when
you reach the end of root canals with the smallest, first negotiating files — data that is so critical
to controlling our use of these instruments and
preventing apical damage. Without an apex locator, you will never know where you are in a root
canal until you have horsed a #15 KF to estimated
length and have taken an X-ray; in small curved
molar canals, this can be disastrous. Working initial
negotiating files short in error invites apical blockage and ledging, while working them erroneously
long invites ripping apically curved canals straight,
outcomes that happen more often than most of
us realize.
Yet the majority of general dentists do not use
EALs. Why? Many have been unsuccessful in first
use — no surprise; EALs are technique-sensitive to
Fig. 1
Fig. 2
Fig. 1_The RootZX-mini. (Photos/
Provided by L. Stephen Buchanan,
DDS, FICD, FACD)
Fig. 2_Make sure your EAL is in good
working condition by checking its
batteries, cords and file probes.
10 I roots
4_ 2013
[11] =>
[12] =>
I technique_ using apex locators
Fig. 3_This straight file probe is
gold plated at its business end
to prevent oxidation.
every six to 12 months. Not autoclaving EAL cords
and probes is no bueno, and the temperature and
steam fatigues the insulation, so accept this and pop
for a new cord set every now and then.
Fig. 3
use. Here are the technique touch points I consider
when using an EAL:
1) Confirm a good condition of the EAL, its batteries, its cords and its file probes (Fig. 2). These are
sensitive electronic devices with boards inside that
can break when drop-kicked in an operatory. Be
gentle with them. When their signal shows halfway,
replace the batteries with fresh ones. When EAL cords
have been autoclaved repeatedly, they may develop
tarnish that inhibits conduction at the cord connections and at the end of the file probe where it touches
the shank of the file being used. Using a bur brush
here will take care of the tarnish.
Ideally, use a straight file probe that has been gold
plated (this prevents oxidation) at its business end. These
work the best of all EAL probe designs I have used (Fig. 3).
My least favorite is the spring-loaded test file leads
that most dentists attach to their files. They are too
wide to fit them between the rubber stop and handle in
canals longer than 22 mm. Test leads attached to files
during negotiation dampen tactile feedback, increasing the risk of damaging tortuous apical anatomy.
The straight probe can be temporarily set on an
alcohol gauze, located on the patient’s bib, as the assistant places the lip clip under the rubber dam — on
the opposite side of the tooth being treated, with the
EAL display nearby. When estimated length is approached, it is then very convenient to simply retrieve
the file probe from under the patient’s chin, touch its
thin, V-cut end to the file shank, between the rubber
stop and the handle (Fig. 4).
The file in hand is then advanced into the canal
until the display meter pegs to the farthest red “Apex”
indication, and the instrument is turned slowly in a
counter-clockwise direction until the meter is only lit
up to the simulated “0.5 mm” mark and the green bar
opposite that mark stops blinking and holds steady
for a couple of seconds.
Lead sets typically need replacing in my office
2) Cut a nice access cavity. I am often asked how I
use EALs when working next to metallic restorations,
as it can be difficult to avoid shorting the signal. My
first consideration is to make sure the line-angles of
the access cavity have been cut so that files may drop
smoothly, without hitch, into each canal without
significant flexure of their shank ends.
A well-cut access cavity will allow files to be easily held away from an adjacent metal crown or alloy
restoration. To do so, get a finger rest, look carefully
as you center the file in the access prep, then direct
your attention to the EAL display as you turn the file
back and forth until the meter arrives at a reproducible length measurement.
If you still have trouble keeping files from shorting, cut heat-shrink tubing (RadioShack) into 9 mm
lengths and place them on your initial negotiating
files and the procedure can go on. A little practice
and this will no longer be necessary. Not to brag, but I
don’t have any greater difficulty using EALs through
metallic restorations or crowns and would rather do
that than work on teeth devastated by caries.
3) Use a lubricant such as RC Prep or ProLube
instead of NaOCl during electronic length determination. This is the second requirement for working
successfully through access cavities with adjacent
metal. In fact, doing all initial negotiation procedures through an access cavity filled with lubricant
will smooth out all EAL use as it helps eliminate the
apical blockage so common in vital cases. Not only
has there been no evidence-based research proving
NaOCl is helpful for negotiation procedures, all of
our clinical experience shows lubricants to be the
ideal solution to have in the pulp chamber as initial
negotiating files are taken into small curved canals.
