Endo Tribune UK No. 1, 2017
Cleaning is key / Irrigating the root canal: A case report / “The immense variability of human tooth anatomy” / ROOTS SUMMIT: Registration open for 2018 edition
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Untitled
ENDOTRIBUNE
The World’s Endodontic Newspaper · United Kingdom Edition
www.dental-tribune.co.uk
Published in London
Vol. 11, No. 9
CASE REPORT
INTERVIEW
ROOTS SUMMIT
Dr Vittorio Franco explains treatment of a 22-year-old male patient with a history of trauma to
his maxillary incisors.
Dental Tribune spoke with Dr
Craig Barrington, USA, about his
technique for capturing high-definition endodontic images.
Everything to know about the
most important international
event in endodontics in 2018.
” Page 20
” Page 22
is coming to
BERLIN
28 June –1 July 2018
” Page 23
Berlin, Germany
www.ROOTS-SUMMIT.com
Cleaning is key
By Aws Alani, UK
Completely disinfecting the canal
system is challenging when all factors are considered. If we are looking at the nano level there are approximately 76,000 dentinal tubules per square millimetre of dentine. Each of which can harbour a
colony of bacteria. Then there may
be inaccessible anatomy such as
lateral canals, apical deltas or fins.
in combination with hand filing
significantly reduced bacterial
load. As such chemomechanical
instrumentation was shown to be
crucial for endodontic success.
They compared irrigation with saline, 0.5 and 5 % hypochlorite over
a sequence of 5 appointments. Interestingly they found no difference in the reduction of bacterial
It seems that irrigation and instrumentation are both highly inter-related in canal disinfection.
Take washing your car for instance, purely covering it with
soapy water and rinsing won’t remove the motorway bugs and bird
produced projectiles. A good
scrubbing with a sponge is needed,
or if you are really serious about
from the dentine. The smear layer
prevents bacteria residing in the
dentinal tubules from being exposed to the irrigant as well as reducing the contact between the
dentine and sealant during obturation. Hence, utilising EDTA to
remove the smear layer prior
to obturation but after completion
of preparation and instrumenta-
© Dzmitry Held/Shutterstock.com
housing the community of microorganisms. They not only share resources, they also share information that promote each other’s survival through RNA or DNA. As the
majority of bacteria will be encapsulated in this layer, purely irrigating without disrupting this layer is
inefficient. The word disrupting is
a bit kind really—it needs to be destroyed to reveal all its contents
and expose it to the bleach for
chemical action. It is the methods
of disruption of the canal biofilm
that has seen a lot of development
over the last 10 years or so. Much
in the same way a pressure washer
can clean that more quickly and efficiently than a sponge, energising
the disinfectant results in improved cleanliness.
Energising the irrigant
This can take many forms. The
simple and straightforward form
ensures appropriate exchange of
the fluid and displacement into
the recesses where airlocks may reside. This can be achieved through
applying a GP point into the prepared canal to displace and disperse.
These are factors that need considering outside of canal curvatures
that may or may not be entirely visible in the plane of the radiograph.
It is clear that outside of the contact
our files make with the walls of the
root canal there needs to be chemical disinfection to further reduce
bacterial load. Irrigants disinfect as
well as lubricate instruments and
they dissolve the pulp. Sodium
hypochlorite has been the mainstay
irrigant for decades.
During the 1980s, Bystrom
and colleagues investigated the effect of mechanical instrumentation with and without adjunctive
use of hypochlorite. They found,
unsurprisingly so, that when compared to pure mechanical instrumentation, the use of hypochlorite
load between 0.5 and 5 % hypochlorite. Despite what was likely
to be a comprehensive protocol
for these teeth, 7 of the 15 specimens in this study still had bacteria that they could grow at the end
of treatment. The presence of cultivable bacteria does not necessarily mean we have failure—it
merely means that there may be a
cohort of bacteria that have resisted treatment. Mechanical instrumentation does reduce bacterial load by itself—this is by way of
physical removal of tissues where
bacteria reside, while also facilitating the dispersal of the irrigant
into the canal. Siquiera and colleagues found that enlarging the
canal from size 30 to 40 resulted in
a significant decrease in endodontic pathogens.
cleaning, a pressure washer! This
begs a further question—how
would your patients feel if they
knew that, more or less, the same
or very similar liquid they use to
clean bathroom suites is the same
that we use to clean the inside of
their teeth? On recent evidence of
a dentist to the “stars” appearance
on national TV not much—he advocated using charcoal to whiten
teeth, which you may be able to
buy from your local petrol station
for barbecues.
