roots C.E. No. 4, 2015
Cover / Editorial / Content / Endodontic diagnosis / Removing separated files with the Terauchi File Retrieval Kit / Looking back on AAE15 in Seattle / Wykle Research expands its Calasept Endo line / Imprint
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roots
International Edition • Vol. 6 • Issue 4/2015
issn 2161-6558
the international C.E. magazine of
4
endodontics
2015
_C.E. article
Endodontic diagnosis
_technique
Removing separated
files
_events
Looking back on
AAE15
[2] =>
[3] =>
editorial _ roots
I
It’s all about
saving teeth
As endodontists, we are heroes. That’s because we save teeth. What we do is important. If you are like me,
you not only find learning about new techniques and technology important, but you also enjoy it as well.
Perhaps you picked up this copy of roots at the Greater New York Dental Meeting — or maybe at one of
the many other meetings — and you are reading this on the plane home. That’s good, because this issue
includes many helpful articles. And they are fun to read, too!
Dr. Gerald N. Glickman offers a report on endodontic diagnosis, and Dr. L. Stephen Buchanan shares his
experience using the Terauchi File Retrieval Kit to remove separated files in his clinical practice. In addition,
Managing Editor Fred Michmershuizen looks back on the American Association of Endodontists annual
session, held earlier this year in Seattle. Were you there? It was a memorable event.
The article by Dr. Glickman, which originally appeared in AAE’s ENDODONTICS: Colleagues for
Excellence newsletter, is being made available in this issue of roots with the permission of the AAE. By
reading this article, and then taking a short online quiz 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.
You can also access the vast library of C.E. articles published in the AAE’s clinical newsletter by visiting
www.aae.org/colleagues.
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.
As always, I welcome your comments and feedback.
Sincerely,
Fred Weinstein, DMD, MRCD(C),
FICD, FACD
Fred Weinstein, DMD, MRCD(C), FICD, FACD
Editor in Chief
roots
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I content_ roots
page 10
page 06
I C.E. article
06
_Gerald N. Glickman, DDS, MS
I technique
10
I events
15 Looking back on AAE15
_Fred Michmershuizen, Managing Editor
I industry
Wykle Research expands its
Calasept Endo line
I about the publisher
19
the international C.E. magazine of
4
endodontics
2015
Removing separated files with the
Terauchi File Retrieval Kit
_L. Stephen Buchanan, DDS, FACD, FICD
18
roots
International Edition • Vol. 6 • Issue 4/2015
issn 2161-6558
Endodontic diagnosis
page 15
_imprint
page 15
04 I roots
4_ 2015
_C.E. article
Endodontic diagnosis
_technique
Removing separated
files
_events
Looking back on
AAE15
I on the cover
The images are of TrueTooth™ training replicas. Designed
by Dr. L. Stephen Buchanan and re-created by a 3-D
printer, these are authentic replicas of the internal and
external anatomy of CT-scanned extracted teeth, with
bleach-dissolvable material in the root canal passageways.
TrueTooth training replicas are available exclusively from
www.DELendo.com and are patent pending. (Image/
Provided by L. Stephen Buchanan, DDS, FICD, FACD)
page 15
page 18
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[6] =>
I C.E. article_ diagnosis
ENDODONTICS: Colleagues for Excellence
ave been a variety of diagnostic classification systems advocated for determining endodontic disease (1).
e majority of them have been based upon histopathological findings rather than clinical findings, often
, misleading terminology, and incorrect diagnoses (2). A key purpose of establishing a proper pulpal
osis is to determine what clinical treatment is needed (3, 4). For example, if an incorrect assessment is
r management may result. This could include performing endodontic treatment when it is not needed
tment or some other therapy when root canal treatment is truly indicated. Another important purpose
versal classification system is to allow for communication between educators, clinicians, students and
e and practical system which uses terms related to clinical findings is essential and will help clinicians
Author_Gerald N. Glickman, DDS, MS, MBA, JD
gressive nature of pulpal and periapical disease, directing them to the most appropriate treatment
ondition.
rican Association of Endodontists
held athere
consensus
to standardize
diagnostic
terms
used
_Historically,
have been aconference
variety of diagnosneeded to validate
the diagnostic
terms
established
_c.e.
credit
tic classification
systems advocated forregarding
determining endodontic
at the conference.
Both the AAE
and the American
The goals were to propose universal
recommendations
diagnoses;
develop
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1
endodontic disease. Unfortunately, the majority of Board of Endodontics have accepted these terms and
on of key
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them have been based upon histopathological findings recommend their usage across all dental disciplines
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age across
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Another important purpose of establishing a universal ated with current pulp testing modalities as well as
ues. In order to render properclassification
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tween educators, clinicians, students and researchers. In order to render proper treatment, a complete ennosis for each tooth evaluated.