When sufficiently small first files are used in a bath of
lubricating solution, apical soft-tissue blockage can
be totally avoided.
Plus, all EAL readings are more stable with lubes,
and most erratic with bleach. Lose the bleach, until
later in the procedure.
4) Increase file size when EAL readings are erratic.
Simply using one or two larger sizes of negotiating
‘If you want to eliminate working films altogether, use a
lubricant and an EAL during apical gauging procedures and
you will know exactly where to fit the cone.’
12 I roots
4_ 2013
[13] =>
[14] =>
I technique_ using apex locators
Fig. 4_When estimated length is
approached, it is then convenient to
simply retrieve the file probe.
Fig. 4
file works virtually every time when first or second
files taken to length return an erratic, jumpy signal.
Going to a larger size file with a lubricant during EAL
use will solve erratic signals for most brands of apex
locators.
Of all the unnecessary obstacles to success with
EALs, this one was my bêté noir for years until Johan
Masrelleiz twigged me to the use of lubricants during EAL use.
5) Use an EAL in every canal you treat, and you will
become proficient. Pulling the office EAL from the
back of a dusty closet once every two months — when
radiographic length determination isn’t working
— and expecting immediate success requires a rich
fantasy life. Conversely, when I have an apex locator,
I can be on a dental mission in an underserved region
and do a pretty nice RCT with no X-ray machine. Get
one, if you don’t already have one, and use that sucker
every time, and you will have waaay more fun doing
RCT. Take this recommendation to heart, and soon
you will be ready for the EAL homerun:
6) Stop taking length determination radiographs.
If you are able to accept gifts from heaven and are
looking for a way to be more efficient when delivering RCT, eschew length determination radiographs.
Remember 80 percent vs. 97 percent? So what do
we accomplish when we stop everything to capture
a length determination X-ray? To see files as they
exit molar root structure, multiple X-rays are usually
required, so why are we doing this?
Furthermore, curved canals change length as they
are worked. When you use an EAL for each negotiating file, it is common to observe the loss of 1/4 to 1/2
mm of canal length just going from the 08 KF to the
10KF, as the original irregular canal path is smoothed.
So do we capture a second length determination X-
14 I roots
4_ 2013
ray after negotiation, and a third after shaping?
Rather than spend the time to capture a radiographic record of a length that will change almost
immediately after, consider this:
Using today’s rotary instrumentation, I can literally cut an initial shape, a final shape, gauge the
terminus and fit a gutta-percha cone in less time than
it usually takes to capture a well-angulated X-ray image of a #15 KF at length. Then, when I take an X-ray
image with the cones in place I can be certain that the
length represented will be stable to the completion
of the case. If you want to eliminate working films
altogether, use a lubricant and an EAL during apical
gauging procedures and you will know exactly where
to fit the cone.
I know this works; I practiced for three years
(including live demonstrations) without taking a
working film after canal location — and my apical
accuracy improved._
_about the author
roots
L. Stephen Buchanan, DDS,
FICD, FACD, is a diplomate
of the American Board of
Endodontics and an assistant clinical professor at the
postgraduate endodontic
programs at USC and UCLA.
He maintains a private practice limited to endodontics
and implant surgery in Santa
Barbara, Calif., and is the
founder of Dental Education
Laboratories, a hands-on training center serving general
dentists and endodontists who want to upgrade their skills in
new endodontic and implant technology. Dr. Buchanan can
be reached through his business, Dental Education Laboratories, www.DELendo.com, info@endobuchanan.com.
[15] =>
education_ University of Tennessee
I
New endo program
is established at
University of Tennessee
_DENTSPLY Tulsa Dental Specialties, a manufacturer and marketer of products for endodontics (ProTaper NEXT, WaveOne, GuttaCore, ProUltra) recently
made a significant donation to help establish the
University of Tennessee’s new Advanced Specialty
Education Program in Endodontics. The university
used the funds to purchase endodontic equipment
featuring the latest technology that is housed in a
newly renovated, state-of-the-art teaching facility
located on the university’s Health Science Center
campus in Memphis, Tenn. The new clinic is named
after the company in honor of its contribution.