Hypochlorite is an effective
bactericidal but does not remove
the smear layer. The smear layer is
a mix of organic material (protein,
pulp remnants, saliva, microorganisms) with an inorganic components consisting of minerals
tion is sensible. A penultimate
rinse with EDTA then a final rinse
with hypochlorite prior to drying
has been advocated heavily in the
literature.
Bacteria
and the biofilms
Unlike what we once thought,
bacteria do not tend to just sit
alone and remote from each other.
If only they were this antisocial
and could be picked off one by
one! Bacteria join forces and create
symbiotic groups, share resources
and protect each other from external influence. This is commonly
known as a “biofilm”, which has a
thin but robust layer of mucilage
that adheres to a solid surface
Ultrasonic irrigation transmits
energy by an oscillating instrument. This results in two different
phenomena. Cavitation is the
growth and subsequent collapse
of small gas bubbles due to a drop
in pressure. Acoustic streaming is
the bulk movement of fluid when
pressure waves are projected, resulting in vortex motion around a
fast moving oscillating instrument. This results in shear stresses
to tear the biofilm apart.
Keeping
the canal clean
Once irrigated and prepared,
the clinician has a choice—to obturate or to dress. Some may argue
that the canal is cleanest at the end
of instrumentation and that for
convenience, obturating in a one
visit arrangement is the best option. As we know, not all bacteria
are removed or killed during treatment. Dressing the canal with calcium hydroxide may continue the
[2] =>
Untitled
ENDO NEWS
18
process of eradication of the residual microorganisms over a 2-week
period. The choice between the
two schemes sometimes boils
down to the presenting factors of
the case. Where a tooth is difficult
to instrument, has a large lesion or
is quite obviously chronically infected with a history of pain, then
dressing may be more of a consideration. If a tooth is treated in a de
novo manner and treatment goals
are achieved with no history of
pain then a single visit treatment
could be utilised.
eign body reaction could also develop.
The goal of obturation is to
seal the canal system to prevent
any reinfection and entomb any
bacteria not eradicated by chemomechanical debridement. If the
obturation is through the apex,
this can have significant implications. GP through the apex can
carry bacteria outwith of the canal
and exacerbate symptoms. A for-
We also have to remember that
a beautiful obturation of a canal
achieved without rubber dam and
utilising saline or local anaesthetic
irrigation is sub-standard treatment. It can be difficult to assess
the “quality” of treatment when a
radiograph of a “failed” tooth is examined in this context. Indeed, an
obturation that is short of the radi-
Endo Tribune United Kingdom Edition | 9/2017
ographic apex having been treated
under rubber dam and with copious amounts of irrigation is more
likely to be successful than the previous scenario. Attributing too
much significance to the radiographic appearance of the obturation is short-sighted. Indeed,
Katebzadeh and colleagues in the
late ‘90s witnessed healing in the
absence of obturation where teeth
were instrumented and irrigated
optimally under isolation. Seal-
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ants are also antibacterial and aide
filling the voids between the
GP and the canal system. One
further option would be to provide a sub-seal to each of the canal
orifices. This can be achieved by removal of 1 mm of GP and packing
a good thick mix of IRM packed
with a plugger.
Covering the cusps
The provision of a coronal restoration (if provided optimally)
can improve the coronal seal while
also structurally protecting the
underlying tooth tissue. Due to endodontic treatment, resulting in
reduction of tissue bulk and stiffness the risk of fracture increases.
Where both mesial and distal margins have not been breached and
the access cavity is confined to the
occlusal surface, a crown restoration may not be required. Once a
margin is breached the tooth is
more likely to flex and result in
cracks or fractures. A commonly
asked question, “When should the
crown be provided? Soon after the
root canal treatment or when the
treatment has proven to be successful?”If the success of endodontic treatment is significantly in
doubt then this should be communicated to the patient and a well
compacted direct restoration may
be the best option, otherwise an
onlay or if tooth tissue is significantly reduced, a crown should be
provided soon after completion.