Endodontic diagnosis
A simple and practical system that uses terms related dodontic diagnosis must include both a pulpal and a
to clinical findings is essential and will help clinicians periapical diagnosis for each tooth evaluated.
Diagnostic Procedures understand the progressive nature of pulpal and periapical disease, directing them to the most appropriate _Examination and diagnostic procedures
is is similar to a jigsaw puzzle—diagnosis
cannot
made from a single isolated piece of information
treatment approach
for eachbe
condition.
st systematically gather all of the
necessary
information
make a “probable”
diagnosis.
taking
In 2008,
the American
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Endodontic
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fromlogical
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1
4
nostic terms used in endodontics. The goals were to piece of information. The clinician must systematically
if there is a chief complaint. The
clinical and radiographic examinations in combination with a thorough
propose universal recommendations regarding endo- gather all of the necessary information to make a “probon and clinical testing (pulp and
tests)a are
then used
to confirm
the preliminary
donticperiapical
diagnoses; develop
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When taking thediagnosis
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arethat
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give conflicting
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in his
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mind a preliminary
but logical
diagnosis,
periapical diagnoses cannot be
made. It iseducators,
also important
to experts,
recognize
that
treatment
should
not be
third parties, generalists and other specialists, and especially if there is a chief complaint. The clinical and
diagnosis and in these situations,
the patient may have to wait and be reassessed at a later date or be
students; resolve concerns about testing and inter- radiographic examinations in combination with a
ontist.
pretation of results; and determine the radiographic thorough periodontal evaluation and clinical testing
criteria, objective test results, and clinical criteria (pulp and periapical tests) are then used to confirm
nology
American
ndodontists and the
of Endodontics (5-7)
)
Examination procedures required to make an endodontic diagnosis (8)
Medical/dental history
Past/recent treatment, drugs
Chief complaint (if any)
How long, symptoms, duration of pain, location, onset, stimuli, relief,
referred, medications
Clinical exam
Facial symmetry, sinus tract, soft tissue, periodontal status (probing,
mobility), caries, restorations (defective, newly placed?)
linical diagnostic category
Clinical testing:
p is symptom-free and
pulp tests
Cold, electric pulp test, heat
to pulp testing. Although
periapical tests
Percussion, palpation, Tooth Slooth (biting)
e histologically normal, a
Radiographic analysis
New periapicals (at least 2), bitewing, cone beam-computed tomography
pulp results in a mild or
by American
to thermal(Table/Provided
cold testing,
Additional tests
Transillumination, selective anesthesia, test cavity
Association of Endodontists)
one to two seconds after
ved. One cannot arrive at
roots
s without comparing
4_ 2015 the tooth in question with adjacent and contralateral teeth. It is best to test the
ontralateral teeth first so that the patient is familiar with the experience of a normal response to cold.
06 I
[7] =>
C.E. article_ diagnosis
Fig. 1
the preliminary diagnosis.4 In some cases, the clinical
and radiographic examinations are inconclusive or
give conflicting results, and as a result, definitive pulp
and periapical diagnoses cannot be made. It is also
important to recognize that treatment should not be
rendered without a diagnosis, and in these situations,
the patient may have to wait and be reassessed at a later
date or be referred to an endodontist.
_Diagnostic terminology approved by the
American Association of Endodontists
and the American Board of Endodontics5-7
Pulpal diagnoses9-14
Normal pulp is a clinical diagnostic category in
which the pulp is symptom-free and normally responsive to pulp testing. Although the pulp may not
be histologically normal, a “clinically” normal pulp
results in a mild or transient response to thermal
cold testing, lasting no more than one to two seconds
after the stimulus is removed. One cannot arrive at a
probable diagnosis without comparing the tooth in
question with adjacent and contralateral teeth. It is
best to test the adjacent teeth and contralateral teeth
first so that the patient is familiar with the experience
of a normal response to cold.
Reversible pulpitis is based upon subjective and
objective findings indicating that the inflammation
should resolve and the pulp return to normal following appropriate management of the etiology.
Discomfort is experienced when a stimulus such
as cold or sweet is applied and goes away within
a couple of seconds following the removal of the
stimulus. Typical etiologies may include exposed
dentin (dentinal sensitivity), caries or deep restorations. There are no significant radiographic changes
in the periapical region of the suspect tooth and the
pain experienced is not spontaneous. Following the
management of the etiology (e.g. caries removal plus
restoration; covering the exposed dentin), the tooth
requires further evaluation to determine whether the
“reversible pulpitis” has returned to a normal status.
Although dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity
mimic those of a reversible pulpitis.