“Ultimately, we are driving better dentistry practices by helping to fund endodontic programs like the
one at the University of Tennessee,” said John Voskuil,
vice president and general manager of DENTSPLY
Tulsa Dental Specialties. “Offering an enhanced education to these students provides health benefits to
the entire community because they train on the latest
equipment and technologies.”
Previously, UTHSC College of Dentistry students
had to leave the state to receive endodontic training.
The addition of the Advanced Specialty Education
Program in Endodontics was a long-time goal at the
College of Dentistry and a demonstration of its com-
mitment to giving patients in the community more
options when a higher level of endodontic care is necessary. With the new clinic, students are immersed
in a total digital operatory with custom endodontic
carts, digital radiography, cone-beam tomography,
practice management software and microscopes
connected to high-definition plasma screens. Faculty
are able to monitor treatment rendered by residents
in HD video, as all microscopes can be displayed to the
remote endodontic conference room.
“We would not have been able to launch this
program without the support and collaboration
of partners like DENTSPLY,” said Adam Lloyd, BDS,
MS, chair of the department of endodontics at the
College of Dentistry. “As a teaching program for the
endodontic specialty, our goal is to provide a clinical
setting that comes as close to a real-life practice as
possible. DENTSPLY is a recognized leader in endodontic best practices and our partnership with them
is a tremendous asset in training our residents using
the best available technology.”
University of Tennessee officials and representatives from DENTSPLY unveiled the new facility by
holding a ribbon cutting and community open house
on Sept. 6._
From left: Dr. Adam Lloyd,
endodontic department chair;
Dr. Adam Davis, UTHSC alumnus;
John Voskuil, DENTSPLY Tulsa vice
president and general manager; and
Dr. David J. Clement, endodontic
program director, stand in a newly
outfitted operatory at UTHSC.
DENTSPLY Tulsa Dental Specialties’
donation has been used to outfit
the state-of-the-art facility with the
latest endodontic technology. (Photo/
Provided by DENTSPLY Tulsa Dental
Specialties)
roots
4
I 15
_ 2013
[16] =>
I industry_ Lasers4Dentistry
X-Runner all-tissue
ablative laser scanner
Designed for use with the Lightwalker AT,
combo erbium, Nd:YAG dental laser system
Fig. 1_ The X-Runner
scanner. (Photos/Provided by
Lasers4Dentistry)
Fig. 2_ The shape and size of
X-Runner cuts.
Fig. 1
_The X-Runner™ was designed specifically for the
award-winning LightWalker AT Dual Wavelength
dental laser. X-Runner is the first ablative all-tissue
laser scanning handpiece in the dental industry. The
X-Runner has automated all-tissue ablation capabilities and lets the user instantly adjust spot size and
shape of the cutting area.
According to the company, X-Runner is the perfect tool to use whenever deep, wide or precise cuts
need to be made in hard or soft dental tissues. The
shape and size of an ablation area can be selected in
advance to optimize the cutting process, enabling
dentists to work more precisely, faster and with
greater ease than ever before. The new handpiece is
ideal for a wide range of treatments, from standard
cavity and veneer preps to high-precision surgical
and implantology procedures.
All parameters and settings that are available
with the Lightwalker AT’s standard laser handpieces
(energy, frequency, mode, spray) can also be used
with X-Runner, and users can instantly switch between the new automated modality and the classic
handpiece modality without the need to swap handpieces. X-Runner offers a variety of treatment shapes
(circular, rectangular/linear and hexagonal) that can
be set according to a number of parameters, such
as the size of the ablation area (width and length, or
diameter in the case of the circle and hexagon) as well
as the number of laser passes needed to produce the
required ablation depth. X-Runner can also produce a
precise linear cut, for instance to cut the root apex or
to perform an incision in soft-tissue surgery. You can
Fig. 2
16 I roots
4_ 2013
watch the X-Runner in action at www.t4med.com/
lightwalker_videos.html.