Conclusion
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Bacteria are public enemy
number one in dentistry. Disinfecting the root canal system by irrigating in combination with mechanical instrumentation is key to
success in root canal therapy. Preventing further re-infection or
persistence of residual bacteria after the formal stages of treatment
through dressing initially and a
quality coronal seal subsequently
is as important as the root canal
therapy.
Editorial note: Aws Alani is leading
a two-year postgraduate diploma
in operative dentistry at King’s College London Dental Institute
www.restorativedentistry.org.
More information is available
online at www.kcl.ac.uk/study/
postgraduate/taught-courses/
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UK. He can be contacted at awsalani@
hotmail.com.
www.restorativedentistry.org
[3] =>
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is coming to
BERLIN
28 June –1 July 2018
Berlin, Germany
www.ROOTS-SUMMIT.com
[4] =>
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ENDO TRENDS
20
Endo Tribune United Kingdom Edition | 9/2017
Irrigating the root canal: A case report
By Dr Vittorio Franco, UK and Italy
The patient reported on in this article
is a student in dentistry and his parents are both dentists. They referred
their son to a good endodontist, who
then referred the case to me. As always, peers are more than welcome
in either of my practices, in Rome and
London, so when I treated this case, I
had three dentists watching me, a future dentist on the chair, placing a
great deal of pressure on me.
The 22-year-old male patient
had a history of trauma to his
maxillary incisors and arrived at
my practice with symptoms related to tooth #21. The tooth,
opened in an emergency by the
patient’s mother, was tender when
prodded, with a moderate level of
sensitivity on the respective buccal gingiva. Sensitivity tests were
negative for the other central inci-
sor (tooth #12 was positive), and a
periapical radiograph showed radiolucency in the periapical areas
of both of the central incisors. The
apices of these teeth were quite
wide and the length of teeth appeared to exceed 25 mm.
My treatment plan was as follows: root canal therapy with two
apical plugs with a calcium sili-
cate-based bioactive cement. The
patient provided his consent for
the treatment of the affected tooth
and asked to have the other treated
in a subsequent visit.
was immediately evaluated using
an electronic apex locator and a
31 mm K-type file. The working
length was determined to be
28 mm.
After isolating with a rubber
dam, I removed the temporary filling, and then the entire pulp
chamber roof with a low-speed
round drill. The working length
As can been seen in the photographs, the canal was actually
quite wide, so I decided to only use
an irrigating solution and not a
shaping instrument. Root canals
are usually shaped so that there
will be enough space for proper irrigation and a proper shape for obturation. This usually means giving these canals a tapered shape to
ensure good control when obturating. With open apices, a conical
shape is not needed, and often
there is enough space for placing
the irrigating solution deep and
close to the apex.
I decided to use only some syringes containing 5 per cent sodium hypochlorite and EDDY, a
sonic tip produced by VDW, for delivery of the cleaning solution and
to promote turbulence in the endodontic space and shear stress on
the canal walls in order to remove
the necrotic tissue faster and more
effectively. After a rinse with sodium hypochlorite, the sonic tip
was moved to and from the working length of the canal for 30 seconds. This procedure was repeated
until the sodium hypochlorite
seemed to become ineffective, was
clear and had no bubbles. I did not
use EDTA, as no debris or smear
layer was produced.
I suctioned the sodium hypochlorite, checked the working
length with a paper point and then
obturated the canal with a of 3 mm
in thickness plug of bioactive cement. I then took a radiograph before obturating the rest of the canal with warm gutta-percha. I used
a compomer as a temporary filling
material.
The symptoms resolved, so I
conducted the second treatment
only after some months, when the
tooth #11 became tender. Tooth
#21 had healed. I performed the
same procedure and obtained the
same outcome (the four-month
follow-up radiograph showed
healing).
Dr Vittorio Franco is an endodontist
who runs an endodontic referral practice in Rome and a practice in London.
An active member of the European Society of Endodontology, Franco is also the
President-elect of the Italian Society of
Endodontics.
[5] =>
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ENDO TRENDS
22
Endo Tribune United Kingdom Edition | 9/2017
“The immense variability of human
tooth anatomy”
An interview with Dr Craig Barrington about his technique for capturing high-definition endodontic images
With his high-definition photography of complex root canal systems,
Dr Craig Barrington, who practices
dentistry in Waxahachie, Texas, is
developing quite a name for himself. Just check out his presence on
Facebook, at craiggbarringtondds.