Fig. 2
I
Fig. 3
Symptomatic irreversible pulpitis is based on
subjective and objective findings that the vital inflamed pulp is incapable of healing and that root canal
treatment is indicated. Characteristics may include
sharp pain upon thermal stimulus, lingering pain
(often 30 seconds or longer after stimulus removal),
spontaneity (unprovoked pain) and referred pain.
Sometimes the pain may be accentuated by postural
changes such as lying down or bending over and overthe-counter analgesics are typically ineffective. Common etiologies may include deep caries, extensive
restorations, or fractures exposing the pulpal tissues.
Teeth with symptomatic irreversible pulpitis may be
difficult to diagnose because the inflammation has
not yet reached the periapical tissues, thus resulting
in no pain or discomfort to percussion. In such cases,
dental history and thermal testing are the primary
tools for assessing pulpal status.
Asymptomatic irreversible pulpitis is a clinical
diagnosis based on subjective and objective findings
indicating that the vital inflamed pulp is incapable of
healing and that root canal treatment is indicated.
These cases have no clinical symptoms and usually
respond normally to thermal testing but may have
had trauma or deep caries that would likely result in
exposure following removal.
Pulp necrosis is a clinical diagnostic category indicating death of the dental pulp, necessitating root
canal treatment. The pulp is non-responsive to pulp
testing and is asymptomatic. Pulp necrosis by itself
does not cause apical periodontitis (pain to percussion or radiographic evidence of osseous breakdown)
unless the canal is infected. Some teeth may be nonresponsive to pulp testing because of calcification,
recent history of trauma, or simply the tooth is just
not responding. As stated previously, this is why all
testing must be of a comparative nature (e.g. patient
may not respond to thermal testing on any teeth).
Previously treated is a clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated
with various filling materials other than intracanal
medicaments. The tooth typically does not respond
to thermal or electric pulp testing.
Previously initiated therapy is a clinical diagnostic
category indicating that the tooth has been previ-
(Photos/Provided by American
Association of Endodontists)
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[8] =>
I C.E. article_ diagnosis
Fig. 4
Fig. 5
Fig. 6
ously treated by partial endodontic therapy such as
pulpotomy or pulpectomy. Depending on the level of
therapy, the tooth may or may not respond to pulp
testing modalities.
Apical diagnoses
Fig. 7
lesion representing a localized bony reaction to a
low-grade inflammatory stimulus usually seen at the
apex of the tooth.
_Diagnostic case examples
9-14
Normal apical tissues are not sensitive to percussion or palpation testing, and radiographically,
the lamina dura surrounding the root is intact and
the periodontal ligament space is uniform. As with
pulp testing, comparative testing for percussion and
palpation should always begin with normal teeth as
a baseline for the patient.
Symptomatic apical periodontitis represents
inflammation, usually of the apical periodontium,
producing clinical symptoms involving a painful
response to biting and/or percussion or palpation.
This may or may not be accompanied by radiographic
changes (i.e. depending upon the stage of the disease, there may be normal width of the periodontal
ligament or there may be a periapical radiolucency).
Severe pain to percussion and/or palpation is highly
indicative of a degenerating pulp and root canal
treatment is needed.
Asymptomatic apical periodontitis is inflammation and destruction of the apical periodontium
that is of pulpal origin. It appears as an apical radiolucency and does not present clinical symptoms (no
pain on percussion or palpation).
Chronic apical abscess is an inflammatory reaction to pulpal infection and necrosis characterized by
gradual onset, little or no discomfort and an intermittent discharge of pus through an associated sinus tract.
Radiographically, there are typically signs of osseous
destruction such as a radiolucency. To identify the
source of a draining sinus tract when present, a guttapercha cone is carefully placed through the stoma or
opening until it stops and a radiograph is taken.
Acute apical abscess is an inflammatory reaction
to pulpal infection and necrosis characterized by
rapid onset, spontaneous pain, extreme tenderness
of the tooth to pressure, pus formation and swelling
of associated tissues. There may be no radiographic
signs of destruction and the patient often experiences malaise, fever and lymphadenopathy.
Condensing osteitis is a diffuse radiopaque
08 I roots
4_ 2015
A mandibular right first molar had been hypersensitive to cold and sweets over the past few months
but the symptoms have subsided (Fig. 1). Now there
is no response to thermal testing and there is tenderness to biting and pain to percussion. Radiographically, there are diffuse radiopacities around the root
apices. Diagnosis: Pulp necrosis; symptomatic apical
periodontitis with condensing osteitis. Non-surgical
endodontic treatment is indicated followed by a
build-up and crown. Over time the condensing osteitis should regress partially or totally.15
Following the placement of a full gold crown on
the maxillary right second molar, a patient complained of sensitivity to both hot and cold liquids;
now the discomfort is spontaneous (Fig. 2). Upon
application of Endo-Ice® on this tooth, the patient
experienced pain and upon removal of the stimulus,
the discomfort lingered for 12 seconds. Responses
to both percussion and palpation were normal;
radiographically, there was no evidence of osseous
changes. Diagnosis: Symptomatic irreversible pulpitis; normal apical tissues. Non-surgical endodontic
treatment is indicated; access is to be repaired with
a permanent restoration. Note that the maxillary
second premolar has severe distal caries; following
evaluation, the tooth was diagnosed with symptomatic irreversible pulpitis (hypersensitive to cold,
lingering eight seconds); symptomatic apical periodontitis (pain to percussion).