The award-winning Fotona Lightwalker AT is a
high-performance, ultra-fast and versatile laser with
both Er:YAG and Nd:YAG wavelengths and a long list
of technological and clinical advancements that puts
it in a class of its own.
According to the company, Lasers4Dentistry, with
the Fotona lineup, is a leader in the U.S. market with a
history of breakthroughs in dental technology:
• The only laser with both Nd:YAG and erbium fully
integrated in the same system.
• The only choice with 20 watts of erbium power.
• The only laser available with an all-tissue ablative scanner.
• The only laser with QSP mode.
• The highest-power erbium laser available, 20
watts of Er:YAG energy for ultra-fast cutting of both
hard and soft tissue.
• 15 Watts of Nd:YAG energy for treating periodontal disease, soft-tissue surgery and effective
biostimulation.
• Quantum Square Pulse (QSP) technology for
ultimate performance, cutting speed and treatment
precision.
• Industry-leading 50 µs Super Short Pulse (SSP),
resulting in less need for local anesthetic.
• Proprietary Variable Square Pulse (VSP) increases cutting precision and speed and provides
patients with a more comfortable experience.
• OPTOflex® articulated arm delivery system, the
gold standard for efficiency, ergonomics and reliability.
• X-Runner, the world’s first and only automated
dental laser scanner.
• Optional high-visibility green aiming beam.
• Internal air compressor, eliminating external
air lines.
• Options for expanded esthetic procedures,
including treatments for wrinkles, pigmented and
vascular lesions and other advanced cosmetic indications._
[17] =>
industry_Technology4Medicine
I
PIPS Laser Endo
harnesses the power
of the Lightwalker
Dual wavelength, all-tissue Er:YAG & Nd:YAG laser cleanses canals
_PHAST™ Laser Endo (PIPS™) harnesses
the power of the proprietary Lightwalker
Er:YAG laser, both exclusively available from
Technology4Medicine (www.T4Med.com), to
create photoacoustic shock waves within the
cleaning and debriding solutions in the canal.
The containment of the shockwaves
thoroughly streams these solutions threedimensionally through the entire canal
system, enhancing their effectiveness. The
canals and subcanals are left clean and the
dentinal tubules are free of smear layer. It is
a well-established fact that different dental
procedures require different laser wavelengths. Wavelength is important to clinical
outcomes because specific body tissues
interact in different ways depending on the
particular laser source.
The Lightwalker is a true dual wavelength
system. With the choice of two complementary
wavelengths, LightWalker is the “universal”
laser. Practically all laser-assisted dental treatments can be performed with either the most
highly absorbed Er:YAG laser wavelength or
the selectively absorbed, deeper penetrating
Nd:YAG laser wavelength.
There are many advantages to using the
Lightwalker and its proprietary PHAST (Photo
Fig. 2
Active Systems Technology) and PIPS (Photon
Induced Photoacoustic Streaming) for endodontic procedures:
• First is the entire root canal and subcanal
system is more effectively cleaned and debrided than with traditional instrument-only
techniques, reducing the risk of re-infection.
• The minimally invasive nature of PIPS
preserves more tooth endoskeleton than
traditional instrument techniques because
filing can be limited to as small as ISO #20
or #25, maintaining more post-restoration
tooth strength.
• Sub-ablative power levels eliminate the
risks of thermal damage, ledging and demineralization inherent to other laser endodontic
methods.
• Because the PIPS tip is inserted only into
the coronal opening and not into the canal,
there is no risk of tip breakage from curved
canals or unwanted apical extrusion of chemical irrigants, as is possible with standard laser
endodontic methods.
• Less filing time and less soaking time for
chemical agents can significantly reduce treatment time while being more effective.
The SEM images below demonstrate the effectiveness of PHAST Laser Endo._
Fig. 3
Fig. 1_ The Lightwalker dual wavelength, alltissue Er:YAG & Nd:YAG laser. (Photos/Provided
by Technology4Medicine)
Fig. 2_Internal surface after conventional
instrumentation, without PIPS.
Fig. 3_Clean dentin surface achieved with the
PIPS root canal treatment.
Fig. 4_Higher magnification after PIPS. Collagen
fibers are intact, with no thermal damage.
Fig. 5_Clean dentinal tubules
after PIPS.