In an interview with DT America,
Barrington talks about how he captures these high-definition endodontic images and how he uses
them to increase his knowledge
and help improve the level of care
he provides to his patients.
Please tell our readers a little bit
about yourself and your dental
practice.
Dr Craig Barrington
I graduated Summa Cum
Laude from the University of
Texas Health Science Center in San
Antonio in 1996. I am a general
dentist in Waxahachie, Texas.
I have been in my current location
for 20 years.
What do you like best about practicing dentistry?
I most enjoy the science, the biology and having a front-row seat
in and around the ability to interact with, affect and watch the human body function and heal. I appreciate the ability to solve problems and the ability to work on
problems that are yet to be solved.
I like being a part of a “past, present
and future” continuum that is the
overall profession of dentistry. I
enjoy having the ability to affect an
individual person, from patient to
fellow practitioner to dental student, all the way up to having the
ability to have a positive effect on
humanity across the globe.
Who influenced you most in your
career?
First, I would thank Dr Joel B.
Alexander. He was an endodontic
professor when I was in dental
school who encouraged and
taught the value of recalling your
cases in order to assess your treatment outcomes.
Secondly, I would thank Dr
Terry Pannkuk. After much awareness, pursuit of and concentration
on the topic of mentorship, I certainly believe he is the best doctor
alive today. He has done much for
our profession from a philosophical standpoint to the actualities of
clinical healthcare. He sees the
value in this tooth clearing and diaphonization project I am involved in and consistently has provided more support and encouragement than anyone else. He has
kept me motivated even if it is just
by simply saying “wow, that result
is amazing”. I can’t say enough
about what he has done for me
personally or in my career as
my friend and mentor. I continue to learn from him
daily and I hope that somewhere along the way, I reciprocate some of the support
he has given me over the
years.
You have become known for
your high-definition photography of the root canal
anatomy. How did you become interested in this area?
That too goes back to Dr
Alexander and Dr Pannkuk.
Both of these doctors influenced me to recall my work
in endodontics and truly
take a scientific approach to
the question of whether endodontics actually works and whether it
actually works in my hands. After
recalling many of my own cases, I
started to see failures and problems that I was not satisfied with. I
started to postoperatively evaluate my work and found that there
were clinical aspects I could change
to improve my outcomes. It was
via the internet that I met Dr Arnaldo Casteallucci. After the interactions we had, I saw the cover of
his textbook.
The tooth on the cover put me
in awe. This was the first “cleared
tooth” I had ever seen. It is from
there that my interest in clearing
teeth originated. I just had to figure out what was going on and
how and why it worked. Fifteen
years later, I am still manipulating
processes in the diaphonization of
human teeth in search of the “answers”. I have a patent pending in
the clearing process, and the
knowledge it has provided has become one of the most valuable
tools in pre-operative and postoperative evaluation of the internal
anatomy of human teeth.
Can you tell our readers a little bit
about how you go about capturing
these images? It must take some
technical skill.
The photography is actually
not difficult. It is oil immersion
oblique illumination light microscopy, which has been done in histology labs for years. It is, however,
a new realisation in this area for
dentistry. In dentistry, we are familiar with the study of microscopic histologic sections. Teeth,
on the other hand, are gross histologic specimens that can understandably be seen via the naked
eye; however, viewing of the internal anatomic structures is greatly
enhanced with microscopic evaluation. Any photographs of the
teeth I work with are simply obtained through my “artistic” ar-
Today, I see characteristics of
the internal anatomy of human
teeth that I never thought possible
or knew existed. Visualising the
immense variability of human
tooth anatomy has changed my
clinical practices and improved
my clinical results, which benefits
the patients I treat.
Do you perform endodontic therapy yourself or do you typically refer cases out?
I do all of my own endodontic
treatments in my office. It has
taken me years to identify the area
of dentistry that I love. Perhaps
one day I will take the necessary
we can just take the time to follow
our rolls as doctors. Doctor by
definition means “to teach”, and
proper teaching is not going to
take place via advertising. Marketing is one aspect. Advertising is
another. We have to start the
movement toward patient-centered treatment, with the true
healthcare providers taking the
first step away from any notion of
what would or could be considered advertising in healthcare.