A maxillary left first molar has occlusal-mesial
caries and the patient has been complaining of sensitivity to sweets and to cold liquids (Fig. 3). There is
no discomfort to biting or percussion. The tooth is
hyper-responsive to Endo-Ice with no lingering pain.
Diagnosis: reversible pulpitis; normal apical tissues.
Treatment would be excavation of the caries followed
by placement of a permanent restoration. If the pulp
is exposed, treatment would be non-surgical endodontic treatment followed by a permanent restoration such as a crown.
A mandibular right lateral incisor has an apical
[9] =>
C.E. article_ diagnosis
radiolucency that was discovered during a routine
examination (Fig. 4). There was a history of trauma
more than 10 years ago and the tooth was slightly
discolored. The tooth did not respond to Endo-Ice or
to the EPT; the adjacent teeth responded normally to
pulp testing. There was no tenderness to percussion
or palpation in the region. Diagnosis: pulp necrosis;
asymptomatic apical periodontitis. Treatment is
non-surgical endodontic treatment followed by
bleaching and permanent restoration.
A mandibular left first molar demonstrates a
relatively large apical radiolucency encompassing
both the mesial and distal roots along with furcation
involvement (Fig. 5). Periodontal probing depths were
all within normal limits. The tooth did not respond
to thermal (cold) testing and both percussion and
palpation elicited normal responses. There was a
draining sinus tract on the mid-facial of the attached
gingiva that was traced with a gutta-percha cone.
There was recurrent caries around the distal margin
of the crown. Diagnosis: pulp necrosis; chronic apical
abscess. Treatment is crown removal, non-surgical
endodontic treatment and placement of a new crown.
A maxillary left first molar was endodontically
treated more than 10 years ago (Fig. 6). The patient
is complaining of pain when biting over the past
three months. There appear to be apical radiolucencies around all three roots. The tooth was tender to
both percussion and to the Tooth Slooth®. Diagnosis:
previously treated; symptomatic apical periodontitis.
Treatment is nonsurgical endodontic retreatment followed by permanent restoration of the access cavity.
A maxillary left lateral incisor exhibits an apical
radiolucency (Fig. 7). There is no history of pain and
the tooth is asymptomatic. There is no response to
Endo-Ice or to the EPT, whereas the adjacent teeth respond normally to both tests. There is no tenderness
to percussion or palpation. Diagnosis: pulp necrosis;
asymptomatic apical periodontitis. Treatment is
nonsurgical endodontic treatment and placement of
a permanent restoration._
_References
1.
2.
3.
4.
5.
6.
Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
Seltzer S, Bender IB, Ziontz M. The dynamics of pulp
inflammation: correlations between diagnostic data and
actual histologic findings in the pulp. Oral Surg Oral Med
Oral Pathol 1963;16:846-71;969-977.
Berman LH, Hartwell GR. Diagnosis. In: Cohen S, Hargreaves
KM, eds. Pathways of the Pulp, 11th ed. St. Louis, Mo.:
Mosby/Elsevier; 2011:2-39.
Schweitzer JL. The endodontic diagnostic puzzle. Gen Dent
2009; Nov/Dec. 560-567.
AAE Consensus Conference Recommended Diagnostic
Terminology. J Endod 2009;35:1634.
American Association of Endodontists. Glossary of
Endodontic Terms. 8th ed. 2012.
I
7.
Glickman GN, Bakland LK, Fouad AF, Hargreaves KM,
Schwartz SA. Diagnostic terminology: report of an online
survey. J Endod 2009;35:1625.
8. Abbott PV, Yu C. A clinical classification of the status of the
pulp and the root canal system. Aust Dent J 2007;52 (Endod
Suppl):S17-31.
9. Jafarzadeh H, Abbott PV. Review of pulp sensibility tests.
Part 1: general information and thermal tests. Int Endod J
2010;43:738-762.
10. Jafarzadeh H, Abbott PV. Review of pulp sensibility tests.
Part II: electric pulp tests and test cavities. Int Endod J
2010;43:945-958.
11. Newton CW, Hoen MM, Goodis HE, Johnson BR, McClanahan
SB. Identify and determine the metrics, hierarchy, and
predictive value of all the parameters and/or methods used
during endodontic diagnosis. J Endod 2009;35:1635.