Fig. 1
Fig. 4
Fig. 5
roots
4
I 17
_ 2013
[18] =>
I industry_ Stropko Irrigator
Stropko Irrigator
removes debris, making
many procedures easier
Author_John J. Stropko, DDS
Fig. 1_The Stropko Irrigator. (Photos/
Provided by John J. Stropko, DDS)
Fig. 2_Vision is obstructed by
debris created during endodontic
instrumentation.
Fig. 3_When the Stropko Irrigator
is used, debris is eliminated as it is
created.
Fig. 1
18 I
_The innovative Stropko Irrigator has essential uses in any discipline of dentistry — to make
restorative, endodontic, periodontal, surgical,
micro-adhesive dentistry, orthodontic and implant procedures easier by constantly maintaining a clean field with uninterrupted vision. The
Stropko Irrigator (Fig. 1) has numerous advantages over the standard dental tips.
It easily replaces the standard three-way syringe
tip and accepts a variety of luer-lock tips, enabling
more precise management of irrigation with air and/
or water. The large variety of luer-lock tips enables
direct access to any area of the mouth or tooth, during any procedure, no matter if it is the lingual of an
anterior, the distal of a molar or an apical retro-prep
during surgery.
Using the Stropko Irrigator, cleaning and drying can be done with more precision and control,
eliminating all unintentional splashing or contamination of the working area. With standard syringe tips, it is not possible to prevent the dentinal
dust from obstructing the vision. A good example
of vision control can be observed while troughing
in search of hidden canals as demonstrated in
Figures 2 and 3.
Figure 2 shows how vision is obstructed by the
Fig. 2
roots
4
_ 2013
debris created during instrumentation. In Figure
3, note the vast improvement of vision when the
Stropko Irrigator is used. The debris is eliminated
as it is created, thus permitting continuous clear
vision.
The outcome of any dental procedure is achieved
easier, faster, with more predictability and less
stress. Needless to say, the advantages of using the
Stropko Irrigator are especially appreciated when
using a surgical operating microscope during any
dental procedure.
The Stropko Irrigator is available in two lengths:
the 2.5-inch original length (SI-OL) and the 4-inch
extra long (SI-XL). The Stropko Irrigator allows the
operator or the assistant to remain ergonomically
comfortable and stay clear of the working site.
Using the supplied adapters, the Stropko Irrigator
easily replaces the older three-way syringe tips. No
adapters are needed for the newer “quick-connect”
three-way syringes.
The Stropko Irrigator is manufactured in the
United States using the strictest of quality control
measures and has the coveted C.E. mark. It has been
imitated but never duplicated and can be purchased at
most dental suppliers, or visit www.stropkoirrigator.
com for more information._
Fig. 3
[19] =>
[20] =>
I industry_ Wykle Research
Wykle Research
expands its
Calasept Endo line
Fig. 1_Calasept Irrigation Needles
(Photos/Provided by Wykle Research)
Fig. 2_Calasept Irrigation Syringes
_Wykle Research has announced the release of
two new Calasept Endo products, which it distributes for Nordiska Dental of Sweden, the manufacturer of Calasept and Calasept Plus.
Calasept Irrigation Needles are high-quality,
double-side-vented, luer-lock irrigation needles
that optimize the cleansing of canals, creating a
“swirl effect.”
The needles are available in 27 g or 31 g, in packs
of 40 needles.
Features include the following:
• Bendability
• Luer-lock hub
• Sterile and disposable
• Designed for ease in cleaning roots
• High-quality stainless steel
Calasept Irrigation Syringes are 3 ml luer-lock,
single-use syringes. They are color-coded to eliminate risk when using multiple irrigation liquids. They
are available in packs of 20 syringes, 10 white and
10 green.
Features include the following:
• High-quality, three-part syringe
• Color-coded
• Luer-lock
These new products complement Wykle’s
Calasept line, which includes Calasept and Calasept
Plus calcium hydroxide paste for temporary filling
of root canals, sold in packages of four syringes
with 20 needles. Calasept EDTA is 17 percent EDTA
solution. Calasept CHX is 2 percent chlorhexidine
solution for irrigation. Both solutions are packaged
with a luer adaptor for easy filling of syringes.