Is there anything you would like to
add?
I am respectfully honored by
this opportunity, your questions
Dr Craig Barrington uses oil immersion oblique illumination light microscopy to capture high-resolution images of root
canal anatomy. (All images provided by Dr Craig Barrington.)
rangement of the specimen in either a visually interesting position
or in what I would consider an
educational interpretation that I
think would most benefit the
viewer of the photograph.
What have you learned most by
taking these root canal photographs?
As Napoleon Hill said: “Whatever your mind can conceive and
believe, it can achieve.”
Where I sit today in my understanding of tooth clearing and diaphonization, I at first thought was
never possible. It started as a simple question, then the development and realisation of a goal. The
process has been consistently
evolving and delivering information and results ever since.
steps to specialise, but life is currently focused on my family and
my children.
Is there anything you would like to
see changed about the way dentistry is practiced today?
Absolutely! More than you
can imagine or can be covered in
this session. In short, we need to
work on our ethical standards
within the profession itself and
move back toward being true, real
doctors over the business-focused patient treatment we are
seeing overwhelm the practice
environment today. The actual
care of the patient is always in
competition with and in direct
contrast to the business and
profit. We have to get back to patient-centered practices. The profits are there in mass quantities if
and in you finding significance in
this work of mine. Thank you!
Editorial note: This interview originally appeared in roots magazine,
No. 1/2017.
Dr Craig Barrington
received his DDS from the University
of Texas Health Science Center San
Antonio in 1996 and is a member of
Omicron Kappa Upsilon. He is also an
associate member of the American
Academy of Endodontists. He maintains a practice in Waxahachie, Texas.
He has written various articles and
publications on the dental operating
microscope in general dentistry. For
comments, questions or presentation
requests, please contact Barrington at
cbdds002@yahoo.com.
[7] =>
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Endo Tribune United Kingdom Edition | 9/2017
ENDO NEWS
23
ROOTS SUMMIT:
Registration open for 2018 edition
By DTI
BERLIN, Germany: Seats for the
next ROOTS SUMMIT, the premier
global discussion forum dedicated
to endodontic dentistry, are still
available. The event, featuring lectures and workshops, will be held
at the European School of Management and Technology (ESMT) in
Berlin from 28 June to 1 July 2018.
Approximately 500 visitors are
expected at the international
meeting, which is again being
organised in collaboration with
Dental Tribune International.
is coming to
BERLIN
28 June –1 July 2018
Berlin, Germany
www.ROOTS-SUMMIT.com
Although the 2018 ROOTS
SUMMIT will mainly feature presentations on the latest techniques
and technologies in endodontics,
the organisers are inviting dental
professionals in all fields, as well as
manufacturers in the industry,
suppliers of endodontic products
and anyone involved in the practice
of endodontic treatment, to attend.
It has been announced that
foremost opinion leaders, including Drs Steve Buchanan, Frederic
Barnett, Gergely BenyĘcs and Elisabetta Cotti, will be speaking at the
conference next year. There will
also be the opportunity to participate in hands-on workshops, speak
to industry professionals on-site
and engage with new equipment,
procedures and protocols in endodontic dentistry. A number of dental companies specialising in endodontics, including META BIOMED
and FKG Dentaire, have already
confirmed their participation.
The ROOTS SUMMIT, which
started as a mailing list of a large
group of endodontic enthusiasts
in the 1990s, has grown significantly over the last few years. With
currently more than 24,000 members from over 100 countries, it
evolved into one of the most
prominent global learning forums
in the dental industry.
Previous conferences have
been held in Canada, the US,
Mexico, Spain, the Netherlands,
Brazil and India. The 2016 ROOTS
SUMMIT took place in the UAE
and was one of the most signifi-
cant events in endodontics that
year, drawing over 300 dental
professionals to Dubai. These
meetings have been known for
their strong scientific programmes. An early bird discount
of 20 per cent is being offered and
dental students too will be
granted a 20 per cent discount.
Additional information and online registration can be found at
www.roots-summit.com.
AD
[8] =>
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Dental Tribune International
ESSENTIAL
DENTAL MEDIA
www.dental-tribune.com
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