12. Levin LG, Law AS, Holland GR, Abbot PV, Roda RS. Identify
and define all diagnostic terms for pulpal health and disease
states. J Endod 2009;35:1645.
13. Gutmann JL, Baumgartner JC, Gluskin AH, Hartwell GR,
Walton RE. Identify and define all diagnostic terms for
periapical/periradicular health and disease states. J Endod
2009;35:1658.
14. Rosenberg PA, Schindler WG, Krell KV, Hicks ML, Davis
SB. Identify the endodontic treatment modalities. J Endod
2009;35:1675.
15. Green TL, Walton RE, Clark JM, Maixner D. Histologic
examination of condensing osteitis in cadaver specimens. J
Endod 2013; 39:977-979.
This article originally appeared in ENDODONTICS:
Colleagues for Excellence, Fall 2013. Reprinted with
permission from the American Association of Endodontists, ©2013. The AAE clinical newsletter is available at www.aae.org/colleagues.
_about the author
roots
Gerald N. Glickman is professor and chair of the Department of Endodontics and director of graduate endodontics at Texas A&M University
Baylor College of Dentistry
in Dallas. He received an MS
degree in microbiology from
the University of Kentucky,
a DDS from the Ohio State
University, a GPR certificate
from the University of Florida,
a certificate and MS in endodontics from Northwestern
University, an MBA from Southern Methodist University and
a JD from Texas A&M University. He is past president of the
American Board of Endodontics, the American Association of
Endodontists and the American Dental Education Association. He is a fellow of both the American College of Dentists
and the International College of Dentists. He is also a founding
member of the Commission for Change and Innovation in
Dental Education (CCI). He maintains a part-time practice
limited to endodontics in Dallas.
roots
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_ 2015
[10] =>
I technique_ file separation
Removing separated
files with the Terauchi
File Retrieval Kit
Author_L. Stephen Buchanan, DDS, FACD, FICD
Fig. 1_The Terauchi File Retrieval
Kit. (Photos/Provided by L. Stephen
Buchanan, DDS, FICD, FACD)
Fig. 2_TFRK ultrasonic
Micro-Spoon Tip.
Fig. 3_TFRK ultrasonic Spear Tip.
_I once asked my good friend Dr. Yoshi Terauchi
how many canals he shaped with a given nickel titanium rotary file before discarding it and bringing a
new file into the procedure. He answered, “I use rotary
files until they break, I remove the broken segment
and then get a new file.” WHAT? I thought to myself
as I looked at him like he had two heads. This blew my
mind because, for me, any practice day that includes
the occurrence of “Short File Syndrome” is a really
bad day in the life of most any dentist who provides
RCT services to patients. I skeptically asked him how
he could say that with a straight face, and he told me
that it only takes him one to five minutes to remove
most any separated file from a root canal.
So now I have heard two different and appar-
ently ridiculous statements from Yoshi; first, that
he does not fear file breakage, and secondly, that
he considers the retrieval of broken files to be a
predictable procedure requiring relatively little time
to accomplish. REALLY? Fortunately, knowing Yoshi
for years allowed me to suspend disbelief about
these outrageous statements long enough to query
him for an explanation. And what he told me turned
all of what I supposedly “knew” about file retrieval
on its head.
These popular myths included:
1. Ultrasonic tips should trough the outside-ofthe-curvature canal wall.
2. Ultrasonic tips work best dry when attempting
file retrieval.
Fig. 2
Fig. 1
Fig. 3
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4_ 2015
[11] =>
[12] =>
I technique_ file separation
Fig. 4
Fig. 5
Fig. 6
Fig. 4_TFRK Micro-Lasso
(Yoshi Loop).
Fig. 5_Close-up of Yoshi Loop
cannula pre-bent for insertion
into a canal.
Fig. 6_Yoshi Loop after retrieving
a file fragment.
3. File segments that have been loosened with
ultrasonic vibration are nearly removed.
4. Retrieving broken file segments necessitates
weakening of the tooth.
5. Files segments cannot be removed from the
apical third of a curved canal.
Here are the critical truths about removing separated files, most of them discovered by Yoshi, and the
Terauchi File Retrieval Kit (TFRK) he has designed to
accomplish this previously challenging procedure
(Fig. 1).