Wykle Research distributes Calasept Endo
products by Nordiska Dental, a Swedish manufacturer of dental supplies. Wykle Research and
Nordiska Dental will continue to provide new
endo products.
For more information, contact Wykle Research at
(800) 859-6641 or visit the company online at www.
wykleresearch.com._
Fig. 1
Fig. 2
20 I roots
4_ 2013
[21] =>
I about the publisher_ submissions I
submissions
formatting requirements
Please note that all the textual elements
of your submission:
• complete article
• figure captions
• literature list
• contact info (email address please)
• author bio
must be combined into one Microsoft Word
document. Please do not submit multiple files
for each of these items. In addition, images
(tables, charts, photographs, etc.) must not
be embedded in the text document. All images
must be submitted separately, and details
about how to do this appear below.
If you are interested in submitting a C.E.
article, please contact us for additional instructions before you make your submission.
_Text length
Article lengths can vary greatly — from a
mere 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 extra long article in multiple parts, but this is usually discussing a subject matter where each part can stand alone
because it contains so much information. In
addition, we do run multi-part series on various topics. 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
Please use single spacing and do not put extra
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Please do not “center” text on the page,
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If you need to make a list or add footnotes
or endnotes, please let the word processing
program do it for you automatically.
There are menus in every program that
will help you apply all sorts of special formatting.
_Image requirements
Please number images consecutively by
using a new number for each image. If it is
imperative that certain images are grouped
together, then use lowercase letters to designate the images in a group (i.e., Fig. 2a, Fig.
2b, Fig. 2c).
Insert figure references in your article
wherever they are appropriate, whether that
is in the middle or end of a sentence, but
before the period rather than after. Our
preference is to have figure references noted
in the appropriate place within the text, as it
helps the readers to orient themselves when
moving through the article. In addition,
please note:
• We require images in TIF or JPEG format
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If you have an image that is greater than
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largest file size available. The larger the
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leeway the designer has in terms of resizing
the image to fill up more space should there
be room available).
Also, please remember that you should
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You may submit images through a
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files via email or post a CD containing your
images directly to us (please contact us
for the mailing address as this will depend
upon where in the world you will be mailing
them from).
Please do not forget to send us a head
shot photo of yourself that also fits the
image requirements noted above so that it
can be printed along with your article.
_Abstracts
An abstract of your article is not required.
However, if you choose to provide us with
one, we will print it in a separate box.
_Contact info
At the end of every article is a contact info
box with contact information along with a
portrait photo of the author.
Please note at the end of your article the
exact information you would like to appear
in this box and format it according to the
previously mentioned standards.
A short bio (50 words or less) may precede the contact info if you provide us with
the necessary text.
_Questions? Comments?
Please do not hesitate to contact us for our
International C.E. Magazine Author Kit or if
you have other questions/comments about
the article submission process:
Group Editor Kristine Colker
k.colker@dental-tribune.com
Roots Managing Editor Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Managing Editor Sierra Rendon
s.rendon@dental-tribune.com
roots
4
I 21
_ 2013
[22] =>
I about the publisher _ imprint
roots
the international C.E. magazine of endodontics
U.S. Headquarters
Tribune America
116 West 23rd Street, Ste. 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
feedback@dental-tribune.com
www.dental-tribune.com
Roots Managing Editor
Fred Michmershuizen
f.michmershuizen
@dental-tribune.com
Managing Editor
Sierra Rendon
s.rendon@dental-tribune.com
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
Managing Editor
Robert Selleck
r.selleck@dental-tribune.com
President/Chief Eecutive Officer
Eric Seid
e.seid@dental-tribune.com
Education Director
Christiane Ferret
c.ferret@dtstudyclub.com
Group Editor
Kristine Colker
k.colker@dental-tribune.com
Marketing Director
Anna Wlodarczyk-Kataoka
a.wlodarczyk@dental-tribune.