_Troughing the canal wall on the inside
of the curve
Perhaps the greatest paradigm shift in my thinking on this subject circled around where we should
work ultrasonic tips next to the fractured surface of
the file segment. It seems logical to trough the canal
wall on the outside of its curvature, because that is
where the fractured edge is engaged. The counterintuitive truth, as explained to me by Yoshi, is that
troughing on the outside of the canal curve doesn’t
work because: a) troughing that wall increases the
curvature of the canal, while cutting the inside-ofthe-curve canal wall straightens the canal, and b)
activating the ultrasonic tip on the outside-of-thecurve wall hammers the file segment and actually
moves it farther into the canal. When Yoshi first explained this to me, I got the dumb chills. Troughing
12 I roots
4_ 2015
on this side of a canal requires his small ultrasonic
tip ends to be bent, without kinking, so they can slide
down the inside of the curve, but what a difference
it makes to do it this way.
Yoshi has designed two beautiful Micro-Spoon
Tips (Fig. 2) that he uses to cut a trough between
the file and the inside of the curve. The two MicroSpoon Tips in the TFRK face toward (the 6 o’clock
tip) and away from (the 12 o’clock tip) the ultrasonic
handpiece and are chosen relative to the direction
of the canal curvature and the position the handpiece will be in while the tip is used to cut a trough
on the inside canal curvature, adjacent to the file
segment.
All the ultrasonic tips in the TFRK are made of
ductile stainless steel and they are extremely elongate, making them easy to pre-bend but susceptible
to premature breakage if not used correctly. The
appropriate power setting for use of these tips
is typically in the lower quarter of the ultrasonic
unit’s power range and must be activated intermittently by tapping the foot control rather than in
continuous mode. Intermittent switching keeps
the tips from overheating and sends a relatively
powerful ripple through the long, thin instruments.
After two or three pulses, the tips are removed and
examined for derangement, they are cooled and
cleaned with a wet alcohol 2-by-2 sponge, and are
then replaced for further work until the file is loosened. Working ultrasonic tips next to file segments
with continuous use rather than pulsed activation
also increases the risk of breaking the file segment
into smaller pieces.
_Cutting dry but ejecting file segments
wet
Dentists typically use ultrasonic tips without water spray so that the tip can be seen as it works, and
this is how the TFRK tips should be used until the file
segment has been loosened. However, once the file
segment has been loosened, it can be quite difficult
to get it to come out of the canal unless 17 percent
EDTA solution is added to the canal and a TFRK Spear
tip (Fig. 3) is used in a push-pull manner, again, between the file segment and the inside-of-the-curve
canal wall.
The Spear Tips are extremely thin and sharp at
their tip ends — a necessity for them to further
vibrate file segments, yet allow space for the file
segment to escape between the Spear Tip and the
canal diameter at the level of separation. While
they are manufactured to a fine point, it is recommended by Yoshi that the latch-grip rubber
polishing point included in the TFRK be used to
further thin and sharpen the Spear Tips before and
between uses as they will dull with use, rendering
[13] =>
technique_ file separation
I
them too large at their ends to allow the file to
escape when vibrated.
Having never considered removal of a file segment with fluid in the canal, I am still amazed at the
difference this makes to the outcome. Most of the
time the file segment simply disappears from the
canal, having shot out at high speed, sometimes
landing on the rubber dam outside the tooth.
_File length as a predictor of retrieval
The third critical issue influencing file retrieval
that Yoshi has figured out is that the length of the
file segment is actually more important than its
position in the canal. He has determined, through
experimentation done in extracted teeth and proven
in patient’s teeth, that the length of the broken file
segment influences the difficulty of its removal; that
file segments greater in length than 4.3 mm will often
require more than Micro-Spoons and Spear-shaped
ultrasonic tips to eject them from the canal.
Early in the development of his technique, after
Yoshi realized the importance of file segment length,
he would intentionally break separated files longer
than 4.3 mm by using higher power settings and
more continuous activation of an ultrasonic tip.
Unfortunately, this caused more frequent breakage
of ultrasonic tips and required another trough to be
cut farther into the canal to loosen and remove the
remaining, most apical portion of the separated file
after the more coronal segment had been removed.
It was the search of a better solution to this conundrum that inspired him to invent what I call the
Yoshi Loop (Figs. 4-6), a stainless steel micro-lasso
that extends from the end of a stainless steel cannula
attached to a handle with a retraction button for
tightening the Loop around a loosened file segment.
Like the ultrasonic tips, the Yoshi Loop is small, fragile,
and easily broken when misused, but a larger tool will
never retrieve a file segment from a canal.
Also, it must be carefully prepared before attempting to encircle a previously loosened file segment. The red retraction button is moved forward to
extend the wire lasso, a DG-16 explorer tip is placed
inside the lasso, and the retraction button is then
carefully pulled backward until the loop is felt to
tighten on the explorer tine, thus rounding the loop
so that it may be placed around the end of the file
segment. Before removing the explorer from the
Loop, it is rotated back to near parallel to the cannula
to bend the rounded Loop to a 45-degree angle. This
rounded, angled Loop wire is then ideally formed to
drop around the end of the file segment as it is moved
into position (Figs. 7a-d).
Once the Loop wire is felt to tighten around the file
segment, it is carefully tugged in several directions
until the file is pulled out of the canal (Fig. 8). If, as of-
Fig. 7a
Fig. 7b
Fig. 7c
Fig. 7d
Fig. 8
Fig. 9
ten happens, the wire lasso slips off the file segment, Figs. 7a-d_a) DG-16 explorer tip
it is simply removed from the canal, reformed, placed placed into wire loop; b) wire loop
back over the file segment and tightened once again. is tightened and rounded on the
_Developing adequate coronal canal
shape without weakening the root
explorer tine; c) explorer is rotated to
bend the formed loop to 45 degrees;
d) loop rounded and angled, ready to
capture a file segment that has been
loosened but will not come out of
the canal.
When file segments are below the orifice level, a
staging preparation to the broken file end is usually
required and is accomplished with the TFRK Modified
#3 Gates Glidden bur (Fig. 8) at 1000 RPM clockwise, Fig. 8_TFRK GGB-3M bur.
then the TFRK Micro-Trephine bur (Fig. 9) at 600 RPM
rotating in a counter-clockwise direction, so as to en- Fig. 9_ TFRK Micro-Trephine bur.
courage a bound file segment to reverse thread back
roots
4
_ 2015
I 13
[14] =>
I technique_ file separation
coronally and loosen. If the file segment is around
a curve in the canal, the TFRK includes a 70-.12 GT
Accessory File to create a better, more straight-line
visual access to the file segment. All three of these
instruments have tip diameters of 0.7mm, a very safe
size to cut a staging preparation through coronal root
structure to the separated file segment.
_Removal of file segments beyond the
middle third of the canal
This is where my experience level is still developing, and I usually refer clinicians to Yoshi’s Facebook
page for review of his cases or advice about their own
cases, and as such I will leave this to our own god of
file retrieval. There are several YouTube videos of his
simple and more difficult cases, and I find them an
excellent review before tackling my next challenge in
the art of file retrieval — a skill that I never expected to
master at the level he has brought me so far.
In my own experience, understanding Yoshi’s
concepts of file retrieval made it possible to
remove broken files — mine and other’s — that I
would have never expected to be possible. Using
the tiny, elegant tools in the Terauchi File Retrieval
Kit have made it a wonderfully predictable proceAD
14 I roots
4_ 2015
_about the author
roots
L. Stephen Buchanan, DDS,
FACD, FICD, is a diplomate
of the American Board of
Endodontics, a fellow of the
American and International
Colleges of Dentists and
serves as part-time faculty
to the UCLA and USC graduate endodontic programs. He
holds patents on the Endobender Plier (SybronEndo),
System-B and Continuous
Wave obturation tools and methods (SybronEndo), GT and
GTX file systems (DENTSPLY Tulsa Dental Specialties), LA
Axxess Burs (SybronEndo), and Buc ultrasonic tips (Spartan/
Obtura). Buchanan lives in Santa Barbara, Calif., where he
enjoys a practice limited to conventional and microsurgical
endodontics and dental implant surgery. He is the founder of
Dental Education Laboratories, a hands-on training facility in
Santa Barbara that he has directed for 28 years.
dure to have in my bag of endodontic tricks.
For further information about the TFRK, visit
Dental Education Laboratories at delendo.com and
DentalCadre — the provider of Terauchi’s TRFK — at
dentalcadre.com._
[15] =>
events_ AAE15
I
Looking back on
AAE15 in Seattle
Author_Fred Michmershuizen, Managing Editor
_AAE15, the annual meeting of the American
Association of Endodontists, took place May 6-9 in
Seattle. The event, billed by the association as “the
most comprehensive endodontic education summit,
vendor exhibition and networking opportunity in the
world,” was held in the heart of downtown, at the
Washington State Convention Center.
Michio Kaku, PhD, offered the keynote address.
Consistent with the meeting’s future-looking theme,
Kaku, author of “The Future of the Mind,” shared his
vision for the future of science and technology.
In his opening remarks, AAE President Robert S.
Roda told attendees, “If we’re going to shape the
future, we need an organization that can study, that
can learn and that can act.” Roda recapped the accomplishments of the association during his term,
including environmental-scanning and quality improvement projects that are helping the AAE prepare
for the future of the specialty.
The meeting offered more than 100 educational
sessions in a variety of tracks, including “Future
Directions on Nonsurgical Root Canal Treatment,”
“Surgical Endodontics — What Lies Ahead” and
“Where Will Biology and Technology Take Endodontics.” Attendees also had the opportunity to partake
in hands-on workshops featuring leading experts in
microsuturing, cone-beam computed technology
and resorption.