com
Product/Account Manager
Humberto Estrada
h.estrada@dental-tribune.com
Product/Account Manager
Will Kenyon
w.kenyon@dental-tribune.com
International Product/Account
Manager
Jan Agostaro
j.agostaro@dental-tribune.com
Feedback & General Inquiries
feedback@dental-tribune.com
Editorial Board
Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
Daniel Heysselaer, Roeland de Moor, Julia
Kamenova, T. Dostalova, Christliebe Pasini,
Peter Steen Hansen, Aisha Sultan, Ahmed
A Hassan, Marita Luomanen, Patrick Maher,
Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit
Sahar-Helft, Lajos Gaspar, Paolo Vescovi,
Marina Vitale, Carlo Fornaini, Kenji Yoshida,
Hideaki Suda, Ki-Suk Kim, Liang Ling Seow,
Shaymant Singh Makhan, Enrique Trevino,
Ahmed Kabir, Blanca de Grande, José Correia
de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep
Arnabat, Ahmed Abdullah, Boris Gaspirc,
Peter Fahlstedt, Claes Larsson, Michel Vock,
Hsin-Cheng Liu, Sajee Sattayut, Ferda Tasar,
Sevil Gurgan, Cem Sener, Christopher Mercer,
Valentin Preve, Ali Obeidi, Anna-Maria
Yannikou, Suchetan Pradhan, Ryan Seto, Joyce
Fong, Ingmar Ingenegeren, Peter Kleemann,
Iris Brader, Masoud Mojahedi, Gerd Volland,
Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz,
Herbert Deppe, Friedrich Lampert, Jörg
Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert
Tribune America is the official media partner of:
roots_Copyright Regulations
_the international C.E. magazine of roots published by Tribune America is printed quarterly. The magazine’s articles and illustrations are
protected by copyright. Reprints of any kind, including digital mediums, without the prior consent of the publisher are inadmissible and liable
to prosecution. This also applies to duplicate copies, translations, microfilms and storage and processing in electronic systems. Reproductions,
including excerpts, may only be made with the permission of the publisher.
All submissions to the editorial department are understood to be the original work of the author, meaning that he or she is the sole copyright
holder and no other individual(s) or publisher(s) holds the copyright to the material. The editorial department reserves the right to review all
editorial submissions for factual errors and to make amendments if necessary.
Tribune America does not accept the submission of unsolicited books and manuscripts in printed or electronic form and such items will
be disposed of unread should they be received.
Tribune America strives to maintain the utmost accuracy in its clinical articles. If you find a factual error or content that requires clarification, please contact Group Editor Kristine Colker at k.colker@dental-tribune.com. Opinions expressed by authors are their own and may
not reflect those of Tribune America and its employees.
Tribune America cannot assume responsibility for the validity of product claims or for typographical errors. The publisher also does not
assume responsibility for product names or statements made by advertisers.
The 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, and the legal venue is New York, New York.
22 I roots
4_ 2013
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[page] => 04
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[page] => 06
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[title] => The rationale and use of electronic apex locators
[page] => 10
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[5] => Array
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[page] => 15
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[6] => Array
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[page] => 16
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[7] => Array
(
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[page] => 17
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[8] => Array
(
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[page] => 18
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[page] => 20
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Table of contents
-
Cover
01 - 01
view
-
Editorial
03 - 03
view
-
Content
04 - 04
view
-
Mineral trioxide aggregate revisited: A cement for all seasons
06 - 09
view
-
The rationale and use of electronic apex locators
10 - 14
view
-
New endo program is established at University of Tennessee
15 - 15
view
-
X-Runner all-tissue ablative laser scanner
16 - 16
view
-
PIPS Laser Endo harnesses the power of the Lightwalker
17 - 17
view
-
Stropko Irrigator removes debris - making many procedures easier
18 - 18
view
-
Wykle Research expands its Calasept Endo line
20 - 20
view
-
Submissions
21 - 21
view
-
Imprint
22 - 22
view
[toc_titles] => Cover
/ Editorial
/ Content
/ Mineral trioxide aggregate revisited: A cement for all seasons
/ The rationale and use of electronic apex locators
/ New endo program is established at University of Tennessee
/ X-Runner all-tissue ablative laser scanner
/ PIPS Laser Endo harnesses the power of the Lightwalker
/ Stropko Irrigator removes debris - making many procedures easier
/ Wykle Research expands its Calasept Endo line
/ Submissions
/ Imprint
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