AAE15 included the largest endodontic exhibit
hall in the world, with nearly 100 vendors offering
the latest in endodontic equipment, materials and
supplies.
Essential Dental Systems (EDS) showcased its
new endodontic system, Tango-Endo. It’s named
that way because with Tango-Endo, it only takes
two instruments, according to EDS. The instruments
have a unique, patented flat along the entire length,
designed for faster engagement with less resistance
and increased flexibility without sacrificing strength.
CJM Engineering, a first-time exhibitor at AAE,
presented its Munce Discovery Burs, which are designed to deal with calcified canals, uncover hidden
From left: Michio Kaku, PhD, offers
the keynote address at AAE15;
Tom Bender of Wykle Research;
a hands-on demonstration of
the GentleWave system at the
Sonendo booth. (Photos/Fred
Michmershuizen, Managing Editor)
roots
4
I 15
_ 2015
[16] =>
I events_ AAE15
Top row, from left: Dr. Robert S.
Roda, president of the AAE, offers
his remarks during the President’s
Breakfast; a lecturer presents an
educational session on the exhibit
hall floor; the Washington State
Convention Center.
Bottom row, from left: Fun at the
EdgeEndo booth; Hiroyuki Ogiwara,
Akihiro Shinozaki, Kazuaki Katoh and
Koichi Arakawa of Mani Inc., with a
copy of roots magazine; Dr. Robert
Sherman of Jacksonville, N.C.
16 I roots
4_ 2015
canals, and to trough the isthmus and cement-line
dissection around posts. According to the company,
the long, narrow yet stiff shafts are designed to provide an excellent view corridor and ensure positive
control, with the familiar tactile feedback of round
burs. The carbide tips enable post-core out and broken or cross-threaded implant screw drill-out.
Roydent Dental Products offered its wideranging armamentarium, including its 2Seal easymiX
Root Canal Sealer, an easy-to-use, auto-mix epoxy
resin sealer, which was recently re-launched in newly
branded packaging. “2Seal easymiX is a safe and ideal
way for doctors to achieve one-handed dispensing
and precise placement in the canal. It is also extremely
radiopaque and biocompatible,” said Nancy Connor,
sales and marketing manager.
At its booth, Sonendo conducted more than 200
demonstrations of its GentleWave technology and
showed how it can provide what the company calls
“unprecedented” root canal cleaning and disinfection when compared to conventional NiTi files and
irrigation. Sonendo’s GentleWave system features
a proprietary technology, known as Multisonic
Ultracleaning, which has been tested clinically
in hundreds of cases and is shown to clean the
entire root canal system regardless of complexity.
Sonendo’s GentleWave technology results in the
removal of bacteria, biofilm and smear layer in a
single visit, which also helps reduce the need for
retreatment, according to the company.
In addition to the in-booth presentations,
Sonendo sponsored a number of educational presentations. Dr. Joseph Maggio offered “A New Paradigm
in Endodontic Therapy: GentleWave,” a corporate
workshop presented on the exhibit hall floor. In the
lecture halls, Dr. Karine Charara presented “Safety
of the Novel GentleWave System Evaluated in a
Simulated Apical Environment.” Dr. Brandi L. Molina
presented “Histological Evaluation of Root Canal Debridement of the GentleWave System in Root Canal
Systems of Human Molars,” and Bettina Basrani of
the University of Toronto presented “NSRCT – Irrigation: Past, Present, Future?”
Sonendo held its second 5K Charity Run/Walk, cosponsored by AAE. Proceeds benefited Fisher House,
a home away from home for families of hospitalized
active-duty military personnel and veterans. To get
participants pumped up for the early morning run,
Rachel L. Engler, MS, CRNA, a lieutenant commander
in the Navy Nurse Corp Reserve, led a warm-up.
In her first remarks as the new president of AAE, Dr.
Terryl A. Propper said she hopes to increase engagement and involvement in the association by the next
generation of endodontists. “I want to inspire a process that will yield effective change for our members
and our specialty,” she said.
The 2016 AAE meeting will be held April 6-9 in San
Francisco._
[17] =>
[18] =>
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
18 I roots
4_ 2015
[19] =>
about the publisher _ imprint
I
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
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
President/Chief Executive
Officer
Eric Seid
e.seid@dental-tribune.com
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
Managing Editor
Robert Selleck
r.selleck@dental-tribune.com
Education Director
Christiane Ferret
c.ferret@dtstudyclub.com
Business Development Manager
Travis Gittens
t.gittens@dental-tribune.com
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Product/Account Manager
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m.kaiser@dental-tribune.com
Product/Account Manager
Will Kenyon
w.kenyon@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,
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Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert
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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
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Tribune America does not accept the submission of unsolicited books and manuscripts in printed or electronic form and such items will
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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
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roots
4
I 19
_ 2015
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